Identification of the Barriers and Effectiveness of Using Electronic Health Record Systems among the Population of UK - Systematic Review Proposal

This proposal aims to investigate the effectiveness of electronic health record systems in healthcare settings in the UK and evaluate the challenges that might be encountered during implementation. A qualitative systematic review of articles will be conducted to accomplish the research objectives.

Running head: ELECTRONIC HEALTH RECORDS
IDENTIFICATION OF THE BARRIERS AND EFFECTIVENESS OF USING
ELECTRONIC HEALTH RECORD SYSTEMS AMONG THE POPULATION OF
UK - SYSTEMATIC REVIEW PROPOSAL
Name of the Student
Name of the University
Author Note

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ELECTRONIC HEALTH RECORDS
Abstract
An electronic health record (EHR), frequently referred to as electronic medical
record (EMR). It is referred as systematized collection of population and patient health
information which is stored electronically in a digital format. These records are often shared
across different health care settings, with the purpose of improving patient health and
preventing medication errors. The records are generally shared through enterprise-wide
information systems or network-connections, or other information exchanges and networks.
EHRs most often include a wide range of data that includes medical history, demographics,
allergies, medication and immunization status, radiology images, laboratory test results,
personal statistics like weight and age, billing information and vital signs. EHR systems are
formulated for storing patient data accurately. They also help to capture the state of patients,
across time. These records eliminate the necessity for tracking down the previous paper
medical records of a patient and also provide assistance in ensuring legibility and reliability
of the collected data. Further benefits of the electronic health records are related to reducing
or eliminating risks of data replication, owing to the presence of a single modifiable file.
Hence, this ensures presence of updated files that reduces associated risks of losing
paperwork. EHRs have been significantly effective while extracting medical data, for
examining potential trends and changes in the health status of a patient. This report contains a
research proposal that will aim to investigate the effectiveness of these electronic health
records, upon being implemented across healthcare settings in the UK. Furthermore, it will
also evaluate the challenges that might be encountered during such implemented. The
aforementioned research objectives will be accomplished by conducting a qualitative
systematic review of articles, relevant to the research question.
Keywords: electronic health records, medical records, patients, effectiveness, challenges

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Table of Contents
1. Introduction............................................................................................................................5
1.1. Background of the research.............................................................................................5
1.2. Rationale of the research.................................................................................................5
1.3. Research Objectives........................................................................................................7
1.4. Research Questions.........................................................................................................7
1.5. Summary of research.......................................................................................................8
2. Literature Review...................................................................................................................9
2.1. Literature Search Process................................................................................................9
2.2. Main Theoretical Perspectives........................................................................................9
2.2.1. Conceptual Framework of Electronic Health Record..............................................9
2.2.2. Benefits of the Framework.......................................................................................9
2.2.3. Implementation in the United Kingdom................................................................10
2.2.4. Disadvantages of the Framework...........................................................................10
2.3. Strengths and Weaknesses of the Literature.................................................................11
2.4. Similarities and Differences in the Literature...............................................................11
2.5. Inconsistencies in the Literature....................................................................................12
2.6. Gaps in the literature.....................................................................................................12
2.7. Interrelationships between Previous Literature and the Proposed Study......................13
2.8. Justification for the Constraints in the Literature Review............................................13
2.9. Scoping Review............................................................................................................13
2.10. Nature of the Research Approach to be adopted.........................................................14

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3. Methodology........................................................................................................................15
3.1. Methods.........................................................................................................................16
3.1.1. Search strategy.......................................................................................................16
3.1.2. Study Selection...........................................................................................................16
3.1.3. Inclusion criteria.....................................................................................................17
3.1.4. Exclusion criteria...................................................................................................17
3.1.5. Quality assessment.................................................................................................18
3.1.6. Assessment of risk bias..........................................................................................19
3.2 Data extraction...............................................................................................................21
3.3 Data synthesis.................................................................................................................21
3.4 Ethical assessment..........................................................................................................24
3.5 Informed consent............................................................................................................25
3.6 Ethical approval by the ethics review board..................................................................26
3.7 Conflict of interests........................................................................................................27
4. Limitations of the systematic review...................................................................................28
5. Dissemination.......................................................................................................................29
References................................................................................................................................30
Appendix 1...............................................................................................................................36
Appendix 2...............................................................................................................................37
CASP analysis for Article 1.................................................................................................37
CASP analysis for Article 2.................................................................................................41

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1. Introduction
1.1. 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).
1.2. 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

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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

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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).
1.3. 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.
1.4. Research Questions
 How effective is the present electronic health record system in the UK?

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 What are the barriers to implementation of electronic health record systems in the
UK?
PICO Question
Populatio
n
Patients in UK
Interventi
on
Elimination of barriers towards optimal implementation of EHR
Comparis
on
No implementation of HER or no eradication of barriers of EHR
Outcome
s
Optimal implementation of EHRs in healthcare system
1.5. 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.

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2. Literature Review
2.1. 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.
2.2. Main Theoretical Perspectives
2.2.1. 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).
2.2.2. 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

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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).
2.2.3. 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).
2.2.4. 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

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possibilities cannot be seized. Data security is a real concern as the nature of the data is
highly confidential (Middleton et al. 2013).
2.3. 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.
2.4. 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

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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.
2.5. 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.
2.6. 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

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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.
2.7. 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.
2.8. 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.

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2.9. 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.
2.10. 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.

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3. Methodology
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.
3.1. Methods
3.1.1. Search strategy
Electronic Database Keywords Boolean search Number of relevant

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operators 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
3.1.2. 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.
3.1.3. Inclusion criteria
Inclusion Criteria
Year 2012 to 2018
Language English

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Type of research Primary and secondary
3.1.4. Exclusion criteria
Exclusion Criteria
Year Articles published before 2012
Language Other than English
Articles Electronic health records based on US
perspectives
3.1.5. 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.

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3.2 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
3.3 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

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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).
3.4 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:

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 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

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 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

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4. Limitations of the systematic review
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.

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5. Dissemination
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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Appendix 1

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Appendix 2
CASP analysis for Article 1
Druss, B.G., Ji, X., Glick, G. and von Esenwein, S.A., 2014. Randomized trial of an
electronic personal health record for patients with serious mental illnesses. American Journal
of Psychiatry, 171(3), pp.360-368.
1. Did the trial address a clearly focused issue? Yes Can’t tell No
Mental health quality helps in assessing patient centered care and also leads to better recovery
of the patients, by improving their symptoms and quality of life. Thus, the trial addressed a
clearly focused issue that was related to quality of medical care, prevalent in mental health
settings.
2. Was the assignment of patients to treatments randomised? Yes Can’t tell No
The assignment of 170 individuals suffering from serious mental disorders, in addition to
comorbid medical conditions was randomized, following their ability to fulfill the inclusion
criteria. Randomized recruitment occurred through community mental health centre for
clinical refererral.
3. Were all of the patients who entered the trial properly accounted for at its conclusion?
Yes Can’t tell No
Of the 170 individuals who had been allocated on an equal basis, to the intervention and
usual care arm, 64 patients were accounted for at the end of the trial in the intervention
group, and 77 patients in the usual care group. Other participants either withdrew or were
lost, during the follow up period.

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4. Were patients, health workers and study personnel ‘blind’ to treatment? Yes Can’t tell
No
Blinding in clinical trial refers to concealment of group allocation from several individuals,
involved in the research study, in order to prevent bias in the results. However, the authors
failed to provide any information on concealing the participants, the researchers or the staff to
the treatment that was implemented.
5. Were the groups similar at the start of the trial? Yes Can’t tell No
All participants were similar at the beginning of the trial, and suffered from a range of mental
disorders such as, schizophrenia, major depression, bipolar disorder, PTSD, or
schizoaffective disorders that were confirmed through chart reviews. This eliminated
chances of bias due to heterogeneity.
6. Aside from the experimental intervention, were the groups treated equally? Yes
Can’t tell No
All the groups were treated equally, with the only exception of the intervention group
receiving personal health records, in addition to medical and mental health care in the
community. Both the groups were also contacted for follow up interviews.
7. How large was the treatment effect? The reviews and interviews of all mental and
medical disorders were conducted at baseline and during the follow up period. Primary
outcome was related to the quality of medical care ( cardio metabolic care, among patients
suffering from such conditions). Secondary outcomes were related to use of e-health services,

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patient activation, and health related quality of life. The results suggested an increase in total
amount of eligible preventive services from 24% to 40%, during the follow-up period in the
intervention group. Hence, personal health records showed significant improvements in use
of medical services and quality of medical care.
8. How precise was the estimate of the treatment effect?
Precision of the estimate regarding a treatment or intervention effects are often demonstrated
by confidence intervals that are computed from the data observed, after an intervention has
been implemented. Higher confidence interval suggests an increased likelihood of obtaining
similar results, when the same experiment is performed repeatedly on the target population.
However, the authors failed to provide any information regarding the confidence interval of
the results obtained after implementation of personal health records.
9. Can the results be applied to the local population, or in your context? Yes Can’t tell
No
The results can be applied to the local population, since people suffering from mental
illnesses are quite prevalent in the society. Owing to the high incidence of the mental
disorders that had been considered in this study, electronic personal health records can be
appropriately implemented among people with serious mental illness and associated
comorbid conditions, to improve the quality of life and help them to recover at a better rate.
10. Were all clinically important outcomes considered? Yes Can’t tell No

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The authors for appropriate in considering all essential clinical outcomes related to use of
health services self-management of patients quality of the preventive services and quality of
cardiometabolic care that was provided to mental patients suffering from cardiovascular
complications.
11. Are the benefits worth the harms and costs? Yes Can’t tell No
There are no potential harms of this intervention. The benefits associated with use of
electronic personal health records pertain to exchange of relevant health information across
the providers and reduce patient burden, thereby increasing their health and overall well
being.

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CASP analysis for Article 2
Ryu, B., Kim, N., Heo, E., Yoo, S., Lee, K., Hwang, H., Kim, J.W., Kim, Y., Lee, J. and
Jung, S.Y., 2017. Impact of an Electronic Health Record-Integrated Personal Health Record
on Patient Participation in Health Care: Development and Randomized Controlled Trial of
MyHealthKeeper. Journal of medical Internet research, 19(12), pp.1-12.
1. Did the trial address a clearly focused issue? Yes Can’t tell No
Patient engagement is an essential element, needed for success for medical practice as it plays
a crucial role for empowering the patients in making certain decisions about their health care.
Thus, the study focused or addressed an important issue related to effectiveness of personal
health records, on improving patient engagement in clinical settings.
2. Was the assignment of patients to treatments randomised? Yes Can’t tell No
Randomisation of the patients was conducted by recruiting 80 patients who visited a specific
outpatient clinic, during a predetermined time of July-September 2016. Randomised
recruitment was followed after evaluating whether the patients matched the inclusion criteria
that focused on providing informed consent, without any history of cancer cardiovascular
disease or other acute disorders, and having a body mass index above 23 kg/m2.
3. Were all of the patients who entered the trial properly accounted for at its conclusion?
Yes Can’t tell No
Of the 80 patients who were initially recruited for the study 51 were allocated to the
intervention group, and 29 to the control group. Of these randomly assigned patients, 44
were accounted for at the end of the study, from the intervention group, and 24 from the

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control group. Failure to account for all patients at the end of the trial can be attributed to
their withdrawal and failure to take lab tests for one patient.
4. Were patients, health workers and study personnel ‘blind’ to treatment? Yes Can’t tell
No
Blinding in clinical trial refers to the procedure in which one or more individuals or groups
are kept unaware of the intervention or treatment, on to which the patients or participants
have been assigned to, with the aim of avoiding bias in the results. Although it forms an
essential aspect of randomised control trial, the authors did not provide any information on
blinding or concealment.
5. Were the groups similar at the start of the trial? Yes Can’t tell No
The groups of patients were similar at the beginning of the trial that met the specific inclusion
criteria. Similarities between the recruited participants ensure that any differences in the
primary or secondary outcomes would be attributed only to implementation of the
intervention (electronic personal health record), and not to any other demographic,
geographical or social characteristics.
6. Aside from the experimental intervention, were the groups treated equally? Yes
Can’t tell No
Both groups received conventional care that pertains to lifestyle modifications, with the aim
of achieving weight loss goal, during the month long study period. The only difference in
between the two groups accounted for the intervention, where the sample group received

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variable mobile app software, and personal coaching for operating the android app that
educated them about the lifestyle modifications.
7. How large was the treatment effect?
The primary outcome of the clinical trial was related to bringing about a change in weight.
The body mass index of all participants were analysed before and after the study period.
Secondary outcomes pertain to changes in certain blood biochemical parameters, such as,
triglycerides, cholesterol and lipoprotein. Significantly higher weight loss (mean 1.4 kg, 95%
CI 0.9-1.9; P<.001) was demonstrated by the intervention group, when compared to the
control group at the end of 4 weeks. Moreover, the triglyceride levels were also found to be
significantly low, at the end of study period in the intervention group (mean 2.59 mmol/L,
95% CI 17.6-75.8; P=.002).
8. How precise was the estimate of the treatment effect?
A 95% confidence interval was obtained for both the primary and secondary outcomes
namely, weight loss and blood biochemical parameters. This suggests that if the experiment
was repeated repeatedly in a similar target population, same results will be obtained for 95%
of the time. Hence, the results were precise.
9. Can the results be applied to the local population, or in your context? Yes Can’t tell
No
Prevalence of a sedentary lifestyle and lack of physical activity among most individuals
across the globe indicates the need for adoption of a healthy lifestyle that will help in
achieving a loss of weight, thereby improving the quality of life among the individuals.
Hence, this electronic personalised health record application can be implemented in the local

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population, with the aim to enhance their overall health and wellbeing by reducing their
weight, thereby eliminating risks of cardiovascular and other chronic complications.
10. Were all clinically important outcomes considered? Yes Can’t tell No
The study could not determine the causal relationship going to the short intervention period.
Moreover, information was not provided about the process improvement in health outcomes
of the intervention group.
11. Are the benefits worth the harms and costs? Yes Can’t tell No
In spite of the limitations, since the primary objective of the study was to determine the
effectiveness of an electronic health record integrated android system in influencing patients
to make lifestyle changes, the intervention can be implemented on the local population to
derive direct benefits