Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method

Abstract

Context: The extensive research literature on electronic patient records (EPRs) presents challenges to systematic reviewers because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches.

Methods: Using the meta-narrative method and searching beyond the Medline-indexed literature, this review used "conflicting" findings to address higher-order questions about how researchers had differently conceptualized and studied the EPR and its implementation.

Findings: Twenty-four previous systematic reviews and ninety-four further primary studies were considered. Key tensions in the literature centered on (1) the EPR ("container" or "itinerary"); (2) the EPR user ("information-processer" or "member of socio-technical network"); (3) organizational context ("the setting within which the EPR is implemented" or "the EPR-in-use"); (4) clinical work ("decision making" or "situated practice"); (5) the process of change ("the logic of determinism" or "the logic of opposition"); (6) implementation success ("objectively defined" or "socially negotiated"); and (7) complexity and scale ("the bigger the better" or "small is beautiful").

Conclusions: The findings suggest that EPR use will always require human input to recontextualize knowledge; that even though secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper may offer a unique degree of ecological flexibility; and that smaller EPR systems may sometimes be more efficient and effective than larger ones. We suggest an agenda for further research.

Figure 1

Summary of Phases in the Meta-narrative Review. Note: See glossary for definitions.

Figure 2

Some Historical Roots and Research Traditions in EPR Research. Note: The historical roots on the left-hand side of the diagram do not link in a simple, linear way with the meta-narratives on the right-hand side. Different meta-narratives are drawn eclectically and in different ways on all these roots.