Tom Bowden and Enrico Coiera
What’s the research –
This is a systematic review of the published literature, summarising the evidence for costs and benefits of using electronic patient records created in primary care during unscheduled care. Unscheduled care is defined as any care that cannot reasonably be foreseen or planned in advance of contact with a health professional, and often is delivered in hospital emergency departments. Unscheduled care, by definition, is urgent with the need to take action at the time of contact with services.
Why it’s important –
One of the key justifications for developing Shared Electronic Health Records (SEHRs) is their potential to improve the quality and outcome of care for unanticipated or unscheduled events such as emergencies. In 1998, British Prime Minister Tony Blair famously stated that “If I live in Bradford and fall ill in Birmingham then I want the doctor treating me to have access to the information he needs to treat me”. This was used as a justification for the £13 billion National Program for Information Technology (NPfIT). Similar large-scale SEHR projects have been undertaken in many other countries including Canada, Australia and The USA. A surprising feature of most SEHR initiatives is that they have proceeded, ahead of any significant body of research evidence for their likely costs and benefits.
What have we learned –
There has been very little research conducted to evaluate large SEHR projects. Since the early evaluations of the UK experience with SEHRs by leading researcher Professor Trisha Greenhalgh and colleagues, there has been a steady accumulation of evidence from post-hoc evaluations of other shared record projects. Parallel literature from the US has explored the benefits of Health Information Exchanges (HIEs), but the generic nature of these systems makes it hard to identify any specific impact on unscheduled care.
However from the literature available we learned that shared electronic records, if well designed and appropriately targeted to meet specific and high value informational needs, could in principle improve the quality, safety and effectiveness of clinical care. At present however, the evidence for such benefits is weak, largely because it has not been sought. It is also the case that there has been little clarity in defining the informational needs which arise during unscheduled care. We suggest that seeing the SEHR as part of an information value chain emphasises that information delivery must be connected to decision making, for example through decision support systems, to deliver the most value.
Who should read this paper –
Policy makers, planners and health services need to question how precious resources are being expended. The low level of evaluation reported here is incommensurate with the expense and effort involved in creating SEHRs. With record systems typically servicing millions of patients, it would seem both prudent to demonstrate value for money in making this investment, as well as to demonstrate clear clinical benefit. At present such an evidence base does not appear to exist.
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little clarity in defining the informational needs during unscheduled care has made it difficult to demonstrate clear clinical benefit from SEHRs.