Electronic Health Records' Support for Primary Care Physicians' Situation Awareness: A Metanarrative Review

Abstract

Objective: Situation awareness (SA) refers to people's perception and understanding of their dynamic environment. In primary care, reduced SA among physicians increases errors in clinical decision-making and, correspondingly, patients' risk of experiencing adverse outcomes. Our objective was to understand the extent to which electronic health records (EHRs) support primary care physicians (PCPs)' SA during clinical decision-making.

Method: We conducted a metanarrative review of papers in selected academic databases, including CINAHL and MEDLINE. Eligible studies included original peer-reviewed research published between January 2012 and August 2020 on PCP-EHR interactions. We iteratively queried, screened, and summarized literature focused on EHRs supporting PCPs' clinical decision-making and care management for adults. Then, we mapped findings to an established SA framework to classify external factors (individual, task, and system) affecting PCPs' levels of SA (1-Perception, 2-Comprehension, and 3-Projection) and identified SA barriers.

Results: From 1504 articles identified, we included and synthesized 19 studies. Study designs were largely noninterventional. Studies described EHR workflow misalignments, usability issues, and communication challenges. EHR information, including lab results and care plans, was characterized as incomplete, untimely, or irrelevant. Unmet information needs made it difficult for PCPs to obtain even basic SA, Level 1 SA. Prevalent barriers to PCPs developing SA with EHRs were errant mental models, attentional tunneling, and data overload.

Conclusion: Based on our review, EHRs do not support the development of higher levels of SA among PCPs. Review findings suggest SA-oriented design processes for health information technology could improve PCPs' SA, satisfaction, and decision-making.

Keywords: cognition; decision-making; electronic health record; primary care; safety; situation awareness.

Figure 1

Adaptation of SA framework (Singh et al., 2012; Wright et al., 2004) that guided mapping of findings. SA = situation awareness.

Figure 2

Document flow. * Criteria listed in methods section.

Figure 3

Summary of mapping to SA framework. This figure illustrates the synthesis of literature findings mapped to the components of the SA framework. SA barriers related to individual, task, and system factors are depicted with dashed-line barricades near the respective factors. SA = situation awareness.

Figure A1

Adapted metanarrative review (Greenhalgh et al., 2005; Wong et al., 2013) with synthesis using SA framework (Endsley, 1995). To explore the literature and synthesize the data from existing scholarly work, we conducted a metanarrative review of recent academic literature and applied the situation awareness framework to organize our findings. Our review concerned information-seeking activity at the point of care (i.e., between encounters), excluding higher-order patient data (e.g., at the clinic and population level). The focus of our review was not on grading the evidence, but rather on identifying research arcs. Our approach accepted both quantitative and qualitative methods, and it facilitated investigating both the processes and impacts of interventions (Pawson et al., 2005).