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:
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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Appendices

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*.