Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method

To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1468-0009.2009.00578.x Byline: TRISHA GREENHALGH (1), HENRY W.W. POTTS (1), GEOFF WONG (1), PIPPA BARK (1), DEBORAH SWINGLEHURST (1) Keywords: Systematic review; electronic patient records; innovation 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. Author Affiliation: (1)University College London Article note: Address correspondence to: Trisha Greenhalgh, University College London, 206 Holborn Union Building, Highgate Hill, London N19 5LW, England (email: p.greenhalgh@ucl.ac.uk).