Electronic Health Records- Implemented (Action Knowledge)

Objective: To assess the impact of electronic health record (EHR) on (DSS) that provides up-to-date medical knowledge, reminders or other actions that the benefits of EHR implementation using the following algorithm.
Table of contents

Our world has been radically transformed through digital innovation. Information technologies play a growing role in healthcare delivery and help address the health problems and challenges faced by clinicians and other health professionals. An electronic health record EHR is a systematic electronic collection of health information about patients such as medical history, medication orders, vital signs, laboratory results, radiology reports, and physician and nurse notes.

In healthcare institutions, it automates the medication, as well as exam, ordering process ensuring standardized, readable and complete orders. An EHR may also include a decision support system DSS that provides up-to-date medical knowledge, reminders or other actions that aid health professionals in decision making.

Although several studies on the effects of EHR implementation have been published, evidence on EHR effects continues to be disputed. Even if most of the studies published seem to provide promising data, some reported different results, such as Han et al. To assess the impact of EHRs on healthcare quality, we hence carried out a systematic review and meta-analysis of published studies on this topic that may provide a rational basis for recommendations. A protocol was developed, and we searched in PubMed, Web of Knowledge, Scopus and Cochrane Library databases to identify studies that evaluated the benefits of EHR implementation using the following algorithm:.

Studies were considered eligible if they investigated the association between the EHR implementation and process or outcome indicators and if they had a control group who did not use the EHR. One reviewer screened titles, and then, abstracts of relevant titles were identified. Full texts of potential citations were subsequently obtained; two reviewers independently screened them for inclusion, and disagreements were resolved through discussion.

Additional relevant publications were identified from the references of the initially retrieved articles. For indicators represented by dichotomous variables, risk ratios RRs with their confidence intervals CIs or data necessary to obtain them were extracted. For indicators represented by continuous variables, sample sizes of both control and intervention groups and differences in mean DMs and their CIs or data necessary to obtain them were extracted.

All data extractions were conducted independently by two reviewers, and disagreements were resolved through discussion. Meta-analysis was performed for each process or outcome indicators evaluated. Heterogeneity was quantified using the Cochran Q test and I 2 statistics. For indicators with available both studies including DSS and not subgroup analyzes were performed. Sensitivity analyzes were conducted by excluding one study at a time from the meta-analysis to determine whether the results of the meta-analysis were influenced by individual studies and whether risk estimates and heterogeneity were substantially modified.

All statistical tests were performed with Comprehensive Meta-Analysis software version 2. After the initial screening of titles and abstracts, articles were considered for full text review. Twelve articles were excluded because full texts were not available, and articles were excluded based on the full text review. After having identified seven additional articles by reviewing bibliographies, 47 articles were included in the analysis figure 1. Nine studies investigated the relationship between EHR use and a reduced documentation time spent by healthcare professionals.

The association between EHR and guideline adherence, medication errors, adverse drug effects ADEs , and mortality were evaluated in 6, 24, 7 and 8 studies, respectively. Forest plot for the meta-analysis of studies reporting on a EHR and documentation time, b guideline adherence, c medication errors, d ADEs and e mortality.

The overall, as well as subgroup, estimates of the effect are represented by diamonds in each plot. Sensitivity analysis has shown the stability of the overall effect sizes with the withdrawal of any of the study from the analysis without a significant improvement of the heterogeneity. This meta-analysis provides evidence that the use of EHR can improve the quality of healthcare, increasing time efficiency and guideline adherence and reducing medication errors and ADEs.

In effect, several studies focused on the economics of medical errors 7—9 and ADEs 10 , 11 point out that considerable cost reductions are achievable through improving quality of care and reducing harm to patients. Guidelines adherence may have an impact on resource use and cost reduction, supporting specialists in their clinical choices by reducing errors and ADEs related to treatment and, consequently, unnecessary waste of resources, as some examples reported by scientific literature.

EHR including DSS, that actively provides up-to-date medical knowledge, reminders or other actions that aid health professionals in decision making, showed in fact generally a better outcome. So, even if in this review we are far from knowing how EHR generates these quality improvements, this may suggest that such dynamic components are ones of the most effective parts of EHRs. However, the absence of association with ADEs reduction for the subgroup of studies not using DSS is probably due to the limitation of having only three studies in this subgroup.

Despite the benefits that EHR can provide, a proper implementation strategy is essential. In our opinion, it is likely that there are cases where the success of EHR was not reached because of a non-effective implementation strategy. An example of an effective strategy may be identified through the WHO guidelines for EHR in developing countries 18 and reassumed in six key actions:.

We believe that such an implementation strategy or a similar one is crucial in effectively setting up an EHR system, reducing the resistance of medical practitioners and health professionals, ensuring that the system is used optimally, and obtaining clinical results. Having used the tool of quantitative meta-analysis of several outcomes to synthesize the evidence on the EHR is definitely a strength of our study.

However, our study has also its limitations. In fact, we focused on different indicators and although we did a comprehensive search, we found only a limited number of articles with quantitative data among the articles identified and even less for each indicator and subgroup. High heterogeneity was also present and may have affected the robustness of the results. Possible source of such heterogeneity includes difference in the software used, their quality and usability, and different settings of implementation. Moreover, information on technical items and procedures that shape the EHR software was not included in most studies.

Further research is therefore needed to determine the differences among the various system, the different items that shape an EHR software, and the different benefits of any of them. Health information technology systems are, in fact, healthcare interventions, and systems for evaluating their efficacy and safety should be as robust as those evaluating other healthcare technologies. Emergent change is perceived as a key characteristic of EHR implementation in complex organizations such as hospitals [ 21 ], and this suggests an implementation approach based on a development paradigm [ 31 ], which may initially even involve parallel use of paper [ 26 ].

The notion of emergent change has been variously applied, including in the theoretical frameworks of Aarts et al. These studies recognize that EHR implementation is relatively unpredictable due to unforeseen contingencies for which one cannot plan. With their emphasis on emergent change with unpredictable outcomes, Aarts et al.

They argue that the changes resulting from these contingencies often manifest themselves unexpectedly and must then be dealt with. Additionally, Takian et al. In line with the arguments for management support and for the participation of clinical staff, Ovretveit et al. By having all the direct stakeholders working together, a better EHR system can be delivered faster and with fewer problems.

Particularly, the physicians constitute an important group in hospitals. As such, their possible resistance to EHR implementation will form a major barrier [ 29 , 33 ] and may lead to workarounds [ 26 ]. Whether physicians accept or reject an EHR implementation depends on their acceptance of their work practices being transformed [ 22 ]. The likelihood of acceptance will be increased if implementers address the concerns of physicians [ 24 , 28 , 32 , 33 ], but also of other members of clinical staff [ 36 ].

The previous finding already elaborated on clinical staff resistance and suggested reducing this by addressing their concerns. Another way to reduce their resistance is related to the process of implementation and involves identifying physician champions, typically physicians that are well respected due to their knowledge and contacts [ 32 , 33 ]. These champions can provide reassurance to their peers. Implementing a large EHR system requires considerable resources, including human ones. Assigning appropriate people, such as super-users [ 36 ] and a sufficient number of them to that process will increase the likelihood of success [ 19 , 32 , 33 , 36 ].

Further, it is important to have sufficient time and financial resources [ 26 , 32 ]. This finding is also relevant in relation to finding A6 ensuring good care during organizational change. These 19 general findings have been identified from the individual findings within the 20 analyzed articles. These findings are all related to one of the three main and interacting dimensions of the framework: This identification and explanation of the general findings concludes the results section of this systematic literature review and forms the basis for the discussion below.

This review of the existing academic literature sheds light on the current knowledge regarding EHR implementation. The 21 selected articles all originate from North America or Europe, perhaps reflecting a greater governmental attention to EHR implementation in these regions and, of course, our inclusion of only articles written in English. Two articles were rejected for quality reasons [ 43 , 44 ], see Appendix B.

All but one of the selected articles have been published since , reflecting the growing interest in implementing EHR systems in hospitals. Eight articles built their research on a theoretical framework, four of which use the same general lens of the sociotechnical approach [ 21 , 22 , 26 , 37 ]. It is notable that the other reviewed articles did not use a theoretical framework to analyze EHR implementation and made no attempt to elaborate on existing theories.

To ensure a tight focus, the scope of the review was explicitly limited to findings related to the EHR implementation process, thus excluding the reasons for, barriers to, and outcomes of an EHR implementation. Some of the findings require further interpretation. Contextual finding A1 relates to the demographics of a hospital. One of the assertions is that privately owned hospitals are less likely than public hospitals to invest in an EHR.

The former apparently perceive the costs of EHR implementation to outweigh the benefits. This seems remarkable given that there is a general belief that information technology increases efficiency and reduces process costs, so more than compensating for the high initial investments. It is however important to note that the literature on EHR is ambivalent when it comes to efficiency; several authors record a decrease in the efficiency of work practices [ 25 , 33 , 35 , 38 ], whereas others mention an increase [ 29 , 31 ].

Finding A2 is a reminder of the importance of carefully selecting an appropriate vendor, taking into account experience with the EHR market and the maturity of their products rather than, for example, focussing on the cost price of the system. Given the huge investment costs, the price of an EHR system tends to have a major influence on vendor selection, an aspect that is also promoted by the current European tendering regulations that oblige semi- public institutions, like many hospitals, to select the lowest bidder, or the bidder that is economically the most preferable [ 45 ].

The finding that EHR system implementation is difficult because good medical care needs to be ensured at all times A6 also deserves mention. Essentially, many system implementations in hospitals are different from IT implementations in other contexts because human lives are at stake in hospitals. This not only complicates the implementation process because medical work practices have to continue, it also requires a system to be reliable from the moment it is launched. The findings regarding the content of the EHR system Category B highlight the importance of a suitable software product.

A well-defined selection process of the software package and its associated vendor discussed in A2 is seen as critical B5. Selection should be based on a careful requirements analysis and an analysis of the experience and quality of the vendor. An important requirement is a sufficient degree of flexibility to customize and adapt the software to meet the needs of users and the work practices of the hospital finding B1. At the same time the software product should challenge the hospital to rethink and improve its processes.

A crucial condition for the acceptance by the diverse user groups of hospitals is the robustness of the EHR system in terms of availability, speed, reliability and flexibility B2. This also requires adequate hardware in terms of access to computers, and mobile equipment to enable availability at all the locations of the hospital. The findings on the implementation process, our Category C, highlight four aspects that are commonly mentioned in change management approaches as important success factors in organizational change.

The active involvement and support of management C1 , the participation of clinical staff C2 , a comprehensive implementation strategy C4 , and using an interdisciplinary implementation group C5 correspond with three of the ten guidelines offered by Kanter et al. These three guidelines are: As the implementation of an EHR system is an organizational change process it is no surprise that these commonalities are identified in several of the analyzed articles.

Three Category C findings C2, C6, and C7 concern dealing with clinical staff given their powerful positions and potential resistance. Physicians are the most influential medical care providers, and their resistance can delay an EHR implementation [ 23 ], lead to at least some of it being dropped [ 21 , 22 , 34 ], or to it not being implemented at all [ 33 ].

This means that clinicians and other key personnel should be highly engaged and motivated to contribute to EHR. Prompt feedback on requests, and high quality support during the implementation, and an EHR that clearly supports clinical work are key issues that contribute to a motivated clinical staff. By categorizing the findings in terms of subject, and by totaling the number of articles related to the individual findings on that subject, one can deduce how much attention has been given in the literature to the different topics.

This analysis highlights that the involvement of physicians in the implementation process, the quality of the system, and a comprehensive implementation strategy are considered the crucial elements in EHR implementation. Notwithstanding the useful results, this review and analysis has some limitations.

Although we carefully developed and executed the search strategy, we cannot be sure that we found all the relevant articles. Although searching the reference lists of identified articles did result in several additional articles, some relevant articles might still have been missed. Another limitation is the exclusion of publications in languages other than English. Further, the selection and categorization of specific findings, and the subsequent extraction of general findings, is subjective and depends on the interpretations of the authors, and other researchers might have made different choices.

A final limitation is inherent to literature reviews in that the authors of the studies included may have had different motives and aims, and used different methods and interpretative means, in drawing their conclusions. The literature is diffuse, and articles seldom build on earlier ones to increase the theoretical knowledge on EHR implementation, notable exceptions being Aarts et al. The earlier discussion on the various results summarizes the existing knowledge and reveals gaps in the knowledge associated with EHR implementation.

The number of EHR implementations in hospitals is growing, as well as the body of literature on this subject. This systematic review of the literature has produced 19 general findings on EHR implementation, which were each placed in one of three categories. A number of these general findings are in line with the wider literature on change management, and others relate to the specific nature of EHR implementation in hospitals. The findings presented in this article can be viewed as an overview of important subjects that should be addressed in implementing an EHR system.

It is clear that EHR systems have particular complexities and should be implemented with great care, and with attention given to context, content, and process issues and to interactions between these issues. As such, we have achieved our research goal by creating a systematic review of the literature on EHR implementation. Academics interested in this specific field can now more easily access knowledge on EHR implementation in hospitals and can use this article as a starting point and build on the existing knowledge.

The managerial contribution lies in the general findings that can be applied as guidelines when implementing EHR in hospitals. We have not set out to provide a single blueprint for implementing an EHR system, but rather to provide guidelines and to highlight points that deserve attention. Recognizing and addressing these aspects can increase the likelihood of getting an EHR system successfully implemented. This appendix provides an overview of all databases included in the used search engines.

The databases in italic were excluded for the research as these databases focus on fields not relevant for the subject of EHR implementations. Assessment was done by questioning whether particular criteria had been addressed, resulting in a rating of 2 completely addressed , 1 partly addressed , or 0 not addressed points. Based on this assessment, two articles were excluded from the search. The category number is related to the general finding as discussed in the Results section. We acknowledge the Master degree program Change Management at the University of Groningen for supporting this study.

We also thank the referees for their valuable comments. AB and JV established the research design and made significant contributions to the interpretation of the results. They supervised AV throughout the study, and participated in writing the final version of this paper. AV contributed substantially to the selection and analysis of included papers, and wrote a preliminary draft of this article. All authors have read and approved the final manuscript.

Janita F J Vos, Email: National Center for Biotechnology Information , U. Published online Sep 4. Deloitte Consulting, Amsterdam, The Netherlands. Received Sep 23; Accepted Aug This article is published under license to BioMed Central Ltd. This article has been cited by other articles in PMC.

Project Management and EHR Implementation

Methods A systematic literature review of empirical research on EHR implementation was conducted. Results Of the initially identified articles, this study analyzes the 21 articles that met the requirements. Conclusions Although EHR systems are anticipated as having positive effects on the performance of hospitals, their implementation is a complex undertaking. Background In recent years, Electronic Health Records EHRs have been implemented by an ever increasing number of hospitals around the world. Study aim, theoretical framework, and terminology In dealing with the complexity of EHR implementation in hospitals, it is helpful to know which factors are seen as important in the literature and to capture the existing knowledge on EHR implementation in hospitals.

Open in a separate window. Methods Search strategies In order for a systematic literature review to be comprehensive, it is essential that all terms relevant to the aim of the research are covered in the search. Table 1 Overview of the search strategies. Data analysis The quality of the articles that survived this filtering was assessed by the first two authors using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers [ 18 ]. Table 2 Overview of studies included in the systematic literature review.

Qualitative Semi-structured interviews, observations, document analysis 10 members of the project team from different disciplines Teaching hospital 4.

Background

Quantitative and Qualitative Survey, semi-structured interviews, focus groups, observations Quantitative: Qualitative Semi-structured interviews, focus groups, observations Physicians, administrators, and information technology personnel 2 teaching hospitals, 2 community hospitals 4. Qualitative Semi-structured interviews, observations, documents 66 users and other hospital staff, 3 hospitals, 1 acute setting, 1 community and mental health. Quantitative Survey 1, hospitals All kinds of hospitals - 13 Gastaldi et al.

To determine the status of implementation of EHRs in hospitals in the state of Alabama; 2. To assess the factors that are driving the decision making for implementation of EHRs; and 3. To assess the perceptions of HIM professionals of the benefits, barriers, and risks that are associated with implementation of EHRs. Qualitative Interviews 12 people, being supported sponsor, process owner or key-user 4 hospitals - 4 Ovretveit et al. Qualitative Interviews 30 persons, project leaders, supervisors, heads of division and clinics, instructor, nurses, physicians, and doctor secretary Teaching hospital 2.

Qualitative Interviews 43 people, physicians, nurses, and administrators 3 hospitals, 2 teaching and 1 community hospital 2. Qualitative Interviews 26 senior physicians, managers and project team members One hospital, 4 clinics Qualitative Interviews, observations, document analysis 48 interviews with senior managers, implementation team members, healthcare practitioners Mental health hospital 2. Quantitative Survey nurses Rural hospital - 3 Ward et al.

Quantitative Survey nurses, providers, and other clinical staff Critical access hospitals 2. Qualitative Interviews 31 interviews with institutional leaders, practice leaders and vendor leaders. Teaching hospital - Theoretical perspectives of reviewed articles In research, it is common to use theoretical frameworks when designing an academic study [ 41 ]. Table 3 Overview of the theoretical frameworks used in the included studies.

Author Theoretical framework Aarts et al. Successful implementation of an information system 1 is defined as the capability to create a support base 2 for the change of medical work practices 3 induced by the system 4. Relevance is defined as the degree to which the user expects that the IT system will solve his problems or help to realize his actually relevant goals.

Participation of employees is perceived to increase their acceptation of the IT system. Effectiveness of participation is moderated by organizational receptiveness, individual ego development, and knowledge availability. Implementation-related findings The process of categorization started by assessing whether a specific finding from a study should be placed in Category A, B, or C.

Category A - context The context category of an EHR implementation process includes both internal variables such as resources, capabilities, culture, and politics and external variables such as economic, political, and social variables. Table 4 Category A - Context findings. General finding Finding code Article numbers Large or system-affiliated , urban, not-for-profit, and teaching hospitals are more likely to have implemented an EHR system due to having greater financial capabilities, a greater change readiness, and less focus on profit.

Large or system-affiliated , urban, not-for-profit, and teaching hospitals are more likely to have implemented an EHR system due to having greater financial capabilities, a greater change readiness, and less focus on profit The research reviewed shows that larger or system-affiliated hospitals are more likely to have implemented an EHR system, and that this can be explained by their easier access to the large financial resources required.

The presence of hospital staff with previous experience of health information technology increases the likelihood of EHR implementation as less uncertainty is experienced by the end-users In order to be able to work with an EHR system, users must be capable of using information technology such as computers and have adequate typing skills [ 19 , 32 ].

An organizational culture that supports collaboration and teamwork fosters EHR implementation success because trust between employees is higher The influence of organizational culture on the success of organizational change is addressed in almost all the popular approaches to change management, as well as in several of the articles in this literature review.

Introduction

EHR implementation is most likely in an organization with little bureaucracy and considerable flexibility as changes can be rapidly made A highly bureaucratic organizational structure hampers change: EHR system implementation is difficult because cure and care activities must be ensured at all times During the process of implementing an EHR system, it is of the utmost importance that all relevant information is always available [ 28 , 34 , 39 ].

Category B - content The content of the EHR implementation process consists of the EHR system and the corresponding objectives, assumptions, and complementary services. Table 5 Category B — Content findings. General finding Finding code Article numbers Creating a fit by adapting both the technology and work practices is a key factor in the implementation of EHR.

Creating a fit by adapting both the technology and work practices is a key factor in the implementation of EHR This finding elaborates on the sociotechnical approach identified in the earlier section on the theories adopted in the articles. Hardware availability and system reliability, in terms of speed, availability, and a lack of failures, are necessary to ensure EHR use In several articles, authors highlight the importance of having sufficient hardware.

To ensure EHR implementation, the software needs to be user-friendly with regard to ease of use, efficiency in use, and functionality Some authors distinguish between technical availability and reliability, and the user-friendliness of the software [ 19 , 24 , 32 ]. An EHR implementation should contain adequate safeguards for patient privacy and confidentiality Concerns over privacy and confidentiality are recognized by Boyer et al.


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EHR implementation requires a vendor who is willing to adapt its product to hospital work processes A vendor must be responsive and enable the hospital to develop its product to ensure a good and usable EHR system [ 32 , 33 ]. Table 6 Category C - Process findings. Identifying champions among clinical staff reduces resistance.

Participation of clinical staff in the implementation process increases support for and acceptance of the EHR implementation Participation of end-users the clinical staff generates commitment and enables problems to be quickly solved [ 25 , 26 , 36 ]. A comprehensive implementation strategy, offering both clear guidance and room for emergent change, is needed for implementing an EHR system Several articles highlight aspects of an EHR implementation strategy. Establishing an interdisciplinary implementation group consisting of developers, members of the IT department, and end-users fosters EHR implementation success In line with the arguments for management support and for the participation of clinical staff, Ovretveit et al.

Identifying champions among clinical staff reduces resistance The previous finding already elaborated on clinical staff resistance and suggested reducing this by addressing their concerns. Assigning a sufficient number of staff and other resources to the EHR implementation process is important in adequately implementing the system Implementing a large EHR system requires considerable resources, including human ones.

Discussion This review of the existing academic literature sheds light on the current knowledge regarding EHR implementation. Table 7 Findings sorted by subject. Subject Related findings Nr. Appendix Appendix A - List of databases This appendix provides an overview of all databases included in the used search engines.


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    5. Web of Knowledge 1 Web of Science. Table 8 Quality assessment results of qualitative studies. Table 9 Quality assessment results of quantitative studies. Means of assessment reported? Table 10 Quality assessment results of mixed methods studies. Table 11 Overview of all findings.

    Author Findings Category Ash et al. A4 Ash et al. A4 Boyer et al. A5 Ford et al. A1 Ford et al. A1 Gastaldi et al. A2 Gastaldi et al. A3 Jaana et al. A1 Jaana et al. A1 Ovretveit et al. A2 Ovretveit et al. A3 Ovretveit et al. A1 Poon et al. A2 Poon et al. A2 Rivard et al. A6 Scott et al. A4 Takian et al. A3 Ward et al. A6 Weir et al. A3 Weir et al. A5 Weir et al. A5 Aarts et al. B1 Aarts et al. B1 Ash et al. B2 Ash et al. B3 Boyer et al. B2 Boyer et al. B4 Cresswell et al. B1 Gastaldi et al. B4 Katsma et al. B1 Ovretveit et al. B3 Ovretveit et al.

    B5 Poon et al. B5 Scott et al. B2 Takian et al. B1 Takian et al. B4 Takian et al. B2 Weir et al. B3 Weir et al. B1 Weir et al. B3 Yoon-Flannery et al. B2 Yoon-Flannery et al. B4 Aarts et al. C4 Ash et al. C1 Boyer et al. C2 Cresswell et al. C4 Cresswell et al. C8 Gastaldi et al. C2 Gastaldi et al. C4 Gastaldi et al. C6 Gastaldi et al. C3 Katsma et al. C4 Ovretveit et al. C2 Ovretveit et al. C5 Ovretveit et al. C1 Ovretveit et al. C3 Ovretveit et al. C1 Simon et al. C2 Simon et al. C3 Simon et al. C4 Simon et al. C5 Simon et al. C6 Simon et al.

    C7 Simon et al. C8 Scott et al. C2 Scott et al. C1 Scott et al. C1 Weir et al. C5 Weir et al. C2 Weir et al. C4 Weir et al. C3 Weir et al. C8 Weir et al. C8 Yoon-Flannery et al. C4 Yoon-Flannery et al. C6 Ash et al. C6 Ovretveit et al. C8 Poon et al. C6 Poon et al. C6 Aarts et al. C7 Poon et al. C1 Poon et al. C8 Rivard et al. C1 Rivard et al. C1 Takian et al. Acknowledgement We acknowledge the Master degree program Change Management at the University of Groningen for supporting this study.

    Footnotes Competing interests The authors declare that they have no competing interests. Contributor Information Albert Boonstra, Email: Electronic health record adoption and health information exchange among hospitals in New York State. J Eval Clin Pract. Implementation and adoption of nationwide electronic health records in secondary care in England: Extract from the report to the Public Accounts Committee on the implementation of electronic patient records at Danish hospitals.

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    Implementing electronic health records in hospitals: a systematic literature review

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    Definition, structure, content, use and impacts of electronic health records: A review of the research literature.

    Implementing electronic health records in hospitals: a systematic literature review

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    J Am Med Inform Assoc. Aarts J, Berg M. Same systems, different outcomes - Comparing the implementation of computerized physician order entry in two Dutch hospitals. Investigating physician order entry in the field: Stud Health Technol Inform. A cross-site qualitative study of physician order entry. Implementing electronic medical records in a psychiatric hospital: Int J Psychiatry Clin Pract. Integration of a nationally procured electronic health record system into user work practices.

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