Community based electronic health system:

a scoping review
Angelika Matic, Czaryna Pablo, Dana Patungan, Ivy Joyce Pantig, Zarinna Faye Peralta

College of Nursing and Midwifery, Main Campus, City of Balanga, 2100 Bataan, Philippines

02 July 2022

Abstract
Objective: Aims to explore the impacts of the transition from traditional to the
electronic health system in communities.
Methods: The founding of a research team marked the start of this scoping review.
Through Google Scholar database, a thorough search of original research publications
using keywords: (Electronic Health Record then and now effect) and (Adopting
Electronic Health Record). All search keywords pertinent to the study goal must be
included for a literature evaluation to be considered adequate.
Results: The majority of the studies gathered as references were published between
2017 and 2019. The USA was the main country of origin. Questionnaires/surveys,
interview, observation, and time-motioned observation were some of the methods used.
Different aspects affected by EHR were observed and noted such as the efficiency to
which lesser consuming tasks were documented as benefit, the inefficiency causing
staffs to focus on EHR alone rather than the patient care, the communication to which
was improved as per implementation, patient empowerment through giving full access
to their medical records, and data information were concerns about security and privacy
were raised
Conclusions: This study will show assessment whether a redesign of workflow is
necessary before implementing the updated healthcare system. More studies are
required to close the disparities in the adoption of EHR systems in various communities.
Almost 72% of patients thought that EHRs will improve the provider-patient
relationship and, thus, patient-provider communication. Doctors recognized the value
of being able to share patient-centered information with patients utilizing EHRs. It is
also claimed that patients' privacy and confidentiality were also a concern and one-third
of clinicians indicated their concern with illegal leakage. This study will further show
more information regarding the advantages and disadvantages of electronic health
record to community healthcare systems.

Keywords: (Electronic Health Record then and now effect) and (Adopting Electronic Health
Record)

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1. Introduction

Today is the information age, and the explosion of information technology has changed
every area of life and work. Electronic Health Systems use information and communications
technology (ICT) for health. Information has a specific role in planning, assessment, training,
legal considerations, and research in health management systems. Enough information is
valuable, and it must be well documented, maintained, retrieved and analyzed.

Electronic Health Systems are acknowledged as an enabling tool to help meet service
delivery objectives. In less-developed nations, information, and communication technology
(ICT) has not been widely adopted in healthcare. In fact, the production, application, and use
of information is the primary difference between developed and developing countries.
Technology is frequently solely used for simple and repetitive tasks such as medical records
management and related financial transactions. However, the development of ICT has more to
offer, where its adoption can steer healthcare in new directions to improve overall patient
wellness.

To monitor and improve community health, public health professionals need more inclusive,
frequently updated information about population health. With the help of Electronic Health
Systems, they can easily access these records and ensure improved delivery of care as well as
reduction of medication errors. In addition, these can overall enhance health monitoring and
surveillance. As well as promote the reduction of delay in health service coverage which can
lead to lower expenses in healthcare delivery. This new system can therefore be a crucial factor
to improve the status quo in public healthcare services. To date, lots of open-source Electronic
Health Record systems have been developed and used by the community. (1)

Given the widespread adoption of electronic health record systems in health care
organizations, public health agencies are interested in accessing EHR data to improve health
(2)
assessment and surveillance. Even while the Electronic Health Systems have the potential
to raise care quality, lower medical errors, and save administrative costs, using them in clinical
practice would necessitate significant technology expenditures as well as modifications to
current systems and procedures. Moreover, implementation of this project has barriers and
restriction, which includes, technical limitations, standardization limits, attitudinal constraints–
behavior of individuals and organizational constraints. For the nurses and staff working in
communities, such might not be affordable as patients come after patients every single day. In

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 addition, the age range of staff working at the site might not be a good indicator to use
technology-based data records.

After almost fifteen years of health sector reform, the Philippine government recognized
health information as one of the six strategic instruments of Kalusugang Pangkalahatan
(Universal Health Care) to achieve Philippine President Aquino’s health agenda. Thus, in 2010,
the DOH articulated its aims to establish a (better national) health information system that shall
provide: (1) evidence for policy and program development, and (2) support for the immediate
and efficient provision of health care and management of province-wide health systems.
Community Health Information and Tracking System development and implementation were
based on the hypothesis that, unlike other ICT systems, people-centric development and
deployment of CHITS enable technology adoption among typical government health workers
and allow its scale and sustainability. While antedating the DOH's call, CHITS, was proposed
and implemented to improve the process of data management that would, in turn, result in
better quality and more reliable health information for individual patient care as well as public
health management. (3)

Hence, this scoping review aims to explore the impacts of the transition from traditional to
the electronic health system in communities. The results shall increase the understanding of the
current issues faced by health workers regarding informatics. Also, this study seeks to examine
real-life experiences in order to analyze the impact of Electronic Health Systems in enhancing
healthcare quality and safety.

2. Methodology

Design

A research area's underlying concepts as well as the primary sources and categories of
accessible information are mapped through scoping reviews. Scoping reviews are described as
"preliminary assessment of potential size and scope of available research literature. Aims to
determine nature and extent of research evidence often includes ongoing research” according
to Grant and Booth (2009).

In addition, according to Levac et al. (2010) the steps in this framework are as follows:
Define the research question and link it to the purpose (1); Identify relevant studies by weighing

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feasibility with breadth and comprehensiveness(2); Choose studies using an adaptive team
approach to study selection and data extraction (3); and Compile, summarize, and report the
results, including the implications(4). Regardless of research quality, scoping reviews are
intended to offer a general overview of the data relevant to a topic and are helpful when
evaluating developing topics, to explain essential ideas and highlight inadequacies.

Search and inclusion

The founding of a research team marked the start of this scoping review. The team provided
recommendations on the general research topic to be addressed and the entire study process,
including the choice of databases to search and the definition of search keywords. Through
Google Scholar database, a thorough search of original research publications using keywords:
(Electronic Health Record then and now effect) and (Adopting Electronic Health Record). This
paper clarifies how technological advancement in the medical field contributes to the
advantages and disadvantages of adopting an electronic health record (EHR) using a scoping
review methodology. All search keywords pertinent to the study goal must be included for a
literature evaluation to be considered adequate. Additionally, we must add pertinent synonyms
and associated phrases. To make sure that no articles were overlooked in the search, a rather
large collection of keywords had to be used, necessitating many search algorithms.

Studies included

The following criteria have to be met by the articles: English language composition; full
text accessibility; use of primary empirical data; emphasis on EHR implementation; and
adherence to predetermined standards of excellence. The analysis comprised peer-reviewed
publications in English from the years 2012 to 2022 that satisfy the goal of the study. There
were around 17,900 articles produced when the keyword was used to search the literature.
Studies that examined the effects of Electronic Health Records (EHR) at the time and up until
the present were deemed eligible. Titles were reviewed by one reviewer, who then found the
abstracts of pertinent titles.

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 The references of the original retrieved articles helped find further relevant papers. The
chosen papers' pertinent references were also examined. Six (6) studies—three (3) qualitative
and three (3) quantitative—were ultimately included in this review after the titles had been
carefully screened.

3. Results

The objective of this scoping review was to give the most recent information on the
consequences of EHR deployment and the obstacles to EHR adoption and use. References from
PubMed, Web of Science, IEEE Xplore Digital Library, and ACM Digital Library were used
to conduct a literature search. EHR implementation's implications on clinical work and
community, data and information, patient care, and economic impact were all recognized. The
reported impediments to adoption and use that frequently occurred included limited resources,
poor/insufficient training, technical/educational assistance for users, as well as low levels of
literacy and technological proficiency.

Most of the research studies included as references were released between 2017 and 2019.
The primary country of origin was the USA. Some of the techniques employed included
questionnaires and surveys, interviews, observation, and time-motioned observation.

Effects of Implementing EHR

Figure 2 illustrates how the research found both positive and negative outcomes relating to the
work of healthcare providers/staff, data and information, patient care, and economic impact.

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Efficiency

It was hypothesized that increased productivity would follow the adoption of an EHR since
clinicians found frequently used EHR features to be helpful for increasing productivity. It was
thought that the removal of the need for paper-based records would result in less time-
consuming tasks. Following the introduction of the EHR, a time-motion observation study of
nurses revealed a significant decrease in the amount of time spent on administrative chores.
Staff members also highlighted increased productivity as a result of quicker information
retrieval from EHRs and shorter documentation times. According to an observational study by
Sockolow et al. (2016) that included data analysis of EHR usage, practitioners completed their
notes more quickly after the deployment of the EHR (mean hours to completion, 10–24 h) than
they did before (600–1200 h). Another study by Tubaishat, A. (2018) revealed that nurses'
opinions of EHRs in terms of perceived use and system quality were generally positive.

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Inefficiency

Providers used EHRs more frequently throughout work shifts as a result of widespread use
of EHRs in all facets of the care process. based on Blijleven et. According to al (2017),
clinicians felt that accessing and finding the relevant information in EHRs was challenging and
took longer than anticipated, which also had a detrimental effect on their productivity. There
is also the issue of how slow the systems are and how inaccessible they are in community-
based healthcare centers. A different poll conducted by Kittler et al. (2018) found that 71% of
the respondents (physicians) believed that more time was being spent on patient documentation
after the adoption of EHRs. Inadequately constructed EHRs and other design (usability) flaws
including the absence of templates and the inability to reuse old information.

Communication

One advantage of the use of EHRs/PHRs was said to be improved patient-provider

communication. While clinicians believed that new communication channels like messaging
through EHRs should improve communication between patients and providers, physicians
understood the benefit of being able to share patient-centered information with patients
utilizing EHRs. Clinicians believed that PHRs could help patients with information
clarification. In addition, a research found that 72% of patients thought PHRs would improve
the provider-patient interaction. Another study found no evidence of a negative effect of EHRs
on doctor-patient contact based on patient interview data. It was also discovered that EHRs had
a mixed effect on communication and the doctor-patient relationship since doctors and patients
had varied perspectives on this.

However, as doctors were preoccupied with entering information into EHRs, there was less
face-to-face/direct communication and less eye contact between patients and doctors during
their clinical consultations. Clinicians believed that the use of EHRs might negatively affect
patients' satisfaction because of the clinicians' fixation on typing and staring at screens, as well
as the placement of computers between patients and clinicians.

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 Empowering the patient

With the adoption of PHRs coupled with EHRs, patients now have more access to all or
certain portions of their medical records. Patients claimed to feel more empowered as a result
of having access to their medical records, and they stated that this made them feel more like
partners with healthcare professionals and in charge of their own care. Additionally, after the
EHR adoption, patients and doctors were said to work more closely together as they reviewed
information in records and made healthcare decisions together. Clinicians also highlighted that
PHR might offer patients the chance to verify recorded information.

Information and Data

Clinicians and patients expressed worries about EHRs and PHRs' privacy and security of
data and information. Regarding the use of PHRs, providers raised concerns about
inappropriate and unauthorized access to the sensitive information, such as mental health
information, they might contain. It was also mentioned that patients/consumers were worried
about privacy, security, and confidentiality issues related to the adoption of PHRs, while the
providers were more worried. one-third of doctors in a study expressed their concern about the
privacy of patient information in EHRs in cases of "illegal leakage."

4. Discussion

This scoping review provides evidence that the use of EHR can improve healthcare quality
by increasing time efficiency, adherence to guidelines and establishing nurse-patient
relationship.

Due to the availability of stored computerized data, EHR is often regarded as an ideal tool
for assessing healthcare quality and monitoring health providers' performance. The latter could
enable automated quality assessment, avoiding the costly and time-consuming processes of
manual chart review and medical record abstraction. This will necessitate future research into
intervention strategies for improving the quality and comprehensiveness of clinical data stored
in EHRs, as well as determining the best data extraction process

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 As a result, EHR can reduce costs associated with medical errors and time inefficiency. It
will also increase productivity. Several studies have found that using appropriate information
technology in healthcare delivery can improve hospital efficiency, with benefits of outweighing
the costs of adoption and patient satisfaction ratings. Regardless of the benefits that EHR can
provide, a proper implementation strategy is required.An implementation strategy is critical in
effectively establishing an EHR system, reducing resistance among medical practitioners and
health professionals, ensuring that the system is used optimally, and obtaining clinical results.

However, the current use of EHR initiated by new technology would have been hard to
foresee.Inspite of its positive effect, it might still have a negative result. Patient’s worry about
the security of the privacy of their data. Moreover, due to less face to face interaction wherein
the monitor has been set as a division between the patient and the provider, there is a big
possibility that it will also affect the patient’s satisfaction.

5. Conclusion
A study produced insightful feedback that will be helpful for a project that aims to use EHR
data to build and disseminate community health indicators for gauging community health. The
workflow would become unmanageable if we moved to a more technologically advanced base
without updating the outdated system of rural healthcare systems. This study will assist in
assessing whether a redesign of workflow is necessary before implementing the updated
healthcare system, taking into account aspects like the manpower shortage and the literacy level
of the RHU employees.

All of the health recording systems showed some universal characteristics that are necessary
to carry out basic tasks. They provide retention for extra medical information such as diagnosis
and medication, as well as user registration and recording of medical data with basic operations.
These records are easily accessible by electronic health systems, which guarantees better care
delivery and a decrease in medication errors. However, there are still significant difficulties,
including social and technical, economic, and technological ones, which prevent the
widespread implementation of EHR systems. More studies are therefore required to close the
disparities in the adoption of EHR systems in rural communities.

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 According to research using questionnaires, surveys, interviews, and observational studies,
72% of patients thought that EHRs will improve the provider-patient relationship and, thus,
patient-provider communication. A time-motion observation study of nurses revealed that
through it, the amount of time spent on administrative tasks was significantly decreased.
Clinicians recognized the value of being able to share patient-centered information with
patients utilizing EHRs, despite doctors' belief that new communication channels like
messaging through EHRs should increase communication between patients and providers.
Additionally, due to quicker information retrieval from EHRs and reduced documentation
times, productivity would increase. EHRs, according to clinicians, could assist patients with
information clarification.

The study shows that some of the issues we face in order to successfully implement
electronic health records include poor or insufficient training, technical or instructional help
for users, along with low levels of literacy and technology ability. Additionally, due to quicker
information retrieval from EHRs and reduced documentation times, productivity would
improve. However, there will still be times when individuals encounter issues or difficulties
when utilizing it, such as when clinicians thought that accessing and locating the pertinent
information in EHRs was difficult and took longer than expected, which also had a negative
impact on their productivity. It is claimed that, in addition to patients' overly-wordy concerns
about their privacy and confidentiality, one-third of clinicians in a research indicated their
concern about the protection of patient information in EHRs in circumstances of "illegal
leakage." As community staff become more accustomed to gaining access to and using EHR
data to support the primary purpose of health assessment, these observations and studies
indicate directions for future study and application development.

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