Review article
The impact on health outcomes of implementing electronic health records to support the care of older people in residential aged care: A scoping review

https://doi.org/10.1016/j.ijmedinf.2021.104471Get rights and content

Highlights

  • Few studies report the impact of nursing home EHRs on resident health outcomes.

  • Studies vary widely in design and indicators/measures of health impact assessed.

  • Nursing home EHRs have positive impact on some but not all health outcomes.

  • More research is needed for solid conclusions to be drawn.

Abstract

Aim

The implementation of electronic health records (EHRs) in the aged care sector has been shown to improve efficiency and quality of care, administrative and funding processes. The aim of this study was to examine whether implementing EHRs and/or interventions leveraging EHRs in residential aged care facilities has any impact on health outcomes for residents and to review and summarise any published evidence.

Methods

Using the Joanna Briggs Institute guidelines for conducting scoping reviews, we searched PubMed, CINAHL, Embase, Cochrane and Scopus databases for articles describing the impact of EHRs and/or EHR-based interventions on health outcomes for residents in residential aged care. We included journal articles published in English between 2009 and 2019. After identifying articles meeting the inclusion criteria, we extracted individual findings and produced a narrative summary.

Results

Out of 6576 articles identified through database searches, seven met our inclusion criteria. The articles varied in study design, experimental methods, sample sizes and health outcomes assessed but there were no randomised controlled trials: four articles employed quantitative methods and three employed both quantitative and qualitative methods. The implementation of EHR-based interventions had positive impact on outcomes related to excessive weight loss, malnutrition, mobility, weighing of residents and use of antipsychotic medicines but had mixed impact (i.e., positive impact in some studies but non-significant or negative impact in others) on pressure ulcers, activities of daily living, behavioural symptoms, use of physical restraints and signs of depression. We also found that these interventions had no statistically significant impact on medication discrepancies, adverse drug events, falls or mortality.

Conclusion

In conclusion, research in this area is not yet comprehensive enough to reach a definitive conclusion on the impact of EHR-based interventions on health outcomes in residential aged care. As provider organisations increasingly implement EHRs, more research is needed to study their impact on resident health outcomes and examine how this impact eventuates.

Introduction

Implementing health information technology (HIT) is viewed as a potentially effective solution for some challenges facing the aged care industry, such as skilled staff shortages [1,2]. For example, the use of HIT, particularly electronic health records (EHRs), may help improve the quality of care by providing staff with accurate, reliable, and up-to-date information about the health issues of residents under their care, and facilitate effective decision-making and appropriate action during care provision [3].

It has also been suggested that EHRs can help facilitate more efficient documentation processes, freeing up time for staff to spend on direct care for residents [4]. However, some studies exploring time efficiency for documentation activities have shown that EHRs increase or have no effect on documentation time [[5], [6], [7]] while other studies have shown improvement in documentation times [[8], [9], [10], [11]]. In one literature review, 8 out of 12 papers that explored EHR impact on documentation times showed positive impact compared to only 5 that showed negative impact [12]. Other reported benefits of EHRs for residential aged care staff include better access to resident information, improved internal and external communication [3,8].

Studies have shown that benefits for organisations resulting from implementing EHRs include streamlined monitoring of staff work performance, efficient collection and use of data to support administrative activities, financial, regulation and compliance reporting [13], quality monitoring and securing funding [3]. In addition to these benefits, staff and management perceptions of EHRs in aged care services have been positive and there is widespread agreement that EHRs are beneficial for aged care [3,5,6].

Research on the impact of EHRs in aged care has been largely focused on perceived non-clinical benefits for consumers (e.g., improved communication and more contact time with care providers) [3,5,14] or operational efficiency for care staff and provider organisations [5,11]. However, the impact of implementing EHRs on health outcomes for residents is paramount to study as EHRs can help improve outcomes for care recipients but can also cause errors that may lead to unintended patient harm [15,16] and HIT problems in other care settings have previously been linked to patient harm and death in other studies [16,17]. As the implementation of EHRs in residential aged care grows, researchers are beginning to explore their impact on residents’ health outcomes. Installing an EHR alone may not be enough to produce favourable outcomes for healthcare consumers but it can enable other interventions which can, such as clinical decision support systems (CDSS), dashboards, real-time alerts, interoperable data exchange, data analytics and artificial intelligence. As we had no prior knowledge of whether residential aged care providers are using solely EHRs or EHR-based interventions to leverage the data contained in EHRs, we sought to include articles that describe studies of interventions building on the presence of EHRs. Therefore, our aim for this study was to:

  • (i)

    Examine whether implementing EHRs and/or EHR-based interventions (integrated into the EHRs or built on the EHRs) in residential aged care facilities has any impact on health outcomes for residents,

  • (ii)

    Review and summarise published evidence of the impact of such interventions on health outcomes for residents.

Section snippets

Search strategy

We followed the Joanna Briggs Institute (JBI) guidelines to conduct this scoping review [18]. Firstly, we drafted the key components of the review (title, aim, and inclusion and exclusion criteria). We then systematically searched academic journal databases that cover the disciplines of informatics, aged care and health i.e., PubMed, CINAHL, Embase, Cochrane and Scopus databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method [19]. We began the

Search results

The database search identified 6576 articles (4866 after de-duplication) which were screened down to 37 articles for full-text assessment for eligibility (Fig. 1). Our approach to use terms related to healthcare information technologies (HIT) and care of older people during the initial database searches returned high numbers of articles describing the use of various technologies, including assistive technologies, for the care of older people in various health care settings. This resulted in a

Discussion

In this review, we found seven studies evaluating the impact of EHR and/or EHR-based interventions on resident health outcomes in residential aged care. The studies explored the impact of interventions that range from basic EHR implementation only to sophisticated tools such as clinical decision support systems integrated into EHRs and education for nursing staff. The studies did not explore how the EHRs were used or whether there were any barriers to effective use of the systems which may have

Conclusion

In conclusion, the implementation of EHRs and/or EHR-based interventions in residential aged care has a positive impact on weight loss, malnutrition, mobility, weighing of residents and use of antipsychotics, mixed impact on pressure ulcers, activities of daily living, behavioural symptoms and symptoms of depression. These interventions do not have significant impact on other health outcomes. However, the evidence is still immature to reach a definitive conclusion on impact of EHR interventions

Summary table

What was already known about the topic:

  • Implementing electronic health records in residential aged care can help provide staff with accurate, and up-to-date information about the health issues of residents under their care and facilitate effective decision-making and appropriate action during care provision.

  • Aged care EHR systems may facilitate more efficient documentation processes that free up time for staff to spend on direct care for residents and improve internal and external communication.

Author contributions

All authors made a direct, substantial, and intellectual contribution to the conception, conduct and write-up of this study.

Transparency document

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Declaration of Competing Interest

The authors report no declarations of interest.

Acknowledgements

This study benefited from the support of the National Health and Medical Research Council Translating Research into Practice Fellowship (APP1151021) and the University of Queensland.

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