Annotated Bibliography: EHRs Impact on Healthcare Outcomes

This annotated bibliography examines the impact of Electronic Health Records (EHRs) on various aspects of healthcare. The included studies explore the effects of EHRs on patient safety, the efficiency and effectiveness of care delivery, and the patient experience. Several articles investigate workarounds in EHR usage and their consequences. Other studies focus on the development and validation of predictive models for adverse outcomes, nurse attitudes toward EHRs, and barriers to EHR adoption. The bibliography also addresses the impact of EHRs on patient outcomes for specific conditions like ischemic stroke, as well as the overall quality of care. Some studies reveal both the benefits and potential drawbacks of EHR implementation, including the need for improved communication between doctors and patients, and the impact of EHRs on small physician practices. The studies utilize various methodologies, including retrospective cohort studies, qualitative interviews, and Delphi studies. Overall, the bibliography provides a comprehensive overview of the current research landscape concerning EHRs and their multifaceted effects on healthcare systems, professionals, and patients. The findings suggest that while EHRs hold promise for improving healthcare, careful consideration of implementation strategies and ongoing evaluation are essential to maximize their benefits and mitigate potential risks.

Running head: ANNOTATED BIBLIOGRAPHY
ANNOTATED BIBLIOGRAPHY
Name of the student
Name of the university
Author’s name

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Blijleven, V., Koelemeijer, K., Wetzels, M., & Jaspers, M. (2017). Workarounds emerging
from electronic health record system usage: Consequences for patient safety,
effectiveness of care, and efficiency of care. JMIR human factors, 4(4), e27.
The research aims to provide insight of the EHR workarounds effects on organizational
workflows and also aims at evaluating their scopes, rationales and hoe they impact workflows of
the healthcare providers, safety of the patients, effectiveness and efficiency of the care delivered.
In order to conduct the study direct observations and follow up semi structured interviews were
conducted with 13 nurses, 31 physicians and 3clerks. Qualitative bottom up coding techniques
was used for identifying, analyzing and classifying EHR workarounds. The research was
conducted at a large university hospital across 3 specialties and settings. Rationales were related
to the components including technology, persons and tools, organization, tasks and physical
environment of the Systems Engineering Initiative for Patient Safety (SEIPS) framework for
revealing their source of origin and also for determining both the scope as well as the impact of
HER workaround.
Churpek, M. M., Yuen, T. C., Park, S. Y., Gibbons, R., &Edelson, D. P. (2014). Using
electronic health record data to develop and validate a prediction model for adverse
outcomes on the wards. Critical care medicine, 42(4), 841.
This retrospective cohort study was conducted in an academic medical center in the
United States with around 500 beds for the inpatients. The study aims at developing a prediction
model and validate it to detect cardiac arrest during the course of the treatment in the ICU as a
challenging risk with the help of EHR. The study has developed a prediction model for inpatients
in the ward that can assist in predicting the risk associated with cardiac arrest and ICU transfer.

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According to the authors, healthcare facilities incorporating the HER system allows to add other
variables and vital signs about the individual patients to the prediction model such as lab values
and other data of the patients that will help to evaluate and determine the risk scores of the
patient that will eventually help in increasing patient outcome by implementing treatment
strategies addressing those risk areas.
Graham, H. L., Nussdorfer, D., & Beal, R. (2018). Nurse attitudes related to accepting
electronic health records and bedside documentation. CIN: Computers, Informatics,
Nursing, 36(11), 515-520.
The study was conducted to explore the attitude of nurses related to beside
documentation and EHR and it aimed at gaining a better understanding of the practices of the
same by the nursing staffs. This study was conducted through a narrative qualitative approach for
carrying out in depth interviews in the focus group meetings. Two 60-90 minute group
interviews were conducted at a time and location that were convenient for the nurses. The study
analyzed nurse’s attitudes regarding bedside documentation and EHR and 3 themes emerged
from the study which will be helpful in designing nursing educational in service opportunity for
the nurses that will promote positive attitudes towards HER and bedside documentation that will
further facilitate a high quality care delivery increasing patient’s health outcomes.
Hamamura, F. D., Withy, K., & Hughes, K. (2017). Identifying barriers in the use of
electronic health Records in Hawai ‘i. Hawai'i Journal of Medicine & Public
Health, 76(3 Suppl 1), 28.

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The fact that implementation of Electronic Health Records (EHRs) can increase patient’s
health outcome is grounded on strong researches, thus, every health organization must adopt to
this technology in order to enhance the care quality and increase patient’s health outcome. The
study thus aims at getting an insight of the current EHR scenario in Hawai‘i and identify the
barriers in adopting this technology and also discuss the future implications in the Hawai‘i
medical community. A total of 8 focus groups were conducted in this study in 2014 for exploring
adoption of the EHR in the Hawai‘i. Open ended questions were asked to the facilitators to
implore discussion. Their reponses were then analyzed with the help of constant comparative
analysis. Themes and subthemes were tabulated following analysis. It was found every
participant groups have stated system compatibility. Thus, the study concluded that there is a
need to conduct more research in this area for getting insights of the EHR adoption and it is also
important to understand how this will impact the health providers in Hawai‘i.
Hunt, L. M., Bell, H. S., Baker, A. M., & Howard, H. A. (2017). Electronic health records
and the disappearing patient. Medical anthropology quarterly, 31(3), 403-421.
The study was conducted to determine how EHRs prioritize needs of the institution
which are exhibited as a list of prerequisites which are required to be documented following
every consultation. The study has conducted interviews, clinical observations and medical chart
reviews at the Diabetes Service Clinic (DSC) and the Weight Services Clinic (WSC) which
considered to be Superior Health Systems. This large healthcare system was found to be strongly
committed to using EHRs in all care settings. The study has successfully found evidences on the
role and importance of EHRs in the systematic transformation of medical records and is an
intimate interplay between heath care professionals and patients.

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Joynt, K. E., Bhatt, D. L., Schwamm, L. H., Xian, Y., Heidenreich, P. A., Fonarow, G. C., ...
& Hernandez, A. F. (2015). Lack of impact of electronic health records on quality of
care and outcomes for ischemic stroke. Journal of the American College of
Cardiology, 65(18), 1964-1972.
The study aimed at determining whether hospitals utilizing EHRs have better care quality
and better patient heath outcome of the patients than the hospitals who do not use EHRs. The
authors have conducted patient-level logistic regression analyses for every outcomes. They have
studied 626,473 patients from 1,236 U.S. hospitals in GET aligning with the guidelines s-Stroke
(GWTG-Stroke) from 2007 through 2010 which was linked to the American Association annual
survey for determining the use of EHRs. However, the study findings suggest that EHR is not
associated with delivery of an enhanced care related to strokes care, it is necessary for
maintaining a transparency in the healthcare system.
Migdal, C. W., Namavar, A. A., Mosley, V. N., & Afsar‐manesh, N. (2014). Impact of
electronic health records on the patient experience in a hospital setting. Journal of
hospital medicine, 9(10), 627-633.
The aim of the retrospective cohort study is to assess the impact of EHR on patient
experience. Ronald Reagan Medical Center and UCLA Medical Center (Santa Monica) two
private health centers were included in the study. A total of 3417 surveys were conducted for the
duration from 1 December 2012 to 30 May 2013. This included medical guidance from 9 UCLA
Health departments. Surveys were reviewed in order to evaluate contact between doctors and
patients. Using χ analysis., statistical comparisons were made. In the three months following
implementation of EHR all 16 questions evaluating medical / patient communication received

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better answers as compared to three months before implementation. Of these 9 issues, there was
statistically significant improvement, compared to the statistically significant improvement of the
remaining 7 questions. These results indicate that EHRs can improve communication between
the doctor and patient. Nonetheless, future research will try more evidence and clarification of
the etiologies of such a development. The CRC infrastructure has made this trend observable.
Sines, C. C., & Griffin, G. R. (2017). Potential effects of the electronic health record on the
small physician practice: A delphi study. Perspectives in health information
management, 14(Spring).
The aim of this qualitative analysis was to analyze the potential impact on wages,
unforeseen expenses and benefits and improvements in patient experiences by implementing an
EHR using a changed Delphi research design. The three-round survey process was completed by
15 professional panelists. The panelists decided that the number of patients seen a day would be
decreased by EHRs and their profits lowered. While their discussion of the effects of patient
results was restricted by the panelists, the loss of time with the patient was their most
predominant concern. They thought that an EHR reduces attention to the patient and may lead to
medical conditions being missed by doctors. The results of this study show EHR vendors an
avenue for developing education opportunities to teach doctors how to optimize EHR and share
success stories showing an improved financial impact.
Tubaishat, A. (2019). The effect of electronic health records on patient safety: A qualitative
exploratory study. Informatics for Health and Social Care, 44(1), 79-91.

ANNOTATED BIBLIOGRAPHY
The overall aim of this research was to explore the patient safety effect of EHRs as
viewed by nurses. The qualitative study was conducted through semi-structured interviews with
nurses in hospitals with the same EHR in Jordan. In a series of units and facilities of 10 hospitals
that used EHRs between one and five years, 17 nurses have been interviewed. After interviews
field notes were collected and thematically examined. The data gave rise to two major themes.
One considered improvements to patient safety by EHRs, and the other raised concerns about the
use of these systems. Four subthemes emerged under each major topic. EHRs also enhanced the
patient safety, either directly or indirectly, by reducing medication mistakes, maximizing data
recording, growing data integrity and ensuring data longevity. They expressed concern that
patient safety could be undermined as follows: data entry failures, technical problems, limited
critical warnings and inadequate use of system communication channels.
Yanamadala, S., Morrison, D., Curtin, C., McDonald, K., & Hernandez-Boussard, T.
(2016). Electronic health records and quality of care: An observational study
modeling impact on mortality, readmissions, and complications. Medicine, 95(19).
The observation study was carried out using the 2011 U.S. Hospital Association report in
the State Inpatient Databases. Surgical and medical patients were included in six broad, complex
situations. We performed univariate analyzes and developed hierarchical regression models for
EHR use and death, readmission rates and complications. In a differential study from 2008-2011,
they examined the impact of EHR implementation on the outcomes. It has been reported that
patients seeking treatment in hospitals without EHR is 3.5%, partial EHR 55.2% and full EHR
41.3%. The lowest patient deaths, readmissions and patient safety indicators in hospitals with
complete EHR is preceded, in univariate analyzes, by patients with limited EHR, and then by

ANNOTATED BIBLIOGRAPHY
patients in non-EHR hospitals (P<0.05). Both comparisons were not therefore significant when
other patient and clinical variables were taken into consideration and implementation of an EHR
program was not related to better patient outcomes (P > 0.05). Such results show that the effects
of medical and surgical care in the hospitals with no EHR framework are similar to those of the
hospitals with complete EHR systems after the contrary.

ANNOTATED BIBLIOGRAPHY
References
Blijleven, V., Koelemeijer, K., Wetzels, M., & Jaspers, M. (2017). Workarounds emerging from
electronic health record system usage: Consequences for patient safety, effectiveness of
care, and efficiency of care. JMIR human factors, 4(4), e27.
Churpek, M. M., Yuen, T. C., Park, S. Y., Gibbons, R., &Edelson, D. P. (2014). Using electronic
health record data to develop and validate a prediction model for adverse outcomes on the
wards. Critical care medicine, 42(4), 841.
Graham, H. L., Nussdorfer, D., & Beal, R. (2018). Nurse attitudes related to accepting electronic
health records and bedside documentation. CIN: Computers, Informatics,
Nursing, 36(11), 515-520.
Hamamura, F. D., Withy, K., & Hughes, K. (2017). Identifying barriers in the use of electronic
health Records in Hawai ‘i. Hawai'i Journal of Medicine & Public Health, 76(3 Suppl 1),
28.
Hunt, L. M., Bell, H. S., Baker, A. M., & Howard, H. A. (2017). Electronic health records and
the disappearing patient. Medical anthropology quarterly, 31(3), 403-421.
Joynt, K. E., Bhatt, D. L., Schwamm, L. H., Xian, Y., Heidenreich, P. A., Fonarow, G. C., ... &
Hernandez, A. F. (2015). Lack of impact of electronic health records on quality of care
and outcomes for ischemic stroke. Journal of the American College of
Cardiology, 65(18), 1964-1972.

ANNOTATED BIBLIOGRAPHY
Migdal, C. W., Namavar, A. A., Mosley, V. N., & Afsar‐manesh, N. (2014). Impact of electronic
health records on the patient experience in a hospital setting. Journal of hospital
medicine, 9(10), 627-633.
Sines, C. C., & Griffin, G. R. (2017). Potential effects of the electronic health record on the small
physician practice: A delphi study. Perspectives in health information
management, 14(Spring).
Tubaishat, A. (2019). The effect of electronic health records on patient safety: A qualitative
exploratory study. Informatics for Health and Social Care, 44(1), 79-91.
Yanamadala, S., Morrison, D., Curtin, C., McDonald, K., & Hernandez-Boussard, T. (2016).
Electronic health records and quality of care: An observational study modeling impact on
mortality, readmissions, and complications. Medicine, 95(19).