It was with great interest that I read the recent article by Al-Rayes et al. Within the authors' institution, not all inpatient physicians have adopted a recently implemented electronic health record (EHR) system. This pilot cross-sectional quantitative study investigated the factors limiting adoption of EHR systems among physicians at King Fahd Military Medical Complex in Saudi Arabia. Using the theoretical Technology Acceptance Model, they found that to increase the EHR systems' adoption rate, the design, social influence, and perception of the system's benefits need to be improved.[1] The authors' efforts should be commended in their systematic approach to improve EHR adoption for their institution and throughout their region.

Paper-based record keeping and documentation has many disadvantages. It is not immediately available, it can be easily lost and destroyed, and is less reliable.[2] [3] In addition to enhancing the reliability of clinical documentation, EHR adoption can potentially lead to reduced human medical error, costs, and patient mortality.[4] It can also aid clinical decision making and may help in the identification and management of complex diseases.[5] [6] Overall, this has led to initiatives encouraging EHR adoption worldwide.[7] [8] [9] [10] [11] But, achieving EHR adoption may be difficult. Some of the known challenges stem from issues that Al-Rayes et al faced in their present study.[1] In addition, interoperability, usability, technical limitations, and patient acceptance also impact the facilitation of EHR adoption.[12] Identifying these barriers early on may assist in successful implementation by allowing healthcare systems to anticipate and avoid these common barriers.[12]

While the adoption of EHR systems is a priority, these are only the first steps. An examination of EHR systems postimplementation has described various effects and unintended consequences. These should not be overlooked after EHR adoption. This may include workflow interruptions, decreased efficiency in documentation, and documentation redunancy.[13] Users may develop workarounds, such as “copy-and-paste” functions, as they adapt to the new EHR system that can perpetuate redundant information and error.[13] There is a significant investment required to ensure the EHR system receives software maintenance and updates.[4] Any new clinician employed will require training to understand the current EHR and may require retraining if major updates to the software are made.[4] EHR systems are promoted to improve the quality and safety of patients, but medical errors can occur due to workflow disruption or software design flaws.[14] Thus, healthcare systems may have to establish policies and procedures to develop best EHR practices, track EHR safety events, and regularly review these events.[15] While EHR adoption is an important first step, maintenance and monitoring of an effective and an efficient EHR should also be an early objective.

Another early objective is ensuring clinician well-being. Physician burnout has become a major issue in the United States.[16] It is associated with high physician turnover, poor productivity, decreased patient satisfaction, and may compromise the quality of patient care.[16] While there are various factors attributed to physician burnout, the EHR has received increasing attention.[17] Studies examining this relationship suggest that EHR systems may be driving physicians to spend more time performing clerical tasks and documentation while spending less time with patients.[18] EHR systems may be contributing to clinician frustration as some designs are suboptimal contributing to usability issues, information, and cognitive overload.[19] Finally, the EHR may render certain processes to deliver medical care, such as simple ordering, arduous, and time-consuming.[20]

While Al-Rayes et al have determined how to facilitate EHR adoption and are rightfully focused on this initial step, the anticipation of the effects of full EHR adoption, both short-term and long-term, should also be stressed. This may require preimplementation workflow analyses to try uncover issues within clinician workflow that may continue to be present or possibly become worse postimplementation. After-hours usage has gained increasing attention in the outpatient setting and may be linked to physician burnout.[21] [22] Any facility adopting an EHR should consider assessing this possibility early on and determine if it is occurring preimplementation. If clinicians are starting to work after-hours after EHR implementation, it may lead to difficulties in EHR acceptance. An assessment of physician burnout may be need to be considered preimplementation to allow time to develop strategies to curb this possibility. Finally, a method of communication with clinicians postimplementation may be required.[15] By having an open dialogue with EHR experts, clinicians may be more open to discuss EHR issues and be willing to implement high-quality solutions.

Overall, the systematic approach to EHR adoption that Al-Rayes et al have outlined should be applauded. By increasing their understanding of the barriers to EHR adoption, they will have a higher likelihood of success. This thoughtfulness, however, should not end with EHR adoption. While there are positive aspects of EHR adoption, there could be undesirable effects. Al-Rayes et al and stakeholders involved in EHR adoption should consider being prepared for both computer and human considerations that can occur post-implementation.

我非常感兴趣地阅读了Al-Rayes等人的最新文章。在作者所在的机构中，并非所有住院医生都采用了最近实施的电子健康记录（EHR）系统。这项初步的横断面定量研究调查了限制沙特阿拉伯法赫德国王军事医疗中心内医生采用EHR系统的因素。他们使用理论上的技术接受模型，发现要提高EHR系统的采用率，需要改进其设计，社会影响力以及对该系统益处的认识。[1] 作者的努力以其系统的方法为机构及其整个地区改善电子病历的采用而受到赞扬。

纸质记录和文件记录有许多缺点。它不是立即可用的，它很容易丢失和销毁，并且可靠性较低。[2] [3]除了提高临床文档的可靠性外，采用EHR还可以减少人为医疗错误，降低成本和降低患者死亡率。[4] 它还可以帮助临床决策，并可能有助于复杂疾病的识别和管理。[5] [6]总体而言，这导致了鼓励在世界范围内采用EHR的倡议。[7] [8] [9] [10] [11]但是，实现采用电子病历可能很困难。Al-Rayes等人在本研究中面临的问题是一些已知的挑战。[1] 此外，互操作性，可用性，技术局限性以及患者的接受程度也影响了采用EHR的便利性。

虽然采用电子病历系统是当务之急，但这只是第一步。对EHR系统实施后的检查描述了各种影响和意外后果。在采用EHR之后，这些都不容忽视。这可能包括工作流程中断，文档效率降低和文档冗余。[13] 用户可能会开发出变通办法，例如“复制和粘贴”功能，因为他们适应了可以永久保留冗余信息和错误的新EHR系统。[13] 确保EHR系统获得软件维护和更新需要大量投资。[4] 如果对该软件进行了重大更新，则任何新雇用的临床医生都需要进行培训以了解当前的EHR，并且可能需要重新培训。[4] 推广电子病历系统以提高患者的质量和安全性，但是由于工作流程中断或软件设计缺陷而可能发生医疗错误。[14] 因此，医疗保健系统可能必须建立政策和程序，以开发最佳的EHR实践，跟踪EHR安全事件并定期审查这些事件。[15] 虽然采用电子病历是重要的第一步，但维护和监控有效的电子病历也应该是一个早期目标。

另一个早期目标是确保临床医生的健康。在美国，医师的倦怠已成为一个主要问题。[16] 它与高医师流失率，生产力低下，患者满意度降低有关，并可能损害患者护理质量。[16] 尽管有许多因素可归因于医生的倦怠，但EHR受到了越来越多的关注。[17] 研究这种关系的研究表明，EHR系统可能会促使医生花费更多的时间来执行文书任务和文档，而花更少的时间与患者联系。[18] 电子病历系统可能会导致临床医生沮丧，因为某些设计对可用性问题，信息和认知超负荷的影响不够理想。[19] 最后，EHR可能会提供某些流程来提供医疗服务，例如简单的订购，繁琐的，

尽管Al-Rayes等人已经确定了如何促进电子病历的采用，并正确地专注于这一初始步骤，但也应强调对短期和长期全面采用电子病历的影响的预期。这可能需要实施前的工作流程分析，以尝试发现临床医生工作流程中可能继续存在或在实施后变得更糟的问题。下班后的使用在门诊环境中引起了越来越多的关注，并且可能与医生的倦怠有关。[21] [22]任何采用电子病历的机构都应考虑尽早评估这种可能性，并确定其是否正在实施中。如果临床医生在实施电子病历后的几个小时后开始工作，可能会导致电子病历接受方面的困难。可能需要考虑预先评估医师的职业倦怠，以便有时间制定策略来遏制这种可能性。最后，可能需要一种在实施后与临床医生沟通的方法。[15] 通过与EHR专家进行公开对话，临床医生可能会更开放地讨论EHR问题，并愿意实施高质量的解决方案。

总体而言，应该赞扬Al-Rayes等人概述的采用EHR的系统方法。通过增加他们对采用电子病历的障碍的理解，他们将更有可能获得成功。但是，这种体贴不应随电子病历的采用而结束。尽管采用电子病历有一些积极的方面，但可能会产生不良影响。Al-Rayes等人和参与采用EHR的利益相关者应考虑为实施后可能发生的计算机和人工考虑做好准备。