Implementing Electronic Health Records in Hospitals a Systematic Literature Review

1 Introduction

It has considerably consented that the usage of information technology (It) in healthcare offers inclusive potentiality for improving the excellence, efficacy, and competence of the provided services, too every bit personnel, meanwhile reduces the organizational overheads.^[1,two] Electronic medical record (EMR) is considered as the incorporation of several information tools (e.g., examination ordering, electronic prescription, decision support system, digital imagery, and telemedicine) would improve clinical conclusion-making. However, using such evidence in everyday clinical practice might abet a secure and effective healthcare system.^[3] Previous studies confirmed several benefits of EMR,^[4] and one of the main benefits stated, is to improve quality of care ensuring the admission of patients' vital health information from dissimilar providers, that considerably improves the coordination of care,^[five] and the efficiency of healthcare practice.^[6]

Regardless of the several advantages mentioned above, the previous studies also reported that the overall adoption rate of EMR is comparatively low.^[6,7] Sines and Griffin^[8] explored that several prior clinical organisation implementations had failed due to a lack of the physicians' adoption. As physicians are the meaning user-group of patients' care, their intention to adopt EMR determines the overall success of its implementation. Yet the previous study revealed that physicians would non exist interested in using a system that interferes with their workflow and modifies the mode they care for patients.^[7] Therefore, identifying barriers affecting physicians' intention to adopt EMR is believed to be one of the critical elements in confirming its optimal integration and ultimately measure the benefits inside the healthcare organisation. Thus, the aim of the nowadays report is to explore and evaluate the potential barriers perceived by physicians regarding the adoption of EMR. We are positive that the critical factors, which have been recognized past the current review, can potentially help the implementers to develop relevant policies and regulations regarding EMR adoption by physicians more conspicuously in the future.

2 Methods

two.1 Search strategy and key terms

Five databases, including PubMed, Spider web of Science, Scopus, The Cochrane Library, and ProQuest, were used to obtain the articles for the present review. Keywords such as "physician," "doctor," "electronic health record" (EHR), "electronic medical tape," "credence," "adoption," "bulwark," and "factor" were employed in different combinations in Boolean AND/OR to search paper.

two.ii Eligibility criteria

Studies explored based on the above strategies had to farther run across the following eligibility criteria to be incorporated in the present review: must exist written in English and published between 2014 and 2018; be focused only on EMR/EHR usage, not included studies regarding other health information arrangement (HIS); imitate original inquiry work published in the peer-reviewed journal, thus studies exhibited in the dissertation, conference, and proceeding were not eligible; accessible from scientific databases enabling both open access and subscription services.

2.3 Included studies

By using the differing database search strategies, 1354 potential papers were identified. After the initial screening, 95 papers were eliminated because of their resemblance. Out of the remaining 1259 papers, 1191 were excluded every bit they did non come across the selection criteria (the title, abstruse, and keywords). Of the remaining 68 papers, 42 were eliminated later reviewing study context, design, and literature review, hence a lack of significant contribution. Thus, 26 papers that met the inclusion criteria were selected for the concluding analysis. Figure i reports the extensive option process, and Table 1  reports all the potential papers, also as the potential barriers explored by authors.

Figure i:

The pick process of the studies included in the nowadays systematic review. → represents the side by side footstep. Identification: In this step, authors started to search the 5 databases to identify the relevant manufactures for the nowadays written report. Screening: In this stride, the authors screened the initially obtained studies by title, abstract, and keywords, focusing on reasons to exclude the studies. Eligibility: In this step, the authors considered the criteria that were employed to select articles for the present report based on the research objectives. Included: In this step, authors finally selected the articles, used for the present study, based on the research objectives.

Tabular array one:

Analysis of studies included in this review.

Table 1 (Connected):

Analysis of studies included in this review.

ii.4 Ethical consent

Ethical consent was not called for the nowadays review as no homo participants are involved in the nowadays report. The present study reviews and explores the barriers in previously published papers regarding physicians' intention to adopt the EMR organization based on the predetermined objectives of the present written report.

3 Results

3.1 Principle findings

By applying different search strategies, a total of 25 barriers were identified, and these 25 barriers appeared 112 times in total. The comprehensive listing of the total number of barriers, their sources, and the frequencies of these barriers appeared in the review are reported in Table 2.

Table 2:

Frequency of barriers.

From Figure 2, we can find that "Privacy and security concerns" is reported as the primal barrier to the implementation of EMR appeared xv.2% of all incidents (17/112).^{[1,five–12,xiv,16–18,20,22,24,26]} High start-upwards price emerged fourteen.3% of all incidents (sixteen/112)^{[1–four,vii,eight,13–17,19,21–23,26]} and workflow changes emerged 8.04% of all occurrences (ix/112)^{[1,two,v,10,11,17,19,23,24]} stood 2nd and 3rd, respectively. System complexity emerged in 6.3% of all occurrences (7/112)^{[1,8,10–12,fifteen,18]} and lack of reliability^{[1,4,5,18,19,21]} and interoperability^{[5,7,9,15–17]} each appeared 5.4% of all occurrences (6/112) stood 4th and 5th, respectively. Lack of customizability,^{[4,9,13,16,25]} lack of usefulness,^{[four,ten,12,sixteen,26]} time consuming,^{[4,8,16,18,26]} and loftier maintaining toll^{[ii,19,21–23]} each appeared 4.five% of all incidents (5/112). Lack of incentives,^{[1,5,sixteen,17]} organizational culture modify,^{[one,ix,sixteen,23]} and lack of standard,^[4,12,22,26] emerged 3.6% of all occurrences (iv/112).

Figure 2:

The total number of potential barriers and the total number of times these barriers appear in the nowadays review. How many times each barrier appears are represented vertically. The horizontal line states the total number of barriers.

3.2 The main barriers and inquiry utilization

Based on the findings of the present report, the top five barriers are equally follows: "privacy and security concerns," "high showtime-up cost," "workflow changes," "arrangement complexity," "lack of reliability," and "interoperability" (Table 2). It is interesting to keep in mind that even if the studies were conducted in 5 years and different geographic settings, non many differences in the type of mentioned barriers are evident. "Privacy and security concerns" is stated around 65% of all included studies (17/26), which brand it the central and top of the list of all barriers. Although every study mostly focused on the principle barriers, in some studies, barriers such as "lack of computer skills," "reduced productivity," "lack of technical training and support," "implementation issues," "doubt over the return of investment," "lack of hardware/software," "incertitude about the vendor," "legal complications," "lack of support from external parties," "perceived mobility," "limitation of system," and "interconnectivity" appeared 3 or fewer times, categorized as a secondary barrier.

3.three Demographic data

On the per-country basis, most of the studies, xi papers, conducted in the United States, represent more than than one-half. The balance of the studies mainly were conducted in Asia (Taiwan, Malaysia, Hong Kong, Korea, Jordan, and Saudi Arabia) and Africa (Republic of kenya, Sub-Saharan Africa). In terms of age of respondents, 5 out of 26 papers^{[half-dozen,xiii,15,18,25]} indicate that 30 to 45 years old is the prime age group of physicians intended to adopt EMR. Regarding the gender result, half-dozen out of 26 papers^{[i,6,15,eighteen,xx,25]} explore this issue. Gender differences denote both psychologic and concrete differences between male and female physicians regarding their intention to adopt EMR. The finding of the nowadays report indicates that male physicians are more interested in adopting EMR than their female counterparts, and male physicians consider that EMR could improve their performance by cutting downwardly medical errors and the time required for treatment. On the specialty issue, 5 out of 26 papers^{[fifteen,eighteen,20,23,25]} report that physician'south intention to adopt EMR differs among different medical specialties. Literature indicated that the different specialties have different requirements in terms of patients' intendance, information drove, and clinical documentation methodologies together with, differences in standard clinical work, invoicing, compliance necessities, and specialty-specific terminology. The findings of the present study indicate that some specialties, such as internal medicine, and surgery are in favor of adopting EMR than other specialties. The 4 out of 26^{[one,half dozen,xv,18]} papers indicate that physicians' maturity regarding professional person efficiency (ten–12 years) influences physicians' intention to prefer EMR.

4 Discussion

The present review found that the privacy and security concerns bulwark seems to employ a considerable agin affect on physicians' intention to adopt EMR.^{[1,5,6–12,fourteen,16–eighteen]} Physicians are indeterminate whether EMR is trustworthy to store patient's data every bit the unauthorized access of the stored data could exist possible, which leads them to legal issues besides losing patient's trust. Even most of the physicians using EMR believe that storing patient's information in EMR is riskier than newspaper records in terms of security and confidentiality. In that location is a clear indication of the extent to which physicians perceived definitive policies associated with the design and implementation of the EMR arrangement. Jawhari et al^[5] emphasized that bereft policy and legislation could play a vital role regarding the physicians' perceived intention to adopt EMR and indirectly influences the overall success of EMR implementation. Thus, physicians consider that regime should come out with a comprehensive security and privacy standard regarding the storage of medical information and strictly instructs parties involved in the implementation of EMR such as vendors, and healthcare providers, to follow the regulations while implementing the EMR system, that could ease the physicians' concerns and likewise improve their trust in the EMR arrangement.

Lack of interoperability, restricting physicians' adequacy to exchange electronic data between other general practices or with HIS they use, is likewise considered 1 of the other primary barriers.^{[7,9,15–17]} Meigs and Solomon^[15] explored that providers have stated their dissatisfaction with the lack of interoperability instituted by government agencies, which allows the dormant nature of EMR evolution at the vendor, and significantly restricts the specialty regarding systems development. However, interoperability is essential as it reduces the toll of EMR, improves diffusion and evaluation of advanced medical cognition amid physicians, and makes the EMR system achievable for an individual or small-scale grouping of physicians.

Financial barriers were the critical arrangement-level measurement determining dr.'south adoption of EMR, from the high commencement-up to the maintaining price: a business emphasized in previous studies.^{[1–4,seven,viii,nine,xiii–17,21–23]} According to the study findings of Adler-Milstein et al^[21] physicians who are working in the hospital are more likely to use and prefer EMR than those who practice privately. Physicians practice in individual is nearly preferably to mention high beginning-upward and ongoing cost as the vital barriers to EMR adoption. Sixteen out of 26 papers reported that high starting time-up costs are one of the chief and critical barriers to physicians adopting EMR, simply only 5 articles associated "high maintenance price" to the adoption of EMR.^[19,21–23] Thus boosted qualitative researches would exist needed to determine the influence of high maintenance cost with other potential barriers regarding medico's intention to adopt EMR.

Implementation of EMR changes the unique way of patient care, which is developed by physicians over the years, and is itself a critical concern. As the change in patient care not only goes along with a switch from the newspaper records to the EMR organization, as well leads to alter in organizational aspects. Or et al^[1] explored difficulties that arise during the workflow alter process, for example, lack of incentives, modify of organizational civilization, issues regarding implementation, creating a barrier to meliorate the quality of intendance. Thus, an EMR friendly culture could support organization-broad utilise of EMR and meliorate the potential of successful implementation of EMR.

Currently, most of the EMR systems tended to exist "ane-size-fits-all" with features and tabs that may be practicable for some specialties only not others. Currently used EMR organisation adapted overall recommendations advocated by dissimilar specialties to fulfill the requirements of all specialties. Thus, EMR arrangement developers must advisedly look into the trouble regarding the lack of specialty related functions as different specialties take different requirements. However, EMR developers have recently developed specialty-specific EMR systems. Though, it is still non clear what kind of effects this specialty-specific plan will have on the implementation of the EMR system before long.

Customizability states the adequacy to exist adapted to the system that breaks down to comply with the definitive requirement of the user applications.^[9] Several studies explored that physicians are unwilling to adopt EMR as they observe the organisation cannot meet their specific needs.^{[iv,9,13,sixteen,25]} Thus it appears that more try is needed from the implementers and healthcare providers of EMR to improve EMR customizability, which in other ways, can meliorate physicians' intention to adopt EMR.

Literature has provided evidence that the implementation of EMR can better the quality of medical intendance, merely a lack of financial incentives is regarded every bit a critical bulwark to physicians adopting EMR. Though, despite physicians find some personal benefit from practicing EMR, they could not be interested in adopting information technology and will stick to their traditional patient intendance process. Hwang et al^[27] and Vishwanath and Scamurra^[28] explored that though physicians perceive some personal incentives during the implementation of EMR, the implementation of EMR will non reach the predicted level. Remarkably, the incentives measured in the literature were mainly financial ones. Still, this finding is not consistent^[ten] as several studies explored the inconclusive effect of financial incentives on EMR adoption.^[ane,7,9] Thus, farther investigation is required regarding the effect of financial incentives on physicians' intention to adopt EMR.

Several studies explored that doctor's lack of technical cognition and skills to cope with EMR every bit one of the vital barriers for adopting EMR.^[1,7,12] Alqahtani et al^[12] stated that EMR utilise introduces a new kind of medical errors: typos. Additionally, it is non just a trouble for physicians but also for other medical staff, who accept insufficient computer skills. This general lack of skills obstructs the comprehensive adoption of EMR. Thus, implementers should create the proper environs to support the physicians to come out with this problem, which could be efficient in both ways: information technology could improve physicians' technical ability and intention to adopt EMR.

The fourth dimension required to enter the patient's record is another critical complication for physicians as they are more comfortable with the summaries, handwritten notes, histories, and then on.^[18] Mahalli^[xviii] indicated that data entry was both burdensome and time-consuming for physicians equally decent typing skills are required to enter patient medical data, notes, and prescriptions into the EMR organisation, and several physicians are not comfortable with doing it. Thus, physicians generally demand a long time to enter the patient's record, which restricts them to stop the consultation in the middle and interrupts the flow of the patient's intendance. For this reason, time consumed to enter the patient'southward tape becomes a commonly experienced problem amid physicians. This barrier may also exist associated with the complexity of the EMR system, lack of technical preparation and support, equally well as the time required to acquire a new arrangement. As the time of physicians is limited and they are unable to spend time to exist familiar with the EMR organisation, thus the organization must organize the proper training for physicians and inspire them to spend fourth dimension with the EMR system to be intimate, which in other ways, develops physicians' intention to adopt the EMR organisation.

Previous studies concluded that the implementation of EMR changes and slows down physicians' workflow, as physicians needed boosted fourth dimension to learn the organization, which in other ways, degrade their productivity and increment their workload.^[6,11,xv] This condition may bring financial losses, such every bit a loss of revenue. Thus, implementers must come up up with policies such equally financial exemption in instance of adopting EMR, etc, to fulfill their initial losses and encourage physicians to adopt EMR for long-term betterment in their medical do likewise as for their improvement in terms of finance and acquirement.

Previous studies indicated that a lack of technical support from vendors is being considered as a vital barrier to the adoption of EMR past physicians. And then, the eminence of vendors is vital for the adoption of EMR as it is still relatively new in the market.^[11] Physicians are concerned that vendors may non be capable of providing proper technical assistants, or may run out of business and disappear from the marketplace, causing a not bad loss of technical back up and finance also.^[one,eleven] That is 1 of the many reasons physicians are reluctant to spend loftier costs for implementing the EMR organisation without the confidence in trustworthy and highly regarded vendors.

four.one Contributions and limitations

The present review also contributes to theory and do in multiple ways. Firstly, implementers should consider the findings of the present review as a synopsis of concerning barriers perceived by physicians to the adoption of EMR while implementing policies and incentive programs for physicians. Secondly, both start-up and maintaining costs are crucial barriers that may particularly influence physicians practicing in small and rural settings or in private. Thus, the government should come up upward with definitive policies, which could meliorate their intention to adopt EMR. Thirdly, in addition to practical implications, the present written report also contributed to previous literature and provide additional evidence that the about common barriers circumduct around security and privacy concerns, cost bug, technical concerns, and ways to change medical practice. Fourthly, policymakers should consider ways how to lessen the disparities among physicians, peculiarly in terms of financial rewards and the context of the working surroundings, which alternatively can better physicians' intention to adopt the EMR system.

Autonomously from the noteworthy results, the present review and analysis have some limitations. Firstly, fifty-fifty though we were extremely cautious in developing our search strategy, given that employing EMR adoption of the physician in the healthcare sector is a comprehensive area, we could not assure that we do not skip any significant outcomes. Secondly, the present study is exclusively based on a literature review. All the incorporated studies have had different objectives and employed different approaches and interpretations coming to their inferences that do non inevitably concord with the present study.

5 Decision

Despite the significant outcomes of using EMR in patients' care, the adoption rate of EMR is nonetheless low. In the present report, based on a systematic literature review of 26 manufactures, the potential barriers backside the comparatively low adoption rate of EMR by physicians are being identified. Among these barriers, the pinnacle 5 barriers perceived by physicians to the adoption of EMR are privacy and security concerns, high commencement-up cost, workflow changes, system complexity, lack of reliability, and interoperability.

The results of the present review could be considered as a synopsis of barriers that physicians might potentially perceive in the EMR implementation process and, per se, could be significant for policymakers and healthcare providers. The review recommends that policymakers should be more responsive to the fact that eliminating technical barriers, such as arrangement complexity, and financial barriers such every bit high start-upwardly cost, and lack of incentive, is not enough to ensure the success of the potential implementation of EMR. The resistance to change is one of the basic characteristics of human being behavior. Thus, the changes in the unique style of patient care developed by the physicians, due to the implementation of the EMR system also need to exist addressed.

Furthermore, the implementation of the EMR system is a critical revolution that is perceived all through medical practise; it appeals to corresponding modifications and comeback in other aspects, for case, to the structure and approach of the patient. Thus, implementers should likewise consider a multifariousness of other measures, such as lack of standard, uncertainty over vendors, implementation problems, etc, might also influence physicians' intention to adopt the EMR system, and they should have corrective measures to eliminate these barriers too.

Author contributions

Bireswar Dutta: Prepare study pattern, Literature review, final draft, and deport the Statistics. Hsin-Ginn Hwang: Cheque Literature review, and final draft.

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Keywords:

adoption; barriers; electronic medical record; physicians; review

Copyright © 2020 the Author(south). Published by Wolters Kluwer Health, Inc.

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