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

Trisha Greenhalgh, Henry W. W. Potts, Geoff Wong, Pippa Bark and Deborah Swinglehurst
The Milbank Quarterly
Vol. 87, No. 4 (Dec., 2009), pp. 729-788
Published by: Wiley on behalf of Milbank Memorial Fund
Stable URL: http://www.jstor.org/stable/25593645
Page Count: 60
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Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-Narrative Method
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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.

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