Identification Of The Barriers And Effectiveness Of Using Electronic Health Record Systems Among The Population Of UK – Systematic Review Proposal

Background of the research

Background of the research

The provision of patient online record is fundamental for the purpose of the empowerment of patients (Mold and de Lusignan, 2015). E-health is defined as an application of information, computer or the communication technology to certain aspects of health or health care. Electronic Health Record (EHR) is a format of patient’s medical history which is available electronically. This record is maintained by the provider from time to time. The record includes all the chief administrative data which is related to the patient. With the presence of EHR, it enables to systematize the access to information which has the potential to restructure the workflow of the clinician (Ross et al., 2016). Some of the valuable information available electronically involves the demographics, notes of progress, problems with medications, previous medical history, laboratory related data, various reports etc. In context to the present-day scenario, it can be put forth that e-health is essential for resolving problems that are present in the healthcare systems because of the ageing population, improvement of treatments and the limited resources (Kruse et al., 2016). There has been a widespread acceptance of the importance of e-health and the various advantages or the benefits associated with it. It can be stated that benefits of e-health have been often slower than the actual anticipation which is mainly because of the difficulties associated with the implementation (Boonstra, Versluis and Vos, 2014).

Rationale of the research

In the UK, the National Health Service or the NHS has stated that it is efficient to make the best use of the available health technologies and put forth the outcome that NHS has previously failed miserably to make the best use of e-health due to the difficulty in understanding the ways to adopt and implement them. There have been various high-profile implementation failures which continue to exist even today (Jawhari et al., 2016). This has a severe impact on the performance and demoralizes the staff. It is necessary to highlight the effective need for undertaking the execution of the e-health or online record service in order to understand the factors that influences the process of implementation. It is feasible for the healthcare department to be well equipped for the devising of strategies and interventions for the improvement of effective use of e-health thereby addressing the barriers of the application of using electronic health record systems (Black et al., 2011). One of the major problems associated with the operation of electronic health record literature lies in the fact that it is extremely fragmented across the various subspecialty areas (Scott Kruse et al., 2016). With the wide range of reviews available on the implementation of various technologies of e-health, it is likely to be quite difficult for the clinicians, managers as well as the policymakers to discover and apply appropriately the various body of evidence. The potential of e-health lies in delivering both cost effective as well as quality healthcare (Jones et al., 2014). The expenditure on e-health by the healthcare systems and government is increasing extensively. The literature has often described the implementation of electronic health record to be problematic and unsuccessful. In order to identify and address the challenges or the barriers along with the effectiveness of using electronic health record system, there is a necessity to conduct a systematic review. With the rapid changes in the technology and the innovative solutions, it is evolving constantly for meeting the needs of the present practice. A present update of the review is essential for understanding the advantages and the disadvantages of e-health (World Health Organization, 2011). The research aims towards the identification, summarization and synthesizing the presently available evidences which will be carried out by a systematic review for exploring the barriers and the effectiveness of associated with the implementation of electronic health record system, across the huge range of healthcare settings. The study will take into consideration the healthcare sector within the United Kingdom. This research will help to improve the practices in healthcare because it will outline all the barriers and the benefits of employing e-health record system. By knowing clearly about both the positive and the negative impacts it will become easier for the healthcare sector to incorporate the essential technological innovation that will be accepted widely by the people (Tan, 2013). The practices will be further improved because the records of the patients will be available online that will smoothen the process to a great extent both for the healthcare organization and the patient’s family. The context of the research question lies in outlining the effectiveness of the electronic record system. It is necessary to first know in detail about the benefits of the e-health system before it is implemented. Next, when it comes to barriers, it is of equal importance to understand because every coin has two sides (Hoholm, La Rocca and Aanestad, 2018). Like it is mandatory to know about the positive side, similarly it is vital to go through the negative side. The research question has been identified as an issue within the contemporary context because with the advent of technology it is necessary to sync technological innovation within healthcare management (Smaltz and Berner, 2007). There is an increasing importance of technology in the designing of healthcare systems. The fervour about the potential of IT offers an array of improvement in the health services that has resulted in the unprecedented investments in information technology. When health services and clinical systems are based on technology it comes it various forms with numerous aims (Board on Health Care Services, and Institute of Medicine, 2012). 

Rationale of the research

Research Objectives

• To explore the current status of the electronic health record systems in UK. 
• To identify the challenges of implementing e-health record system in the UK.

Research Questions

• How effective is the present electronic health record system in the UK? 
• What are the barriers to implementation of electronic health record systems in the UK?

PICO Question

Population	Patients in UK
Intervention	Elimination of barriers towards optimal implementation of EHR
Comparison	No implementation of HER or no eradication of barriers of EHR
Outcomes	Optimal implementation of EHRs in healthcare system

Summary of research

The research will outline the literature associated with EHR and proceed towards outlining the methodology of the research. Literature is essential for a study to check that sufficient research is available for conducting the review. The study will gradually proceed towards outlining the research protocol, limitations and lastly the dissemination of the research.

Literature Search Process

According to Kalra et al. (2012), a systematic review requires literature search process to systematically identify, retrieve and synthesize various independent and distinguished studies so that the project can be fundamentally substantiated. Implementation of EHR systems in the UK health care management is a huge technological leap (Johnson et al. 2014). However, this chapter will assess the systems in terms of the overall usability. The researcher conducted an intense study on the topic to select the most useful, journal articles in compliance with the research aims, objectives and questions to embark on this research.

Main Theoretical Perspectives

 Conceptual Framework of Electronic Health Record

The research aims to identify the barriers and effectiveness of EHR. Therefore, it is important to throw some light on the entire conceptual framework behind this system. An EHR typically contains the real-time medical diagnoses, history, medications, treatment progress, allergies, and dates of immunization, test results and images of radiology (Holroyd-Leduc et al. 2011). Electronic health record system not only simplifies accessing patient’s data but it allows the medical experts to review different aspects. Moreover, different tools can be used to decide more accurately on patient’s treatment and care. Undoubtedly, the technology is revolutionary but the practical implementation may be different as its success depends on the acceptance by both health care professionals and patients (Lau et al. 2012).

Benefits of the Framework

Decision making in the health care system is the most crucial part. The patients resign to the doctors and other health care professionals to at his/her most vulnerable state (Black et al. 2011). Therefore, it is important to take advanced measures to perfect patient care and treatment. The highlights of the benefits of EHR include real-time reporting, quick access to patient’s data, optimized decision support, medical information, clinical reminders, instant measures and fewer paper works and easy tracking of patient’s curing and treatment progress (McGinn et al. 2011).

Implementation in the United Kingdom

The government of United Kingdom incorporated electronic health record system as the part of National Programme for Information Technology NHS Record Service in 2002 (Ajami and Bagheri-Tadi, 2013). The project miserably failed and eventually was officially dismantled in 2011 (Menachemi and Collum, 2011). Considering the status, Wales, Northern Ireland and Scotland have succeeded with implementing and using the electronic health record systems and the electronic health record of Northern Ireland has been awarded industry awards (Carrington and Effken, 2011). Moreover, the system at present is limited to share only the adverse reactions, allergies and prescriptions. The sharing radius is also restricted to GP surgeries, hospitals, community pharmacists and walk-in centres (King et al. 2014).

Research Objectives

Disadvantages of the Framework

In order to implement electronic health record, the health care organizations have to bear an enormous start-up cost and eventually a maintenance cost. That amount is not less. According to Hersh et al. (2013), the average cost of implementing electronic health record system is $162,000 approximately and the maintenance cost during the first year is $85,500. Over the time, this cost is expected to increase and this really makes difficult to rapidly implement the system in all health care centres. Another major disadvantage is the data vulnerability. There may be different security measures available for virtual data, but the possibilities cannot be seized. Data security is a real concern as the nature of the data is highly confidential (Middleton et al. 2013).

Strengths and Weaknesses of the Literature

The literature is strongly established the conceptual framework of the electronic record. However, it did not much focus on distinguishing the barriers and effectiveness of electronic health record among the population of UK and systematically reviewing them so that the technology can be further enhanced in future. The literature must contain more synthesis on the area of the United Kingdom. Apart from the initial failure, there are not many studies that critically evaluate the re-incorporation of electronic health record in the UK hospitals and health care organizations. On the other hand, the framework of electronic health record has been the focus of many studies. For example, Ross et al. (2016) wrote a systematic review of reviews in relation to the exploration of challenges of implementing electronic health. But they refused to use the context of any geographic region.  Another weakness of the literature is accounting the evolution of the electronic health record. Studies lack evaluation of how EHR has evolved and the reasons behind the evolution. 

Similarities and Differences in the Literature

As it has been already mentioned, electronic health record has been the topic of many scholarly evaluations. Nonetheless, each study perceived EHR differently. The only similarity was the studies were on the electronic health record and most of them were systematic reviews. Apart from that, the literature selected for this systematic review was mainly determined by the research objectives and research questions. The first objective is to explore the current status of electronic health record and secondly the challenges of implementing electronic health record systems in the United Kingdom. Therefore, the literature mostly concerned the troubles or hindrances being faced at present. One of the major differences is that as most of the studies are not specified by geographic region the studies address different time frame. For example, quality and safety of health careare impacted by electronic health and Sheikh et al. (2011) only focused on the issues of EHR at its time of Genesis. However, the same study like other ones pays major attention to the economic downturn caused by the implementation of EHR.

Research Questions

Inconsistencies in the Literature

A few inconsistencies have been found in the course of literature. Such inconsistencies can be considered as the scopes for the researcher to independently think through this systematic review to include a new perspective. The paper by Ross et al. (2016), they aim to explore the potentials of the electronic record in order to establish the cost-effective health care system. However, the paper seems more like a critical review of the conceptual framework of the electronic record. Most importantly, in the articles by Ross et al. (2016), Sheikh et al. (2011) and in Stone (2014), the demography seems inconsistent. Especially, Stone (2014) claims the paper to be an outline of EHR implementation around the world but she only accounts the United States and France. It should be noted that currently, the United Kingdom ranks very high with a 97% success rate after Norway and Netherlands (with 98% success rate both) and the UK is followed by New Zealand (97%), Australia (97%), Germany (82%), United States (69%), France (97%), Canada (56%) and Switzerland (41%) (Holroyd-Leduc et al. 2011). In the literature, UK is only marked by its initial failure. But, this success rate seems to be ignored in most of the past studies.

 Gaps in the literature

Gaps in the literature are the stepping stone in this systematic review. The previous section mentioned the names of the top ten successful countries in EHR implementations and UK is one of them. However, no studies have used this perspective yet to find out the barriers and effectiveness of electronic record in that country. More importantly, it was a government initiative. No studies threw light upon how the process of implementing EHR in the UK restored (Middleton et al. 2013). This systematic review will develop the study on the basis the literature between the time 2011 onwards as the government shut down the project in 2011. The barriers and challenges and the effectiveness will be identified in the current context as specified.

Interrelationships between Previous Literature and the Proposed Study

This study proposes to conduct an intense investigation in order to find out the barriers and effectiveness of electronic health record systems among the UK population. United Kingdom will be critically reviewed through various data to determine the areas of challenges and effectiveness. The literature reviewed and synthesized the fundamental theoretical knowledge about the electronic health record in this chapter. The previous studies accounted electronic health record as the failure in the UK. However, this research will extend the same thread by elaborating on how it has been succeeded and what the current status is in this scenario.

Summary of research

Justification for the Constraints in the Literature Review

Statistical data are necessary to measure the limitations and effectiveness in any area. However, this literature was not adequate to offer a substantial picture of the United Kingdom in regards to EHR implementation. Moreover, the researcher could not explore apart from the university library due to time constraints. The research topic is very simple yet it covers a wide area to be analyzed. EHR in UK is bound to consider various hospitals and health care organizations with this system. However, the researcher also could not arrange the distinguished case studies for each organization as those were not available in the university library.

 Scoping Review

The internet is a source to a limitless database for any topic. Moreover, the electronic resources offer the latest and updated information which will help this systematic review to be more relevant and accurate. Scoping review assists the researcher to get out of the books and journals and look into the authentic but non-academic resources of the topic because those are most likely to be updated. However, the availability to statistical data does not seem adequate for this entire systematic review. 

Nature of the Research Approach to be adopted

After assessing different aspects, it has been decided that the researcher will perform systematic review research articles published in the domain of EHR. The systematic review o of the secondary data collected from published literary articles is expected to be proved useful for achieving all the objectives of this research.

The methodology of this systematic review of literature will be erected based on the research question and the type and design of the study will be manifested throughout the systematic review and its subsequent methodology (Gough et al, 2012, p7). As stated previously, the review question is how effective is EHR and what are the barriers towards optimal implementation of EHR. Therefore, the answers to this research question will be objective rather than containing multiple subjective realities and thus will follow positivist paradigm because it best suits the overall nature of the research question.

Qualitative research deals with analysis and proper understanding of a complex phenomenon via thematic analysis. It uses inductive research approach in order to answer the research questions. In qualitative research, he research initiates via the observation and collection of non-numerical rich data and thereby attempting to recognize the pattern in data (through themes) and generating new theories about the present phenomenon (Ross, 2012, p260). The research will follow qualitative research method for the conduction of the systematic review. However, the qualitative research will use research papers of both primary and secondary data for answering the research questions.

Literature Review

Methods

Search strategy

Electronic Database	Keywords	Boolean search operators	Number of relevant searchers selected
PubMed	Electronic Health Records OR EHR, EHR AND  barriers, EHR AND advantage, EHR AND disadvantage, EHR AND UK OR United Kingdom	AND/OR	10
MEDLINE	-Same-	-Same-	7
ScienceDirect	-Same-	-Same-	4
Cochrane	-Same-	-Same-	4
Total	25

Study Selection

After the removal of the duplicates from the search results, the authentic and relevant studies will be highlighted via screening of the research titles along with the abstracts for inclusion and exclusion criteria. After screening of the articles on the basis of the inclusion and exclusion criteria, the review of the entire body of the published literature will be performed for the final selection of the articles.

Inclusion criteria

Inclusion Criteria
Year	2012 to 2018
Language	English
Type of research	Primary and secondary

Exclusion criteria

Exclusion Criteria
Year	Articles published before 2012
Language	Other than English
Articles	Electronic health records based on US perspectives

 Quality assessment

The article selected on the basis of the keyword search followed by review of title and abstract, further quality of the article will be done on the basis of quality assessment. Study of the quality of the article is done to ascertain the internal validity of the study along with methodological parameter of biasness (Petticrew, 2006, p127). It is essential to incorporate good quality study under a systematic review because this with make sure that the evolved results are valid, reliable, generalized and will help to generate a strong conclusion. The Centre for Reviews and Dissemination (CRD) recommended the application of checklist in comparison to scales for the quality assessment of the research papers. The CASP tool will be used to tally the quality of the studies selected for systematic review of literature.

Data extraction

The process of data extraction can be defined as the stage that is followed while conducting a systematic review where data that is pertinent and relevant to the research queston is collected from the studies that have been included in the review. Moreover, data extraction also encompasses the procedure of elaborating on the similarities and dissimilarities between the articles that have been extracted, for detailed analysis. The following information will be presented during data extraction:

• Name of the authors of the published articles
• Date of publication
• Study/research design
• Country and source of origin of the article
• Quality criteria
• Demographics and number of the patients/participants who have been recruited in the study

Research paradigm

Research paradigm consists of a network of coherent ideas on the function of researchers and the nature of the world. According to Arghode (2012), there are various types of research paradigm and this includes epistemiology, ontology, positivism and interpretivism. This study will follow positivism research philosophy. Epistemology deals with the theory of knowledge along with assumptions and beliefs of knowledge. The importance of selecting positivism research paradigm is, it helps in proper synthesis of the factual knowledge via proper observation, analysis and measurements of the research findings from the studies, which will be incorporated within the systematic review. Thus, positivism research paradigm is best suited for the systematic review and hence selected for this research proposal. Though interpretisim also deals with qualitative research, it is not selected for this research because it depends in both trained researcher and human subject as the instrument to measure the outcome. Since, it is systematic review, no direct influence of the human subject can in-corporated and thus interpretivism is eliminated (Arghode, 2012).  

Data synthesis

Data synthesis refers to the combination of results from a range of studies with the aim of obtaining an accurate estimate of the overall effects of particular variables or interventions that are related to the defined outcomes. Hence, the process of data synthesis will involve combination and integration of data from all the articles that have been included, thereby integrating them to form a new piece of information.

It has been stated previously that the review will follow a qualitative method. It will collect and then critically analyse numerous research papers or studies by using methods that are chosen before the research question was formulated. This will be followed by finding and analyzing the articles that pertain to the research question, by following a structured methodology. Moreover, the qualitative approach will be designed in a way that provides an exhaustive and complete summary of relevant literature (Gough, Oliver and Thomas, 2017). An objective and transparent approach will be employed for the research synthesis with the aim of minimizing the aforementioned bias. The primary outcome of the systematic review is to determine the current state of electronic health record systems, and determine their effectiveness. The secondary outcome focuses on evaluating the challenges that exist in the UK, related to implementation of these electronic health records across healthcare settings. The studies that will be included in the systematic review will differ from each other in several aspects that are given below:

• The studies will vary in their design and will be of different types such as, case reports, randomized controlled trials, cohort studies, case control studies and systematic reviews. While some studies will be retrospective, others will be prospective and evaluate the outcomes during the study period. The outcomes will be observed followed by implementation of the intervention (electronic health records).
• The outcomes reported by the participants might vary in each study. While most of the trials will report on the benefits or effectiveness of the electronic health records, with reference to improved patient outcomes and safety, not all of them will report the effectiveness. Some of the included articles will also determine the cost-benefits and challenges that are encountered while electronic health records are implemented across all hospitals in the UK.
• The time or intervention period during which the primary and secondary outcomes were reported by the different articles might vary in all the included studies. This might led to bias in the results. This can be attributed to the fact that  the total length of time that the participants are subjected to during the study often comprises of the intervention period and the follow-up time. 

Heterogeneity in the population or samples leads to different results. Hence, the possibility of conducting a meta-analysis has been ruled out. A narrative synthesis will be used for this qualitative research. This approach will help in synthesizing findings from multiple studies that primarily rely on the use of appropriate words for summarizing and explaining the findings, obtained after synthesis of the articles (Ryan et al., 2013). The narrative synthesis will encompass the following aspects:

• Developing a theory related to how and why that intervention (electronic health record) created an effect
• Undergoing preliminary synthesis of the research findings, collected from the included studies
• Exploring the existing relationship in the obtained data between and within the studies
• Analyzing robustness of the narrative synthesis

One of the first limitations of a systematic review lies in the fact that it requires access to a huge range of databases along with some peer-reviewed journals. This process can turn out to be extremely problematic and expensive especially for the researchers who are non-academic. Secondly, for the achievement of objectivity, the criteria for inclusion and exclusion are used for finding out relevant studies. When a huge number of researchers are involved, there is a scope of inevitable subjectivity in the process of screening. In order to have a systematic review on cash transfers, there is a necessity to have different researchers at different stages of the process. For the purpose of minimizing the risk of inconsistency, the screening process is required to be piloted. Although the piloting enables the researchers to screen more efficiently the presence of subjectivity always remains. Thirdly, it is necessary to search for international websites for the purpose of ensuring the breadth of the systematic review. This is mainly because the relevant researches are more often present outside the formal channels. The search process of institutional website undermines the objectivity of the search along with the retrieval process thereby introducing biases to the entire process of review. Such a situation occurs mainly due to the variance in the search function of the websites. It means that the search strings should either rejected or modified together by excluding a number of websites.

This part of the research is prepared for the purpose of communicating the findings with the suitable audience. Dissemination reports should always be peer-reviewed from the independent colleagues. It is necessary to be from the same field of research that has not participated while conducting the study. The peer-reviewed reports ensure objectivity thereby increasing the likelihood of a reliable and a valid report. The dissemination plan was prepared much prior to the completion of the study which has helped to identify the strategies for disseminating and the target population. In order to share the findings of the research, public library quarterly acts as a peer-reviewed journal that examines the suitable practices and models to bring about an improvement in the service. This library is observed to be indexed which makes it extremely easy for the researchers and the students to retrieve it as per convenience. The research is likely to turn out to be extremely beneficial due to the improved practices associated with it. The e-health record system will not only benefit the patient’s family but also the healthcare organisation. Each and every detail about the patient will be computerized which can be availed as and when required. People can also check the detail when they are away from the healthcare unit. Such mobility and flexibility within healthcare management will influence positive policy decisions. When the decisions are taken positively then it is bound to bring positive changes to the healthcare sector 

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