Experience of Health Care Professionals Using Digital Tools in the Hospital: Qualitative Systematic Review

Background The digitalization of health care has many potential benefits, but it may also negatively impact health care professionals’ well-being. Burnout can, in part, result from inefficient work processes related to the suboptimal implementation and use of health information technologies. Although strategies to reduce stress and mitigate clinician burnout typically involve individual-based interventions, emerging evidence suggests that improving the experience of using health information technologies can have a notable impact. Objective The aim of this systematic review was to collect evidence of the benefits and challenges associated with the use of digital tools in hospital settings with a particular focus on the experiences of health care professionals using these tools. Methods We conducted a systematic literature review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to explore the experience of health care professionals with digital tools in hospital settings. Using a rigorous selection process to ensure the methodological quality and validity of the study results, we included qualitative studies with distinct data that described the experiences of physicians and nurses. A panel of 3 independent researchers performed iterative data analysis and identified thematic constructs. Results Of the 1175 unique primary studies, we identified 17 (1.45%) publications that focused on health care professionals’ experiences with various digital tools in their day-to-day practice. Of the 17 studies, 10 (59%) focused on clinical decision support tools, followed by 6 (35%) studies focusing on electronic health records and 1 (6%) on a remote patient-monitoring tool. We propose a theoretical framework for understanding the complex interplay between the use of digital tools, experience, and outcomes. We identified 6 constructs that encompass the positive and negative experiences of health care professionals when using digital tools, along with moderators and outcomes. Positive experiences included feeling confident, responsible, and satisfied, whereas negative experiences included frustration, feeling overwhelmed, and feeling frightened. Positive moderators that may reinforce the use of digital tools included sufficient training and adequate workflow integration, whereas negative moderators comprised unfavorable social structures and the lack of training. Positive outcomes included improved patient care and increased workflow efficiency, whereas negative outcomes included increased workload, increased safety risks, and issues with information quality. Conclusions Although positive and negative outcomes and moderators that may affect the use of digital tools were commonly reported, the experiences of health care professionals, such as their thoughts and emotions, were less frequently discussed. On the basis of this finding, this study highlights the need for further research specifically targeting experiences as an important mediator of clinician well-being. It also emphasizes the importance of considering differences in the nature of specific tools as well as the profession and role of individual users. Trial Registration PROSPERO CRD42023393883; https://tinyurl.com/2htpzzxj


Background
The digitalization of the health care industry and hospitals aims to enhance the quality of patient care [1], increase operational efficiency [2], and reduce health care expenditure [3].The use of digital technologies in health care settings has gained momentum in recent years with the introduction of various digital tools, including electronic health records (EHRs) [4], clinical decision support (CDS) tools [5], artificial intelligence (AI) applications [6], telemedicine [7], wearable devices [8], and health apps [9], which hold great potential to transform and revolutionize the delivery of health care services [10].This trend is expected to accelerate with recent advances in AI technologies for language [11][12][13][14].
Despite the potential benefits, digitalization in health care raises concern about the well-being of health care professionals (HCPs) [15,16].Previous research has demonstrated that suboptimal use of health information technologies and inefficient work processes can be associated with burnout, leading to feelings of frustration and reduced job satisfaction among HCPs [17,18].In 2022, a study with >13,000 participants revealed that 48% of physicians working in hospitals reported feeling burned out, with the use of EHR cited as a main factor by 28% of respondents [19].Similar findings, including the association of EHR design and use factors with clinicians' stress and burnout, have been reported [20,21].Burnout is a prolonged response to chronic work-related stress and is characterized by exhaustion, cynicism, and inefficacy and is influenced by both individual and organizational factors [22].Clinician burnout can negatively affect the quality of care and can result in a range of negative consequences, including dysfunctional relationships with colleagues, self-medication or substance abuse, depression, and even suicide [23].
This issue becomes even more significant when considering physician burnout, as it is associated with physicians leaving clinical practice, consequently impacting a country's health care system [24].The loss of physicians from the workforce is an escalating problem in numerous countries, particularly those that are already facing a shortage of HCPs [25].Insufficient numbers of young physicians entering the profession combined with many experienced physicians leaving patient care exacerbate this issue.For instance, in Switzerland, 1 out of every 7 physicians who graduated between 1980 and 2009 eventually opted out of patient care [26].Moreover, burnout is also a concern among students during medical school and has been found to have a positive correlation with dropout intention [27].Thus, addressing and mitigating burnout is crucial for the well-being of individuals, the educational system, and the health care system [28].
The impact of digitalization, in particular the introduction of EHR, on clinician well-being has been extensively studied [29][30][31][32].Early EHR implementations were shown to have a negative impact on clinician well-being, reducing job satisfaction and increasing rates of clinician burnout owing to poor system usability, misaligned job roles, and increasing workloads associated with documentation requirements [32,33].It may be anticipated that technological innovations might have mitigated the situation somewhat; however, at the same time, the pace of technological change has created new challenges such as the need to consider increasing quantities and varieties of data, including patient-reported outcomes [33] and the advances of AI into clinical applications [34].Previous research suggests an urgent need to prioritize the lived experiences of clinicians when interacting with digital tools to suggest new approaches to design and implement tools to avert negative impacts [35][36][37][38].
At present, approaches and interventions aimed at reducing stress and preventing burnout among clinicians primarily involve individual-based practices, including psychoeducation, interpersonal communication, and mindfulness meditation [39].However, recent findings indicate that enhancing the user experience of health information systems is a crucial factor in reducing stress and improving physician well-being [37,38].To facilitate improvements in the user experience of EHR systems, strategies have been developed to empower clinicians to collaborate with local administrators, health IT personnel, and EHR developers [35,36].However, a focus on usability and system design may neglect other important aspects and the effect of digital tools on other human interactions within complex clinical systems [29].To gain a more comprehensive and mechanistic understanding of the impact of digitalization on clinician well-being, emotions, behaviors, and cognitive processes associated with the use of digital technologies must be explored [40,41].These questions have largely not been emphasized in previous research [42,43].

Objective
Previous systematic reviews have explored specific aspects of digital tool integration in health care, offering valuable insights into topics such as mobile health, EHRs, and AI-based technologies [44][45][46].These reviews have effectively highlighted the impacts of digital tools on HCP interactions, communication, and documentation, contributing to a better understanding of the advantages of digital tools in health care and their negative impacts on clinician well-being and burnout [15,[47][48][49][50]. Another review provides comprehensive insights into the positive experiences, facilitators, challenges, barriers, and suggestions for the enhancement of digital care visits [51].However, most reviews are narrowly focused on specific aspects, overlooking the broader context of health care practices.Moreover, some of these systematic reviews are dated, potentially making their findings less relevant to the current health care landscape as the digital technology evolves.In addition, the frequent lack of firsthand experience from HCPs who use these tools might lead to a limited perspective on their lived experiences.

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In this systematic review, we aimed to provide a comprehensive overview of the available evidence on HCPs' experiences using digital tools in hospital settings.We performed a qualitative synthesis to provide a more nuanced understanding of the impact of digital tools on HCPs' experiences at work and to offer insights that can inform the development, adoption, implementation, and evaluation of these tools in hospital settings.

Methods
To investigate the experiences of HCPs using digital tools in clinical settings, we conducted a comprehensive systematic literature review.This review adhered to the updated PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was conducted between February and March 2023 (Multimedia Appendix 1) [52].

Protocol Registration and Amendment
The protocol for this systematic review of qualitative studies has been prospectively registered on PROSPERO (registration number CRD42023393883).We kept the PROSPERO protocol status up-to-date throughout the research process, aligning it with our research's progress and stages until review completion.No additional modifications were made to the previously published protocol.Before registering the protocol, we conducted PROSPERO searches using various combinations of keywords, including "digital tools," "healthcare professional," and "experience" to identify any registered protocols that aim to explore the experience of HCPs with digital tools in hospital settings and to ensure our review makes a significant and novel contribution to this research domain.

Search Strategy and Information Sources
Our search strategy involved performing a keyword search of peer-reviewed literature published from January 2018 to January 2023 and retrieved from the electronic databases PubMed, Scopus, and Web of Science.The search was limited to the past 5 years to ensure the inclusion of the most current research on the experiences of HCPs, as digital tools evolve over time, and thus, older studies would be less relevant.Our search strategy included keywords such as "digital tools," "digital applications," "digital devices," and "technology" as well as "healthcare professionals" including "clinicians," "physicians," and "nurses."We also used keywords related to "experience" such as "expectation," "perception," "adoption," "acceptance," and "qualitative."We used variations of search terms to match synonyms, abbreviations, alternative spellings, and related topics (Multimedia Appendix 2).In addition to the systematic search, we conducted a backward search by reviewing the reference lists of the key publications identified.

Eligibility Criteria
To be considered for inclusion in the review, the articles had to meet our defined eligibility criteria.We sought to identify qualitative, descriptive interview studies that provided clear and distinct qualitative data and results describing the experiences of HCPs with at least 6 months of experience using digital tools in a hospital setting.Given our primary focus on capturing HCPs' firsthand experiences with digital tools, we focused our attention on qualitative interview studies.Interviews provide conceptual and theoretical knowledge about people's life experiences and offer insights into their views, opinions, feelings, knowledge, and expertise [53].In health-related research, qualitative interviews stand out as a significant approach, allowing individuals to articulate their understanding of the world, leading to deep and novel insights [54].Unlike other qualitative methods such as ethnography, which observe actions, qualitative interviews allow us to understand the "how" of people's thinking and lived experiences [55].Therefore, we also included the qualitative components of mixed methods studies (Multimedia Appendix 3).We defined "experience with digital tools" as the integration of digital tools and technology in health care provisions supporting the achievement of health objectives, including prevention, assessment, diagnosis, consultation, treatment, or monitoring of a patient and medical condition.Our search was limited to peer-reviewed English literature within the defined time frame, population, and setting.

Selection and Data Collection Process
A panel of 3 independent researchers conducted a rigorous selection process to identify relevant publications for this study.The Covidence web application (Veritas Health Innovation Ltd) [56] was used to screen the titles and abstracts of the studies retrieved from the search strategy by at least 2 reviewers.Any discrepancies were resolved through discussion among the 3 reviewers.Full-text analysis was then performed by 2 authors to assess eligibility, with clear reasons provided for exclusion, and any disagreements were resolved by the third author.
To ensure accurate and consistent data extraction and quality assessment, we developed templates for recording study characteristics, including general publication information, key study and method characteristics, study population and background characteristics, and key findings.We used the "Critical Appraisal Skills Program" qualitative assessment checklist (Multimedia Appendix 4) to evaluate the methodological quality and validity of the study results.Data were independently collected and assessed by 2 authors, and any disagreements were resolved through discussion with the third author.

Data Items and Synthesis
For data analysis and management, "ATLAS.ti"software (Scientific Software Development) [57] was used to allow line-by-line coding by 2 reviewers to capture key data and identify recurrent topics.Primary codes were then compared and synthesized to derive descriptive themes and higher-order constructs based on grouping, reviewing, and analyzing similar topics and concepts in the primary codes underlying the experiences of HCPs using digital tools in a hospital setting.To ensure a comprehensive approach, we used iterative coding and synthesis of codes, considering the findings from a thorough review of the theoretical frameworks presented in the existing literature.This iterative process supported the development of a novel theoretical framework specific to this study.The framework was then continuously evaluated through its application to the coding process, allowing for refinements and adjustments as necessary.

Study Selection
In total, 2236 publications were identified, of which 1061 (47.45%) were removed owing to duplication.Subsequently, during the initial screening phase, 1143 (51.12%) articles were excluded based on predefined inclusion and exclusion criteria.The remaining 32 (1.43%) studies underwent a thorough full-text review, leading to the further exclusion of 15 (0.67%) articles owing to insufficient experience of HCPs with the respective digital tools (n=5, 33%), outcomes that focused on factors other than the experience of HCPs (n=3, 20%), excluded study populations (n=3, 20%), publication date outside the time frame (n=2, 13%), exclusion of study location and setting (n=1, 7%), and quantitative study analysis (n=1, 7%).Ultimately, 17 studies were included in the review (Figure 1).

ing primarily on the issue of responsibility
System usability depends on factors such as ease of use, workflow improvement, Exploration of physicians' perspectives and experiences using electronic order sets Canada Physician experience with electronic order sets Fishbein et al [60] and simple design, but searchability issues can complicate navigation.Electronic order sets enhance patient safety by reducing reliance on physician memory, providing real-time access to best practices, and enabling individualized care.
Collaboration with a machine learning system is facilitated by viewing it as a Understanding the role that clinicians see machine learning as playing in United States Human-machine teaming is key to AI adoption: clini-Henry et al [70] supportive validation tool across work-acute clinical care and pathways and cians‚ experiences with a flows, building trust through experience.barriers to building trust with machine learning-based recommendation deployed machine learning system However, concerns include overreliance and potential harm from standardized care, emphasizing the need for clinicians to be willing and able to integrate system information into patient care.
CDSSs can enhance the autonomy of nurses in patient assessments, but further Description of how registered nurses make use of a CDSS f to triage calls to Sweden Registered nurses' experiences of using a clinical decision support system for Holmström et al [63] improvements are needed in areas such as technical optimization, interoperability, emergency medical dispatch centers, from the perspective of professional autonomy triage of emergency calls: a qualitative interview study and nurse education and training on the system.

Findings Study aim Location Publication title Study
Clinicians' adoption of the decision support app was influenced by app-specific features, social factors, and internal organizational dynamics.The app facilitated workflow efficiency, improved practice, and offered location flexibility, but adoption was hindered when cultural acceptance was lacking or interoperability with other digital systems was limited.
Understanding clinicians' roles in the adoption of an oncology decision support app, the factors impacting this adoption, and its implications for organizational and social practices United Kingdom, Ireland, France, Italy, Spain, and Portugal Clinicians' role in the adoption of an oncology decision support app in Europe and its implications for organizational practices: qualitative case study Jacob et al [71] Implementing an EMR g impacted nurses' autonomy, workflow, and professional role, with motivation identified as a crucial factor in adapting to the new system.When implementing a new system, considering motivation becomes essential to ensure successful adoption.
Exploration of Australian nurses' postimplementation experiences of an organization-wide EHR system Australia Nurses' experiences after implementation of an organization-wide electronic medical record: qualitative descriptive study Jedwab et al [64] Digital health had both positive and negative impacts on the patient-physician relationship, enabling patients to access their health data but causing confusion regarding when to alert a physician.The study led to 6 ethical recommendations based on shared responsibility for measurements.
Exploration of the perspectives of patients and health care providers on the patient-physician relationship in digital health, focusing on roles and responsibilities in perinatal care and the influence of technology on medical decision-making Netherlands How digital health affects the patient-physician relationship: an empirical-ethics study into the perspectives and experiences in obstetric care Jongsma et al [72] Initially met with skepticism, the AI program eventually supported triage decisionmaking for emergency nurses but could not assist with culturally nuanced decisions.Sufficient resources and workforce were crucial for technology acceptance.

United States
The impact of cultural embeddedness on the implementation of an artificial intelligence program at triage: a qualitative study Jordan et al [65] The implementation of EMR was directly linked with ownership of own digital hardware and health care professionals valued it for the digital availability of patient data.Lack of training and experience on EMR systems was a hindering factor.
Analysis of physicians' attitudes regarding EMRs and the predictive factors that may influence their attitudes.As a result, the findings will have an influence on future adoption success and physician acceptability of EMR systems Ethiopia Physicians' attitude towards electronic medical record systems: an input for future implementers Kalayou et al [74] Workflow success depends on factors beyond CDS design and features, including sociotechnical elements, organizational processes, and work dynamics.Although well-designed CDS is valuable, it cannot substitute for medical skills, knowledge, and adequate training.
Evaluation of the appropriateness of CDS alerts in supporting clinical workflow from a sociotechnical perspective Malaysia Evaluating the appropriateness of clinical decision support alerts: a case study Olakotan and Yusof [61] Psychological and behavioral barriers, such as fear of missing a pulmonary embolism and time pressure, hindered the use of CDS.Support from hospital leadership, adequate training, and trust can promote CDS adoption.

Exploration of the psychological and behavioral barriers to the use of a CDS tool
United States Barriers to the use of clinical decision support for the evaluation of pulmonary embolism: qualitative interview study Richardson et al [62] Limited familiarity with the EHR system led to underuse of features.Challenges with interoperability and patient data storage compromised safety, whereas patient involvement as a third-party user remains unaddressed.
Analysis of the user experiences, perceived usability, and the attitudes among health care professionals toward a specific EHR system that is commonly used Norway User experiences and satisfaction with an electronic health record system Smaradottir and Fensli [73]

Findings Study aim Location Publication title Study
Successful implementation of a new nursing information system required collaboration between end users, administrators, and technical personnel.Nurses should be involved in system development to optimize user experience and system usability.
Investigation of nurses' perceptions and experiences with transition to a new nursing information system 2 y after its first introduction China Transition to a new nursing information system embedded with clinical decision support: a mixed-method study using the HOT i -fit framework Zhai et al [66] a EHR: electronic health record.
b QUiPP: quantitative innovation in predicting preterm birth.

Theoretical Framework
Our preliminary assessment of the literature highlighted the need for a theoretical framework to understand the complex interplay between the use of digital tools, experience, and outcomes within clinical and general workflows.In recent years, several theoretical frameworks have been developed to predict and explain the acceptance behavior of new technologies [75].In the health care context, the Technology Acceptance Model and the Unified Theory of Technology Acceptance and Use are among the most widely used models for predicting acceptance behavior [76].However, direct experiences when using tools, which are potential moderators for the downstream impact on well-being, are often not distinguished from other outcomes or moderators.Building on this literature and informed by our thematic analysis of the included studies, we defined a theoretical framework to distinguish and illustrate connections between using digital tools, the experience of using digital tools, moderators that seem to impact the use of digital tools positively or negatively, and outcomes as a result of using the tools (Figure 3).The framework explicitly includes the experiences of each individual user as a separate construct.Experiences are private to the individual, encompassing thoughts, emotions, and feelings.They can be influenced by either the outcome of using digital tools or using the tool itself, which plays a crucial role in further promoting or hindering the use of digital tools either positively or negatively.Thus, as indicated in Figure 3, there are possibilities for the development of positive or negative feedback cycles.
In the subsequent sections, we present our findings using this theoretical framework and provide a comprehensive analysis of the relationships between digital tool use, moderators, experience, and overall outcomes.

Overview
Our analysis and synthesis of themes resulted in the identification of 6 overall constructs according to our theoretical framework, encompassing positive and negative experiences of HCPs when using digital tools, positive and negative moderators that possibly affect their adoption and use, and the corresponding positive and negative effects and outcomes of the use of digital tools may result in (Table 2).Overall, clinician experiences were less frequently reported as compared with moderators or outcomes, with positive experiences reported in 31 annotations and negative experiences reported in 40 annotations.Overall, moderators were the most frequently reported phenomena across publications, with 194 annotations on positive moderators and 121 annotations on negative moderators.Furthermore, 108 positive and 131 negative annotations for outcomes were identified (Multimedia Appendix 5).

Table 2. Most frequently emerging themes and topics in the selected studies (N=17).
Exemplary quote from study Publications, n (%) Category and most frequently reported topics

Positive experience
"Nurses attributed reinforcement of their triage process to AI a feedback, which increased their confidence."[65] 10 (59) Feeling confident "However, they saw themselves as maintaining ultimate responsibility for diagnosis and treatment decisions."[70] 6 (35) Feeling responsible "The work here with emergency triage builds on my experience in emergency nursing to a great extent."[63] 6 (35) Expressing satisfaction with the tool or situation "[Clinicians] acknowledged the benefits of having the BUC [blood utilization calculator]..." [59] 4 (24) Feeling grateful

Negative experience
"The lack of online access to scans performed in some hospitals is a clear source of frustration for certain HPs b ..." [68] 8 (47) Feeling frustrated "Providers also reported that they may be overwhelmed by the number of inbasket messages..." [58] 7 (41) Feeling overwhelmed by information load "Nurses' anxiety about needing to learn and use a new system, stress related to additional pressures in an already busy work environment, and fear and resistance 7 (41) Feeling frightened to change with the EMR c implementation emerged as emotional barriers to EMR use by nurses."[64] "...while others perceived it to be confusing and hard to use, since the technology was not tailored to their needs."[59] 5 (29) Feeling confused Positive moderator "...physicians who got EMR training had more knowledge about the system than their colleagues, which improved their attitude and motivation towards the system."[74] 11 (65) Sufficient training "The EMR implementation was described as successful by nurses when they felt that they had learned the system and adapted their ways of working and workflows."[64] 10 (59) Adequate workflow integration "...there are other social and organizational factors that play a crucial role in the adoption and success of such new technologies..." [71] 8 (47) Favorable organizational structures "User-centered design, wherein the user is centrally involved in all phases of the design process, is essential for AI health care technologies."[59] 7 (41) User-friendly design of interface Negative moderator "...there are also social and organizational aspects such as shortage of time and financial resources that can cause limitations to such solutions' adoption."[71] 9 (53) Unfavorable social structures "Lack of continuity of training was also a problem for nurses."[66] 8 (47) Lack of training "...others perceived it to be confusing and hard to use, since the technology was not tailored to their needs."[59] 6 (35) Lack of a tailored tool design "Also, poorly designed alert interfaces have led to difficulty in retrieving patient information, which may lead to cognitively based errors and impedes the performance of clinicians."[61] 6 (35) Insufficient design of user interface Positive outcome "The system has improved care quality by reducing medication errors."[61] 12 (71) Improvement in quality of patient care "HPs report that the introduction of PACS d had a dramatic impact on the clinicians' working day, bringing a newfound convenience to the clinical workflow."[68] 10 (59) Increase in workflow efficiency "Specifically, PACS has increased the amount of useful information available to clinicians, and improved the availability of images..." [68] 8 (47) Better information availability "...the use of order sets increased safety by ensuring that physicians followed evidence-based practices and minimized the possibility of omitting important interventions."[60] 6 (35) Increase in patient safety

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Exemplary quote from study Publications, n (%) Category and most frequently reported topics Negative outcome "Clinicians often had to figure out a way to bypass the system and place their blood transfusion order, adding to their existing workloads and slowing down the transfusion process."[59] 13 (76) Increase in workload "The loss of nurses' narrative owing to EMR use was raised as a concern for patient safety..." [64] 8 (47) Increased patient safety risks "Another user problem is the copy and paste of text between sections in the record, which might produce potentially outdated and inaccurate information."[73] 8 (47) Missing or outdated information "Overriding default options before completing prescriptions has increased workflow disruption in dermatological settings."[61] 7 (41) Complications and interruption in workflow a AI: artificial intelligence.
b HP: health professional.

Positive Experiences of HCPs Using Digital Tools
Almost all studies reported positive experiences of HCPs using digital tools (Multimedia Appendix 5).The most frequently reported experiences were feeling confident about using a tool (10/17, 59%), feeling responsible (6/17, 35%), being satisfied with a tool or situation (6/17, 35%), and feeling grateful (4/17, 24%).Other experiences that were less frequently reported include feeling comfortable using the tool; expressing appreciation; feeling autonomous and empowered; and feeling supported, encouraged, or optimistic.

Negative Experiences of HCPs Using Digital Tools
Of the 17 studies analyzed, 14 (82%) reported negative experiences of HCPs using digital tools (Multimedia Appendix 5).The most frequently reported negative experiences were frustration (8/17, 47%) owing to various reasons, such as communication issues, deteriorated physician-patient interaction, lack of sufficient resources, increased workload, difficulties in adapting to an unintuitive system, challenges in finding information within the EHR system, and limited or impaired access to web-based information stored within digital systems.Other commonly reported negative experiences were feeling overwhelmed by information (7/17, 41%) and various fears (7/17, 41%), including fear of change and replacement, fear of forgetting, or fear of losing or misinterpreting information.Moreover, feeling confused was mentioned owing to a conflict with the professional identity of HCP.This conflict stemmed from the impact of digital tools on their perceptions of their professional image, concerns about their work visibility, as well as their perception of digital tools as a threat to their professional autonomy (5/17, 29%).Other negative experiences that were less frequently reported included feeling disrupted, feeling concerned mainly for the patient, feeling disappointed by the tool, feeling uncertain, feeling unsatisfied with work situations, feeling stressed, or even feeling shocked.

Moderators With a Potential to Positively Influence Digital Tool Use
We identified several moderators that possibly result in positively impacting HCPs' use of digital tools, such as sufficient tool design, improved patient care and safety, and favorable structural factors.The most reported factors that reinforced the use of digital tools were sufficient training (11/17, 65%), workflow integration (10/17, 59%), favorable organizational structures (8/17, 47%), and well-designed user interfaces (7/17, 41%).Other relevant factors include the HCPs' perception that the tool supports clinical excellence, quick and easy information access, trust in the tool, an appropriate workstation setup, and a great extent of prior use or familiarity with the tool or technologies.

Moderators With a Potential to Negatively Influence Digital Tool Use
Conversely, negative moderators have been reported that potentially hinder or limit the use of digital tools.We identified various moderators that may have a negative impact on HCPs' use of digital tools, such as technical issues and a nonintuitive interface design, unfavorable structures, personal attitude, limited prior exposure, and concerns about patient care and data privacy.Unfavorable social and organizational structures (9/17, 53%), the lack of training (8/17, 47%), insufficient user interface design (6/17, 35%), and the lack of tailored tool design and features (6/17, 35%) were the most frequently reported negative moderators.Other negative moderators include time constraints, insufficient workstation setup, the lack of workflow integration, and limited or impaired information accessibility.

Positive Effects and Outcomes of Digital Tool Use
Studies reported several positive outcomes resulting from the use of digital tools.These included patient-centered care and empowerment, improved quality of care, streamlined workflow and productivity, efficient information management, optimized cognitive support of HCPs, and collaborative care.The most frequently reported positive outcomes were improved quality of patient care (12/17, 71%), increased workflow efficiency (10/17, 59%), better information availability (8/17, 47%), and increased patient safety (6/17, 35%).Other frequently reported positive outcomes included improved time efficiency through quick and easy access to information, the promotion of critical thinking, and a reduction in errors.

Negative Effects and Outcomes of Digital Tool Use
The use of digital tools also resulted in negative outcomes.These included communication and information management challenges, issues with information accuracy and availability, patient safety risks, reduced quality of care, and organizational and workflow issues.The most frequently reported negative outcomes were increased workload (13/17, 76%), patient safety risks (8/17, 47%), missing or outdated information (8/17, 47%), and complications or interruptions in the workflow (7/17, 41%).Other reported negative outcomes included time-consuming information management, incomplete information transfer, inefficiencies in the documentation process, and reduced or suboptimal patient care overall.
The most reported negative experience for conventional CDS systems was feeling disrupted [62,66].In contrast, for AI-based CDS tools, the most frequently cited negative experience was feeling frightened [65,69].Although frustration was the most frequently mentioned negative experience in EHR systems [58,60,64,68,73,74], only a few publications mentioned it for conventional [66] and AI-based [65] CDS systems.The same also applied to feeling overwhelmed by information [58,60,68,73].Similarly, feeling insecure, shocked, stressed, and unsatisfied with the work situation [64] was only mentioned for EHRs and not for the CDS tools.In contrast, uncertainty was only reported for conventional [69] and AI-based [67] CDS systems but not for EHRs.The primary moderators that may positively impact the use of digital tools were largely consistent across all electronic systems.Sufficient training was deemed highly important for conventional CDS [62,66,71], AI-based CDS [59,61,69,70], and EHR [64,68,73,74] systems.Similarly, sufficient workflow integration was mentioned for conventional CDS [62,67,71,74], AI-based CDS [61,69], and EHR [58,64,68,74] systems.For AI-based CDS tools, trust [59,69,70] and the perception of support [59,69,70] were reported as highly critical factors to enhance use.Moreover, it is essential for AI-based CDS tools to provide clinicians with a sense of advice and collaboration, augmenting their choices and assisting in their day-to-day work.In the case of CDS AI-based tools, creating a perception of being an adviser and cooperating partner, along with a deep understanding of the fundamental aspects of the tool [69,70], was found to be of significant importance when compared with other tools.In contrast, for EHRs, favorable organizational structures [60,64,68,74] and providing quick and easy access to information [58,60,68] were reported as essential for using the system.Furthermore, the fear of negative consequences [64], sufficient IT infrastructure [60], commoditization of the tool [68], and the perception of a service to the community [68] were only mentioned for EHR systems.Across all studies, HCPs commonly reported unfavorable organizational structures as the most critical negative moderator for the use of conventional CDS [66,67,71], AI-based CDS [61,65], and EHR [60,64,68,74] systems.In addition, unfavorable social pressure was mentioned for conventional CDS tools [62,67,71].In addition, the lack of training was identified as a negative factor, particularly for EHRs [64,68,73,74] but also for conventional CDS [66,67] and CDS AI-based [61,65] systems.In addition, for EHRs only, insufficient user interface design [11,14,19,20], workstation setup [58,68,73,74], and data privacy concerns were mentioned [64,68].In contrast, for AI-based CDS systems, the lack of tailored design [59,69] and distrust [65,70] were reported as negative moderators.In addition, unfavorable features for AI-based CDS [65] and conventional CDS [63] systems, high costs (AI-based CDS [69] and conventional CDS [71]), and negative attitudes toward technology (AI-based CDS [69] and conventional CDS [71]) were only reported for CDS systems but not for EHR.
The analysis of the experiences of physicians and nurses as individual population groups revealed that nurses more frequently reported feeling confident and supported by health care tools [64][65][66] as compared with physicians [61].However, both nurses and physicians reported feeling satisfied, responsible, and grateful [58][59][60]63,64] with the tools.Furthermore, physicians expressed feeling comfortable and encouraged [58,59], whereas nurses did not report such feelings.
Negative moderators with the potential to hinder the use of digital tools were identified by both nurses and physicians.Nurses mostly reported a lack of training [64][65][66], whereas physicians commonly reported a lack of workflow integration [58,61,62] as the main challenge.In addition, both groups of HCPs identified unfavorable organizational structure (physicians [60,61] and nurses [64,66]) and insufficient user interface design (physicians [58,61] and nurses [64,66]) as negative moderators that can impede the use of digital tools.Moreover, physicians were more likely than nurses to report a lack of workstation setup as a hindrance [58,61].

Principal Findings and Significance
Digital transformation is altering many aspects of the health care system and the accompanying clinical workflows.Many of these changes are improvements with the potential for more and easier access to information and innovations in workflows toward better care; however, there are also concerns about possible unintended consequences.The interactions between clinicians and digital tools and systems are the direct frontier of digital transformation, affecting clinical work, roles, team dynamics, and clinical encounters with patients.As mentioned in the Introduction section, previous studies have extensively explored the impact of digitalization, particularly the introduction of EHR, on clinician well-being.Early findings indicated that EHR implementations had negative effects, leading to reduced job satisfaction and increased rates of clinician burnout.Our systematic literature review aimed to provide an up-to-date overview of the literature encompassing the perspective of clinicians using digital tools in hospital settings.
Our first finding was that despite the many calls to take clinician experiences into consideration, the body of research addressing this topic is still quite small, and only 17 studies since 2018 met all inclusion criteria.We found that many of the studies retrieved by the search but subsequently discarded were explorations of clinician experiences in using newly introduced tools or design studies that evaluated experiences with tools while they were under development.These studies are valuable but can provide only limited insights into the impact of the long-term use of tools on experiences, job satisfaction, and workflows.This suggests that 1 factor that may be relevant in driving the small size of the research literature on this topic is poor alignment with research agendas and funding priorities.
Among the studies that were included in the review, we also observed that although the moderators that might positively or negatively affect the use of digital tools and their outcomes were commonly reported, the experiences of HCPs, such as their thoughts, emotions, and feelings, were less frequently discussed in the literature.However, these direct experiences are likely to have a significant impact on the well-being of clinicians, the care they can provide patients, and the overall functioning of the health care system.This suggests that research specifically targeting the direct lived experiences of clinicians using digital tools in hospital settings would benefit from an explicit emphasis on individual thoughts and emotions as an important driver for HCPs to use digital tools.
Digital tools may enforce or be the front end for administrative tasks, taking time away from the work that clinicians want to do.Administrative tasks are typically seen as less meaningful work, and finding meaning in one's work serves to offset stress and reduce burnout [78].
Another significant aspect is workflows with interruptions and higher cognitive burden, which contribute to lower clinician satisfaction and higher emotional exhaustion.This is evident in previous studies that reported that the introduction of EHRs resulted in numerous additional and often unnecessary interruptions caused by excessive and often irrelevant or poorly timed alerts and inbox notifications that disrupt the workflows and interactions with patients [79,80].Such interruptions have been identified as a major issue contributing to alert fatigue and are likely to be associated with burnout [81,82].Furthermore, previous studies have highlighted information overload as a serious problem associated with the use of EHR that also contributes to this problem [83,84].The findings suggest that a digital tool should strike a balance between reducing workload and promoting critical thinking among HCPs when dealing with provided information.
The usability and interoperability problems with the EHR, combined with the demands of documentation and reporting requirements, create an administrative and clerical burden for clinicians that allows less time for patient care or nonwork-related activities.This is exemplified in an observational study of 57 physicians in 4 specialties, where physicians dedicated 49.2% of their office day to EHR and desk work and 37% during examination room visits, nearly double the amount of time spent doing direct patient care tasks.In addition, physicians reported spending 1 to 2 hours of after-hours work, primarily focused on EHR tasks [85,86].
This also affects nurses and nursing leaders, who are often frustrated with the current EHR system, as its design fails to support their workflows and presents significant usability issues.This not only impacts nurses themselves but also has negative repercussions on patients and health care organizations [87].
Another study indicated that nurses spend up to half of their time in front of a computer documenting patient information [88].
The digitalization of clinical work not only allows for the capturing of documentation in digital systems but also enables the possibility or expectation of doing so remotely and from home.In this sense, digitalization in hospital settings mirrors a wider transformation of the workplace that is ongoing and has been accelerated by the recent pandemic.Our findings suggest that clinicians report some positive outcomes from the use of digital tools, including improved quality of patient care, enhanced workflow efficiency, and better information availability.In contrast, negative outcomes such as increased workload, heightened patient safety risks, outdated or missing information, and disruptions in workflow were also identified as still relevant, even with modern clinical information systems.The positive and negative outcomes were often perceived in pairs, such as increased patient safety versus increased patient safety risks, better information availability versus missing or outdated information, increased workflow efficiency versus complications, and workflow interruptions.
The findings of our review suggest that the use of digital tools by clinicians can be influenced by various moderators.These moderators can positively enhance the use of digital tools.For instance, adequate training may equip clinicians with the essential skills and confidence to effectively use digital tools, along with seamless workflow integration, a user-friendly interface design, and favorable organizational structures.This ensures minimal disruption and efficient use and makes it easier for clinicians to navigate the digital tools.Conversely, certain moderators can have negative effects on the use of digital tools, such as unfavorable organizational structures, leading to a lack of support and motivation; inadequate training, which may lead to frustration, errors, or misuse of the tool; and insufficient interface design and customization, which may lead to struggles while navigating the interface or finding the desired information need.As with outcomes, positive and negative moderators are frequently reported as opposing pairs, as is the case with sufficient training positively impacting tool use and lack of training hindering tool use, similar to favorable and unfavorable organizational structures.

Limitations
This review encompasses a diverse range of studies in hospital settings, and the underlying theoretical framework highlights the complexity of the interconnection between positive and negative experiences, moderators, and outcomes.
This review has several limitations.Although every effort was made to be comprehensive in the search for relevant literature, it is possible that the inclusion and exclusion criteria may have biased the results.The review focused solely on physicians and nurses working in a hospital setting, either secondary, tertiary, or quaternary care, and not in primary care.In addition, we did not include studies that were focusing on pilot, implementation, or validation studies.As we were primarily interested in the experience of HCPs using digital tools, we also did not focus on studies that evaluated the improvement of quality of care as a primary study outcome.As a result, some papers exploring the relevant experiences of general practitioners and in other study contexts were excluded.We also excluded studies that involved populations of students who had not yet started their professional careers.
Although our search was conducted using global research repositories, the focus on English language publications may have biased the results; indeed, a majority of the included studies were conducted in English-speaking countries.
Furthermore, owing to the timing of our systematic review, experiences of clinicians using large language models such as ChatGPT have not yet been reported in the literature we reviewed.However, this is likely to be an increasingly important topic for future research.

Implications for Future Research
This review indicates a need for future studies to focus more on the direct lived experiences of HCPs including thought processes, feelings, and emotions, as this has not been widely reported in previous studies.Moreover, there is a need to explore the experiences of HCPs in other regions of the world where digital transformation, drivers, constraints, workflows, and organizational cultures may differ markedly from those reflected in the predominant body of the existing literature.For example, a notable research gap exists in various regions, including South America; significant parts of Africa, Southeast Asia, and the Pacific; as well as in specific countries within Middle and Eastern Europe (Figure 2).Only limited attention has been directed toward exploring this topic in these regions.

Conclusions
This literature review surveyed the recent experiences of clinicians using digital tools in a hospital setting.This paper presents information about the experiences as well as moderators that can promote or hinder the use, and outcomes of digital tools in hospitals and identifies opportunities for further research.We proposed a theoretical framework to explain the complex interplay between the use of digital tools, experience, moderators, and outcomes.The framework emphasized the need to consider the individual experiences of users, which can be influenced by either the outcome of using digital tools or by the use of the tool itself.In addition, our review also revealed that tool-specific factors, such as the design and goals of the tool, as well as the professional role and responsibilities can impact the user experiences.The review findings highlight the influence of adequate training for clinicians using digital tools and emphasize the need for favorable organizational structures to positively influence use.

Figure 1 .
Figure 1.Flow diagram of the study selection process.
app (clinical decision-making individualizing risks of early delivery within the relevant time frame) in clinical practice medical mobile phone app (QUiPP b V2) designed to predict the risk of preterm birth and aid clinical decision making Analytical efficacy alone does not guarantee technology adoption; it relies on the Investigation on how clinicians perceived this AI c -based decision support United States Clinicians' perceptions of an artificial intelligence-based blood utilization calculator: qualitative exploratory study Choudhury et al [59] system's design, user perception, and knowledge.AI systems should be self-explanatory in their use instructions, and us-system and, consequently, understand the factors hindering BUC d use ing technology outside its intended audience limits user perception and use.Health care professionals rely on the PACS in their workflow, but there is a Exploration of health care professionals' experiences, practices, and prefer-Ireland, United Kingdom, United Arab A qualitative analysis of the needs and experiences of Cronin et al [68] lack of awareness and limited use of its ences when using PACS e to identify Emirates, United States, and Australia hospital-based clinicians when accessing medical imaging advanced features.Training; enhanced usability; and the adoption of touchless, voice-controlled PACS are viewed posi-shortcomings in the existing technology and inform future developments tively by most users and would bring benefits.
c AI: artificial intelligence.
d BUC: blood utilization calculator.e PACS: Picture Archiving and Communications Systems.
f CDSS: Clinical Decision Support System.g EMR: electronic medical record.hCDS: clinical decision support.iHOT: human, organization, and technology.

Figure 2 .
Figure 2. Geographic distribution of studies by country.

Figure 3 .
Figure 3. Proposed theoretical framework distinguishing moderators; outcomes; and experience of using digital tools, including positive and negative examples.
c EMR: electronic medical record.d PACS: Picture Archiving and Communications Systems.
a CDS: clinical decision support.bAI: artificial intelligence.c EHR: electronic health record.

Table 1 .
Overview of the publications selected for analysis.

Table 4 .
Most emerging themes and topics per study population.