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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