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Table 2 Summary of micro, meso and macro level factors influencing PCP attitudes to EMR adoption

From: Primary care physicians’ attitudes to the adoption of electronic medical records: a systematic review and evidence synthesis using the clinical adoption framework

Study

Designa (Country)

Micro level

Meso level

Macro level

Quality

Use and user satisfaction

Net benefits

People

Organization

Implement-ation

Healthcare standards

Funding and incentives

Legislation/policy/governance

Societal/political/economic trends

Aaronson et al. (2001) [33]

SQ (USA)

NR

NR

NR

Neutral: Prior computer experience.

NR

Positive: Training length.

NR

NR

NR

NR

Alasmary et al. (2014) [61]

SQ + QI (Sauda Arabia)

NR

NR

Positive: Improved clinical productivity.

Positive: Computer literacy.

NR

NR

NR

NR

NR

NR

Christensen & Grimsmo (2008) [48]

FG + SQ (Norway)

Negative: Time-consuming navigation; Lack of accessible patient reports.

Negative: Impact on clinician-patient relationship.

Positive: Time-saving e.g. automated prescription renewal/key administrative and clinical information.

NR

Negative: Shifted administrative workload from health secretaries to PCPs.

NR

NR

NR

NR

NR

De Lusignan et al. (2003) [49]

QI (UK)

Negative: Challenging to locate appropriate Read Codes. Positive: Templates/lists of key codes helpful.

Negative: Challenging to record emerging diagnoses/vague symptoms; Risk of stigmatising patients.

Positive: Supported audit and feedback to demonstrate quality of care.

NR

NR

NR

NR

Positive: Financial support.

NR

NR

Desroches et al. (2013) [34]

SQ (USA)

Negative: Difficult to generate specific lists of patients.

Positive: Existing experience/meaningful EMR use.

NR

NR

NR

NR

NR

NR

NR

NR

Djalali et al. (2015) [50]

CSQ (Switzerland)

NR

Negative/neutral: impact on workflow processes; Impact on physician-patient-relationship

Negative/neutral: Impact on quality of care. Positive: impact on operating costs, time, cooperation and provision patient reports.

Positive: Younger, less clinicially experienced PCPs.

Positive PCPs based in a group practice compared to single-handed practice.

 NR

NR

NR

NR

NR

Dossa & Welch (2015) [35]

QI (USA)

NR

Negative: Challenging to record sensitive information; Risk of stigmatising patients.

NR

NR

NR

NR

NR

NR

Positive: Availability of robust EMR privacy laws.

NR

Doyle et al. (2012) [36]

QI (USA)

Positive: Improved organization and accessibility.

Negative: Impact on patient interaction.

Positive: Impact on medication management.

NR

NR

NR

NR

NR

NR

NR

Emani et al. (2014) [37]

CSQ (USA)

NR

NR

Negative/neutral: Impact on medical errors; effectiveness/patient-centered/quality of care.

NR

NR

 NR

NR

NR

NR

NR

Ernstmann et al. (2009) [51]

SQ (Germany)

Negative: System specification did not meet needs.

NR

Positive: Impact on medication errors; communication; administration time.

NR

NR

Positive: Training to improve system familiarity.

NR

NR

Positive: Belief that PCP interests were considered by policy makers/ represented by medical associations.

NR

Goetz Goldberg et al. (2012) [38]

SQ + QI (USA)

Negative: Difficult to navigate; Not customizable; Difficult to track patients; Disruptive impact of system failures.

Negative: Impact on patient interaction.

Positive: Impact on organization, accessibility, accuracy of patient data; Impact on communication; Potential to generate patient reports; Potential to support quality-improvement. Negative: Time-commitment.

NR

Positive: PCPs based in a group practice compared to single-handed practice.

Positive: PCPs based in practices that redesigned work processes, policies and procedures to support implementation

NR

Negative: Cost of upgrading system.

NR

NR

Greiver et al. (2011) [59]

FG (Canada)

Negative: Complex/ inflexible system; Software interface issues and immaturity; Adverse impacts of IT structural failures inc. lack of technical support.

Negative: Impact on patient interaction.

Negative: Reduced efficiency e.g. additional data entry time. Positive: Improved efficiency e.g. automated prescription renewals/consultation letters; Quality/accessibility of patient records.

Negative: Lack of basic IT/keyboard skills; Limited benefits for older PCPs.

NR

Negative: Lack of ongoing training post-implementation; Lack of technical support. Positive: Having designated champion to support/problem solve.

NR

Negative:Cost of system installation

NR

NR

Holanda et al. (2012) [62]

CSQ (Brazil)

Negative: Speed; Technical failures; Lack of functionality e.g. checking lab results. Negative/neutral: Accessibility of previous notes; Ability to review medication list.

NR

Negative: Speed in comparison to paper records.

Neutral: Length of clinical experience;.Positive: Basic computer literacy; Being female; Younger PCPs.

Positive: Seeing less than 16 patients per half-day.

NR

NR

NR

NR

NR

Keddie & Jones (2005) [52]

CSQ (UK)

Negative: Incompatibility with secondary care systems; Inability to transfer records between practices.

Negative: Intrusion of PC in consulting room; Lack of fit with current work practices.

Negative: Time-consuming.

NR

NR

Negative: Lack of training; lack of technical support.

NR

Negative: Cost of system installation.

Negative: Concerns about the medico-legal implications; Llack of policy-maker support for implementation.

NR

Loomis et al. (2002) [39]

CSQ (USA)

NR

NR

Positive: More secure and confidential than paper records.

Negative: Being a non-EMR user.

NR

NR

NR

NR

NR

NR

Meade et al. (2009) [53]

SQ (Ireland)

NR

NR

Negative: Time-consuming.

Negative: Lack of basic computer skills.

NR

Negative: Poor training.

NR

Negative: Cost of introducing system.

NR

NR

O’Malley et al. (2010) [65]

QI (USA)

Negative: Lack of system interoperability; Lengthy/ irrelevant problem lists.

Negative: Mismatch with work practices; Lack of usefulness for complex patients/situations.

Positive: Comprehensive/consistent/ accessible documentation; Automated record completion; Quality and efficiency of patient care.

NR

Negative: Limited impact on collaborative decision making.

NR

NR

Negative: Lack of financial and other incentives; Emphasis on use for billing and litigation prevention.

NR

NR

Or et al. (2014) [63]

QI + SQ (Hong Kong)

Positive: Accessible/efficient user-system interaction/interface; System flexibility and reliability.

Negative: Impact on patient interaction; Slower workflow.

Positive: Potential to improve medication management and/or patient safety issues. Negative: Burdensome data migration process and disruption to work processes

Negative: Lack of basic computer skills.

NR

Positive: Provision of post-implementation technical support and training.

NR

Negative: Cost of introducing system.

NR

NR

Pare et al. (2014) [60]

SQ (Canada)

Negative: Poor quality systems e.g. usability, security); Lack of system interoperability.

Negative: Adverse impact on doctor–patient relationship.

Negative: Costs greater than potential benefits.

Negative: Lack of basic computer skills.

NR

Negative: Lack of expertise in EMR systems; Transience of software vendors; Lack of technical support.

NR

NR

NR

NR

Pizziferri et al. (2005) [40]

SQ (USA)

NR

Negative: Reduced time spent with patients.

Positive: Improved quality, access, and communication of records.

NR

NR

NR

NR

NR

NR

NR

Pocetta et al. (2015) [54]

QI (Italy)

NR

NR

Positive: Improved effectiveness and efficiency eg via audit-and-feedback. Negative: Time-consuming, esp. recording lifestyle data.

NR

NR

NR

NR

Negative: Lack of financial incentives; Lack of professional recognition for the additional work involved.

NR

NR

Prazeres (2014) [55]

SQ (Portugal)

NR

Neutral: Impact on patient interaction; Length of consultation time.

NR

NR

NR

NR

NR

NR

NR

NR

Rose et al. (2005) [41]

FG (USA)

Negative: Difficult to navigate and access patient notes; Lack of available screen real estate/ cluttered screen. Positive: Use of screen contrast/ colour; Ability to customize.

Negative: Mismatch with existing workflow patterns.

NR

NR

NR

NR

NR

NR

NR

NR

Rosemann et al. (2010) [56]

SQ (Switzerland)

NR

Negative: Impact on patient interaction; Impact on doctor-patient relationship.

Negative: Cost-benefit ratio.

Positive: Younger PCPs

Positive: PCPs based in group practices.

NR

NR

NR

Negative: Concerns re data security law.

NR

Sequist et al. (2007) [42]

SQ (USA)

Negative: Technical limitations eg slow response time.

Negative: Impact on patient interaction.

Negative: Clinical productivity loss; Patient privacy/safety. Positive: Quality of care.

Positive: More clinical experience Negative: Lack of basic computer skills.

NR

Negative: Lack of technical support; Lack of training.

NR

NR

NR

NR

Shachak et al. (2009) [64]

QI (Israel)

Positive: Data-related comprehensiveness, organization, and readability.

Positive: Reduced cognitive load; Simple to use. Negative: Impact on patient interaction.

Positive: Automated review of patients’ medical histories/ test results; Provided clinical decision aids; Enhanced patient safety. Negative: Introduced new types of medical errors e.g. typos.

Positive: Advanced computer/ communication skills.

NR

NR

NR

NR

NR

NR

Steininger & Stiglbauer (2015) [57]

SQ (Austria)

NR

NR

Negative: Impact on patient privacy.

NR

NR

NR

NR

NR

NR

NR

Stream (2009) [43]

SQ (USA)

NR

NR

Negative: Productivity loss.

NR

Positive: Presence of students and residents in practice; Attitude of individual practices; Being based in group rather than solo practices.

NR

NR

Negative: Start-up financial costs, ongoing financial costs and training costs; Pay-for-performance and interest free loans. Positive: Grants and increased reimbursement.

NR

NR

Villalba-Mora et al. (2015) [58]

SQ (Spain)

NR

Positive: Availability of ePrescription/ patient management services e.g. appointments and referrals.

NR

Positive: Being female; Having basic computer skills; Use of internet outside the workplace.

NR

NR

NR

NR

NR

NR

Williams et al. (2011) [44]

QI (USA)

Negative: Accessing/ navigating family history information.

Positive: Helping to directing patient care; Building relationship/rapport.

Positive: Increase in practice efficiency.

NR

NR

NR

NR

NR

NR

NR

Wright & Marvel (2012) [45]

SQ (USA)

NR

NR

NR

Positive: Younger PCPs.

NR

NR

NR

NR

NR

NR

Yan et al. (2012) [46]

SQ (USA)

Negative: Technical limitations.

Negative: Adverse impact on -patient interaction.

Negative: Substantial productivity loss against limited direct benefits.

Negative: Older PCPs; Lack of EMR experience; Lack of computer skills.

Neutral: Practice size.

Negative: Training needs.

NR

Negative: Substantial financial costs.

Negative Lack of uniform industry EMR standards.

NR

Zhang et al. (2016) [47]

QI (USA)

Positive: Use of templates. Negative: Time consuming functions e.g. clinical reminders; Technical limitations e.g. slow user interface, lack of shortcuts; limited flexibility

Positive: Promoted patient engagement as viewing tool. Negative: Adverse impact on -patient interaction.

Negative: Productivity loss

NR

NR

NR

NR

NR

NR

NR

  1. aDesign: CSQ - cross-sectional survey questionnaire; FG - focus groups; QI - qualitative interviews; SQ - survey questionnaire