The Impact of Electronic Health Record Interoperability on Safety and Quality of Care in High-Income Countries: Systematic Review

Abstract

Background: Electronic health records (EHRs) and poor system interoperability are well-known issues in the use of health information technologies in most high-income countries worldwide. Despite the abundance of literature exploring their relationship, their practical implications on patient safety and quality of care remain unclear.

Objective: This study aimed to examine how EHR interoperability affects patient safety, or other dimensions of care quality, in high-income health care settings.

Methods: A systematic search was conducted using 4 web-based medical journal repositories and grey literature sources. The publications included were published in English between 2010 and 2022, pertaining to EHR use, interoperability, and patient safety or care quality in high-income settings. Screening was completed by 3 researchers in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Risk of bias assessments were performed using the Risk of Bias in Non-randomized Studies of Interventions and the Cochrane Risk of Bias 2 tools. The findings were presented as a narrative synthesis and mapped based on the Institute of Medicine's framework for health care quality.

Results: A total of 12 studies met the inclusion criteria to be included in our review. The findings were categorized into 6 common outcome measure categories: patient safety events, medication safety, data accuracy and errors, care effectiveness, productivity, and cost savings. EHR interoperability positively influenced medication safety, reduced patient safety events, and reduced costs. Improvements in time saving and clinical workflow are mixed. However, true measures of effect are difficult to determine with certainty because of the heterogeneity in the outcome measures used and notable variation in study quality.

Conclusions: The benefits of EHR interoperability on the quality and safety of care remain unclear and reflect extensive heterogeneity in the interventions, designs, and outcome measures used. The establishment of common health information technology research outcome measures would support higher-quality research on the topic. Future research efforts should focus on both the positive and negative impacts of interoperable EHR interventions and explore patient perspectives, given the growing trend for patient involvement and stewardship over their own electronic clinical data.

Trial registration: PROSPERO CRD42020209285; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=209285.

International registered report identifier (irrid): RR2-10.1136/bmjopen-2020-044941.

Keywords: digital health; electronic health records; health information exchange; interoperability; patient safety; systematic literature review.

Figure 1

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) systematic review search strategy and screening process flow diagram. Search terms appear as used in Li et al [25].

Figure 2

Risk of Bias in Non-Randomized Studies—of Interventions traffic lights plot for domain-level risk of bias judgments for nonrandomized studies.

Figure 3

Risk of Bias in Non-Randomized Studies—of Interventions summary plot of biases present in nonrandomized studies included in the review [31-42].

Figure 4

Risk of Bias 2 traffic lights plot for domain-level risk of bias judgments in randomized studies.