Discussion
The above themes are discussed in further detail below as part of the
thematic analysis. Some articles were re-grouped based on the
overarching themes.
Service delivery
Documentation
The major advantage of computerized documentation is legibility, which
was highlighted in multiple studies (Qian et al., 2015, 2020; Wang et
al., 2012).
Data entry in EMRs primarily differs from entering data in paper records
in that the former allows field selection options such as drop-down
menus. This introduces a new type of error that can harm the integrity of
documentation. Qian and colleagues (2020) discovered among all types of
errors, the service option error accounted for more than half.
Compared with their paper counterparts, an increased rate of completion of
documentation, such as discharge summaries, management plans, and
screening proformas in EMRs was demonstrated in studies by Curtis and
Witkowski (Curtis et al., 2021; Witkowski et al., 2021). Completion of
key demographic and patient data (patient weight, for example) impacts
subsequent workflows, including medication delivery, which was seen to
be a benefit in Firman’s study (Firman et al., 2021).
Whereas overall completion tended to fare better with EMR vs paper
systems (Wang et al., 2012), caveats remain that other factors influence
completion rates. These include demands on the health workforce,
training, and motivation (Curtis et al., 2021, 2021; Wang et al., 2012).
Not all studies reported positive findings in this area. Fairley et al.
found no difference in quality between paper and electronic records (Fairley et al., 2013).
Most research in this area highlighted that documentation practices and
standards can vary over time, which hinders the ability to draw
conclusions about improvements longitudinally. Most of the studies use a
nationally recognized paper form template to audit electronic records,
which may not be tailored for electronic format (McLain et al., 2017).
Studies reporting on documentation were often very domain-specific: for
example, research in the residential aged care setting conducted by Wang
et al., (2013) reported on factors that would not be applicable to a
surgical ward in a hospital, such as ‘membership’. A resident’s
cognitive capacity may also contribute to incomplete data entry (E. N.
Munyisia et al., 2012; Wang et al., 2012).
Optimization and continuous education regarding documentation
requirements are key to improvements in this area, and it was also
recommended that further research be conducted to solidify the link
between documentation and outcomes of care (Curtis et al., 2021; E. N.
Munyisia et al., 2012; Wang et al., 2012).
Efficiency
Most studies reported increased efficiency after EMR implementation
(Bingham et al., 2021; Curtis et al., 2021; Fairley et al., 2013; E.
Munyisia et al., 2014; Witkowski et al., 2021). Several studies provided
statistically significant evidence of more patients being treated in the
same amount of time post-implementation compared to pre-implementation:
Witkowski et al., (2021) demonstrated a 19.5% increase in patient
reviews; Fairley (2013) demonstrated 5% more consultations per hour,
and Curtis (2021) showed nursing staff were caring for more patients of
a similar acuity in the same amount of time.
Negative impacts on efficiency were related to increased time taken for
medication reviews by pharmacists (Westbrook et al., 2019) and the use of
mixed paper and electronic documentation systems (E. N. Munyisia et al.,
2012; Walker et al., 2020).
Overall, recommendations centralized around guidance for standardization
and proformas, combined with a need for education and sustained continuous
improvement practices (Curtis et al., 2021; E. N. Munyisia et al., 2012;
Schwarz et al., 2020; Witkowski et al., 2021).
User-experience design improvements were recommended to enhance
documentation features for efficiency gains by Bingham et al., (2021),
Munyisia et al., (2014), Qian et al., (2015, 2020), and Walker et al.,
(2020), as poorly designed user interfaces can result in longer
documentation times (E. Munyisia et al., 2014).
Limitations within this topic were mostly due to the observational
nature of the studies, which often limits sample size and
generalizability, even when standardized techniques such as STAMP and
WOMBAT are used (Bingham et al., 2021; E. Munyisia et al., 2014; Qian et
al., 2015; Walker et al., 2020; Westbrook et al., 2019). The presence of
an observer in time and motion studies could have led to the Hawthorne
effect, though this was noted in the limitations sections of these
papers, and steps taken to minimize the effects (Mohan et al., 2013; E.
Munyisia et al., 2014; Walker et al., 2020).
Medication management
The majority of papers reporting the impact of EMRs on medication
management offered mixed findings and were often reported impartially
(Baysari et al., 2019; Bingham et al., 2021; Firman et al., 2021; McLain
et al., 2017). Several studies demonstrated a higher rate of pharmacist
review of medication orders in EMR systems than in paper systems (Baysari
et al., 2019; Firman et al., 2021; McLain et al., 2017; Westbrook et
al., 2019). However, few reported on whether this was a positive change
or a negative one. Baysari et al., (2019) reported this had negative
impacts on pharmacy staff wellbeing.
Medication management seems to be uniquely impacted by the transition to an
EMR, in that most studies report cannibalization of some tasks which
results in either no change in completion to perform tasks, or in several
instances, an increase in time required to perform medication management
activities (Baysari et al., 2019; Bingham et al., 2021; Westbrook et
al., 2019). This led to the suggestion that regular reviews of
workflow planning post-EMR rollout are crucial for a safer and more
streamlined transition from paper to digital systems (Baysari et al.,
2019).
EMRs can, however, support additional initiatives to improve medication
management: one study demonstrated improved antimicrobial stewardship
compliance using a modified add-on to an existing EMR (Devchand et al.,
2019).
Quality and safety
Patient outcomes.
Few shortlisted studies reported on patient outcomes and findings were
mixed. The most recent study in this review reported a clinically
significant, sustained 22% decrease in in-hospital mortality post-EMR
implementation and supports ongoing investment in these systems (South
et al., 2022).
However, an older study reported a statistically significant
deterioration in all ED KPIs (including ambulance offload times
>30 mins and total treatment time) (Mohan et al., 2013).
Mixed impacts on patient care were reported by Wynter and colleagues
(Wynter et al., 2021).
Patient satisfaction
Studies considering the patient satisfaction of care related to EMR
implementation were rare. One such study was conducted at a large urban
primary care sexual health Centre in 2013 by Fairley et al. and found
that patient satisfaction with their care was unchanged following EMR
implementation. Given the increasing emphasis on the consumer viewpoint
in healthcare transformation (Australian Commission on Safety and
Quality in Health Care, 2022), one would expect to see this perspective
being captured in future EMR research.
Medication safety
This scoping review identified EMRs almost eliminate certain types of
medication errors such as error-prone abbreviations (EPAs), omitted
doses, and errors related to clarity of prescriptions (McLain et al.,
2017; Qian et al., 2015; Van de Vreede et al., 2018). However, they
introduce other errors, such as incorrect patient selection and
incorrect dose scheduling resulting in dose duplication (Van de Vreede
et al., 2018).
Several authors state EMR design changes could help mitigate some of
these new errors by modifying drop-down lists, for example. The same
authors argued that electronic systems help identify errors easier than
paper-based systems, which can drive quality and safety improvement
projects (Qian et al., 2015; Van de Vreede et al., 2018).
McLain et al., (2017) highlighted national medication audit criteria
need to be adapted to electronic systems, as the current criteria were
designed for paper-based systems and fall short in areas assessing EMRs.
Since the publication of this research the Australian Commission on
Safety and Quality in Health Care (ACSQHC) has revised its audit
criteria, but are still not suitable for auditing EMRs (Australian
Commission on Safety and Quality in Health Care, 2018). The ACSQHC has,
however, published guidance on the display of on-screen medicines
information (Australian Commission on Safety and Quality in Health Care,
2017), and has also produced a comprehensive guide to the safe
implementation of EMRs (Australian Commission on Safety and Quality in
Health Care, 2019).
Reliability was compromised in some of these studies when mixed paper
and electronic medication systems were in use (Dabliz et al., 2021; Qian
et al., 2015).
Regulatory requirements
One study reported on EMRs as contributing to compliance with
Residential Aged Care Accreditation standards (Jiang et al., 2016).
However, the link between accreditation and patient safety and quality
of care has recently been contested (Duckett, 2018a).
Workforce factors
Workforce satisfaction
Different user groups reported different levels of satisfaction with
EMRs (Baysari et al., 2019; Dabliz et al., 2021; Lloyd, 2021; Schwarz et
al., 2020; Wynter et al., 2021).
Nurses generally had positive acceptance for EMRs (Dabliz et al., 2021;
Fairley et al., 2013; Lloyd, 2021; E. N. Munyisia et al., 2012; Van de
Vreede et al., 2018), whereas pharmacists and medical staff were more
likely to report issues with automation (Dabliz et al., 2021), safety
risks (Van de Vreede et al., 2018), and increased workload (Baysari et
al., 2019).
Baysari and colleagues (2019) discovered pharmacists are often the
cohort teaching other healthcare staff how to use the system and
reviewing additional information as part of a changed workload. This can
increase stress and anxiety in the pharmacy workforce (Baysari et
al., 2019).
This led to the recommendation that further research aimed at different
user groups is vital to target education and improve user experience
pathways (Dabliz et al., 2021; Lloyd, 2021).
Sample sizes were a common limitation in this topic (Baysari et al.,
2019; Lloyd, 2021; Schwarz et al., 2020; Wynter et al., 2021), as was a lack of generalizability due to system brand (Baysari et al., 2019;
Dabliz et al., 2021; Fairley et al., 2013).
Usability
Usability varies between user groups due to their workflows. Nurses and
medical professionals have different experiences with EMR usability,
which also depends on the area of work and which feature is measured.
This often hinders the generalizability of findings (Lloyd et al., 2021).
The greatest usability issues were related to protocol-mandated care,
whereby if a user wanted to order outside of an order set, for example,
this created difficulty (Dabliz et al., 2021).
Well-designed user interfaces can ‘…reduce the mental energy
required searching for important information and the time taken to
achieve this', (Dabliz et al., 2021) whereas poorly designed interfaces
were associated with increased levels of dissatisfaction and longer
times to perform tasks (E. N. Munyisia et al., 2012).
Both Lloyd et al., and Dabliz et al., (2021) advocate the need for
multidisciplinary usability studies to represent different user groups
and their associated environment.
Lloyd et al., (2021) promoted the use of the NuHISS tool to measure the usability of EMRs in the Australian context.
When an interface is less than optimal, all research in this area focused on the need for continuous improvement, utilizing lessons
learned, and support for staff (Dabliz et al., 2021; Lloyd et al., 2021;
E. N. Munyisia et al., 2012).
Limitations
The limitations of this study were that only English language papers
were included due to the assumption that Australian research would be
conducted and published in the English language. There is a very small
possibility that researchers have assessed EMR implementation in the
Australian context but have published in another language.
Grey literature, scoping, and systematic reviews were also excluded based
on constraints and compatibility with the quality checklist used,
meaning some industry data could have been missed.
Only a single researcher with a time constraint of 14 weeks was able to
perform this scoping review. Hence personal researcher bias cannot be
excluded from this study.
The MMAT checklist was used as a broad indicator of quality to
contribute to answering the research question. Grading literature is not
within the typical methodology of scoping reviews, so should be
interpreted with caution (PRISMA, 2021; Rethlefsen et al., 2021; Subbe
et al., 2021).
Conclusion
This is the first scoping review,
to the author’s knowledge, to systematically determine how EMR
implementation is evaluated in the Australian context. This is in
response to government reports exposing a current lack of evaluation
frameworks to assess EMRs, and the fact that EMRs are a relatively new
addition to the Australian healthcare system compared to other nations,
primarily occurring over the past decade (Duckett, 2018a; Jedwab et al.,
2019). Previous reviews have often either focused on a particular topic
(Subbe et al., 2021) or workforce group (Jedwab et al., 2019), and refer
to international data, which is often stated as a limitation and/or
knowledge gap in these studies.
This scoping review rigorously analyzed the literature and out of the 25
articles found, the themes that were most evident were in quality and
safety, and service delivery, though in recent years there has been an
increase in studies reporting on workforce factors (satisfaction and
usability). Workforce factors have been identified as important by
authors such as Lloyd et al (2021)and Dabliz et al (2021), since
different workforce groups are likely to report different outcomes.
Studies overall were mostly qualitative in nature, with only 16% being
mixed methods, and just over a third being quantitative. Only seven of
the 25 shortlisted articles were pre-post studies, reflecting the
difficulty in designing and implementing such studies.
To date, most health workforce groups have been evenly represented,
though there is limited research on how EMRs affect midwives and allied
health professionals.
The system in use was not consistently referenced in the literature. If
it was, the brand was most likely to be Cerner (Millennium). The
differing brands of EMRs were cited as common limitations in most
studies, restricting generalisability. Generalisability was also often
restricted due to the specialty and/or setting under scrutiny.
Healthcare is a complex system, with multiple disciplines and
workstreams. EMRs traverse all these systems, yet there is no consistent
framework to determine if EMRs present value for money, or indeed
improve patient care. An evaluative framework that incorporates one or
more validated tools such as the WOMBAT or STAMP for time and motion
studies, and NuHISS for user experience could be a recommendation.
This review solidifies the following benefits of EMRs:
- They provide a huge advantage regarding legibility and ease of access
to patient records. This can reduce errors associated with paper
records, including poor readability and abbreviation-prone errors.
- EMRs have been shown to generally improve the efficiency of multiple
workflows, except for pharmacists.
- Most worker dissatisfaction with EMRs was related to change management
and the EMR interface, though this varied across disciplines.
Research gaps include lack of patient viewpoint, non-medication-related
patient safety outcomes (e.g. mortality rate, improvements in clinical
outcomes), and how usability and EMR design impacts patient outcomes.
This review demonstrates the need to address the above research gaps, and
to ultimately design uniform and validated outcome measures and
frameworks to drive consistency across EMR evaluations. This will ensure
benefits are tracked, realized, and maintained. Overall, the articles in
this scoping review provide evidence to support the continued rollout of
EMR systems across Australia, and have even drawn parallels with
international findings (Lloyd, 2021; Westbrook et al., 2019). This
indicates Australian policymakers could rely on international evidence,
as well as that conducted in Australia. Whether the current selection of
evidence is sufficient to guide policy or digital strategy in Australian
healthcare remains to be seen.
Future research
Future research could be to use the same thematic analysis applied to
global literature (for example, the U.S & Canada), and compare with
findings of this study to determine if outcomes and themes are the same.
This would permit the scientific community to apply with more certainty
non-Australian research to Australian healthcare settings, and would
also allow researchers to determine the proportion of Australian
evidence in relation to the worldwide evidence base.
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https://doi.org/10.2196/30564Appendices
Appendix 1: List of search term
combinations
Between each keyword the “AND” Boolean operator was used. For
example, the first line search term entered into the search engine would
be EMR AND Evaluat* AND Australia*. Similarly, the fifth line would read
EMR AND “outcome measure” AND Australia*.