Adopting electronic medical records in primary care: Lessons learned from health information systems implementation experience in seven countries

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Abstract

The adoption of health information systems is seen world wide as one method to mitigate the widening health care demand and supply gap. The purpose of this review was to identify the current state of knowledge about health information systems adoption in primary care. The goal was to understand factors and influencers affecting implementation outcomes from previous health information systems implementations experiences. A comprehensive systematic literature review of peer reviewed and grey literature was undertaken to identify the current state of knowledge regarding the implementation of health information systems. A total of 6 databases, 27 journal websites, 20 websites from grey sources, 9 websites from medical colleges and professional associations as well as 22 government/commission websites were searched. The searches returned almost 3700 article titles. Eighty-six articles met our inclusion and exclusion criteria.

Articles show that systems’ graphical user interface design quality, feature functionality, project management, procurement and users’ previous experience affect implementation outcomes. Implementers had concerns about factors such as privacy, patient safety, provider/patient relations, staff anxiety, time factors, quality of care, finances, efficiency, and liability. The review showed that implementers can insulate the project from such concerns by establishing strong leadership, using project management techniques, establishing standards and training their staff to ensure such risks do not compromise implementation success. The review revealed the concept of socio-technical factors, or “fit” factors, that complicate health information systems deployment. The socio-technical perspective considers how the technical features of a health information system interact with the social features of a health care work environment.

The review showed that quality of care, patient safety and provider/patient relations were not, positively or negatively, affected by systems implementation. The fact that no articles were found reviewing the benefits or drawbacks of health information systems accruing to patients should be concern to adopters, payers and jurisdictions. No studies were found that compared how provider–patient interactions in interviews are effected when providers used electronic health information systems as opposed to the paper equivalent. Very little information was available about privacy and liability.

Introduction

In many countries, the health care sector is entering into a time of unprecedented change [1]. Never before have there been such strong demographic trends between health care demand and supply. Canada is no exception. By 2041, 22% of the Canadian population is expected to be aged 65 or over, up from 13% in 2001 [2]. The number of aged is growing and their care needs will progressively become more intense. But soaring health care demand is not just driven by age. Many drivers exist, including obesity which is on the rise in both children and adults [3]. Obesity brings its own health complications which are managed in primary care. These examples stem from chronic disease management in primary care, but are only indicators of similar trends in demand found in other forms of disease management.

Just as there are a large number of patients in the baby-boom generation, there are also a proportionately large number of physicians. These physicians are also increasingly heading towards retirement. In 2004, 30% of physicians working in Canada were 55 years of age or older, and 61% were 45 years of age or older [4]. Declines in the physician work force were evident early in the millennium when provinces saw an average 3.1% drop in physician resources [5]. Canada's health workforce is retiring earlier and the average age of the remaining working population is increasing (from 39.1 years in 1994 to 40.8 in 2000) [6].

The gap between health human resource supply and demand for care will not be temporary. Not only is the baby-boom generation of primary care physicians retiring alongside their patients, but a shortfall in replacements is expected in the next decades. A shortfall in medical school enrolments is expected because of increased training requirements, higher average tuition fees [7], and increasing certification requirements due to more health professions being regulated (now over 30 professions) [6]. Of those entering into medical schools, fewer are choosing primary care as their area of speciality. Even though there are many sub-specialties within family practice, family practice students have only occupied half of the available spaces, whereas in other areas of medicine, the number of students wanting to enrol is double the available space [6]. Primary care physicians are remunerated less [8] and are faced with developing and sustaining a business to make a living, which they are not trained to do. Comparatively, specialists are paid a salary by the jurisdiction or health region to show up for work in a ready-made job context [9]. Geriatric primary care physicians are expected to be even fewer because of the extraordinary professional challenge that caring for the elderly, often with complex needs, represents. Finally, there is also a shift in the demographics of care providers. More women than men have been choosing health care as their profession. In 1999, 76% of health care students in Canada were female, and these graduates have now become today's providers. Female carers are more likely to take time off for family and are less likely to work overtime; many work part-time [6].

The adoption of health information systems is seen world wide as one method to mitigate the widening health care demand and supply gap [10], [11]. The adoption rates of electronic medical records are on the rise [12]. Even though popular opinion holds that the application of health informatics improves patient safety [11], [13], improves physician office efficiency [11], [13], and mitigates shortages in health human resources [13], such systems can compromise short-term physician office performance [14], [15], [16], intimidate physicians and their office staff [9] and have been shown, on occasion, to increase medical errors [17], [18]. Previous analyses [19] have shown that the implementation process is as important as the system itself. With particular shortages of clinicians expected in primary care in the future, it becomes imperative to understand the barriers to implementation success, so that adopters can be more successful.

The objective of this research was to undertake a systematic review of the literature from several countries to identify the current state of knowledge about health information systems adoption. The goal was to understand factors and influencers from previous experiences of health information systems implementations and to respond to the question: “What lessons can adopters of Electronic Medical Records in general practice learn from previous implementation experiences?” A structured literature review of peer reviewed and grey literature published during the period 2000 to the end of 2007 from Canada, the United States, Denmark, Sweden, Australia, New Zealand and the United Kingdom was conducted from November 2007 to January 2008 to identify the current state of knowledge regarding implementations of health information systems. These countries were selected based on their reputations as leaders in health care reform and adoption of health information systems.

The term “general practice” was considered to refer to the same care setting as the term “primary care”. Primary care is defined as the first point of contact a person has with the health system and usually refers to family practice. This is the point where people receive care for most of their everyday health needs [20]. While our objective was to extract lessons learned for adopters in primary care, we examined implementation experience from other care domains to see if experienced would vary by care domain. We defined ambulatory care as any form of care delivered on an outpatient basis, including care delivered from physician offices, emergency departments and urgent care centres. We considered acute care as care delivered for severe illness, often, but not exclusively, from hospital settings. We considered community care to be primary care provided in non-hospital settings. Secondary care, tertiary care and specialty care were considered to be similar concepts where care was provided to patients who were referred from primary care.

An Electronic Medical Record (EMR) is a computerized health information system where providers record detailed encounter information such as patient demographics, encounter summaries, medical history, allergies, intolerances, and lab test histories. Some may support order entry, results management and decision support [21]. Some may also contain features or be integrated with software that can schedule appointments, perform billing tasks, and generate reports [22]. Providers use this system to record encounter, medical or physician-specific information [23]. Such systems are configured to reflect the needs of individual physicians or groups of physicians who are directly caring for a patient in their practice. An EMR is a provider oriented health information system. Such systems are sometimes referred to as physician office systems or practice management systems [21], [24].

It is appropriate to clarify the difference between EMRs and Electronic Health Records (EHRs), at least for the purposes of this review. While in some jurisdictions, the concept of an EHR refers to those described above for EMRs [13], [25], for purposes of this review, an EHR is a patient-oriented, aggregated, longitudinal [26] system of systems which assembles health information about a patient over a wide area network from, potentially, many geographically dispersed data sources. An EHR provides each individual with a aggregate, secure and private lifetime record of their key health history and care within the health system and shares encounter information available electronically with authorized health care providers and the individual anywhere, anytime in support of high quality care [27]. It may draw on health information from sources such as EMRs, drug repositories, centralized lab data sources and other point-of-service applications over many encounters to assemble a complete health record about the patient [27], [28]. It is a patient centric document that may contain information from a broad range of providers other than family physicians, such as specialists, social workers, pharmacists, radiologists, dietitians, physiotherapists, and nurses.

Section snippets

Methodology

Peer reviewed articles were searched using search strings on CINAHL, MEDLINE, PUBMED, EMBASE, The Cochrane Library, and IEEE Xplore. The search was conducted in both MEDLINE and PUBMED because PUBMED contains citations before they are indexed with MeSH and added to MEDLINE [29]. Health informatics and general practice journals were searched for articles not yet indexed in the databases. Databases were subsequently searched by author to find any other articles that were not found through the

Results

A total of 6 databases, 27 journal websites, 20 websites from grey sources, 9 websites from medical colleges and professional associations as well as 22 government/commissions websites were searched. The searches returned almost 3700 article titles. Applying inclusion and exclusion criteria systematically produced 466 articles whose abstracts were to be reviewed. Screening the articles by abstract reduced the data store to 242 articles to be read. After reading the articles, 86 unique articles

Discussion

This literature review was a comprehensive systematic search of several sources to understand factors which affect implementations of health information systems in general practice. Fig. 1 illustrates several factors which affect the goal of implementation success. Fig. 1 shows the “fit factor” or “socio-technical factor” directly adjacent to the project goal as the review found it can directly influence implementation success. Implementers also had concerns over privacy, patient safety,

Strengths & weaknesses

This literature review has examined the last 8 years of health information systems implementation literature in seven countries. While the study has yielded a number of key factors that are relevant to adopters, governments, payers and vendors, the study may have missed relevant articles published prior to 2000 or after 2007.

This literature search was carried out by one reviewer (one of the authors), and this may have introduced bias into the search process because only that person's background

Conclusions

Health system stakeholders cannot expect our health care system's performance to meet the increasing demand placed on it, unless interventions are taken. Populations are aging which increases the intensity and diversity of care demand. But soaring health care demand is not just driven by age. More people are obese than before [3]. Obesity brings many complicating health risks [102] such as cardiovascular diseases, diabetes, arthritis, sleep and breathing disorders, depression, and cancer all of

Acknowledgement

The author thanks Dr. Nicola Shaw, Research Chair, Health Informatics, University of Alberta for her guidance and support.

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