In this study we have shown that the introduction of an EMR that contains the paper-based medical record as document images is possible without a major negative impact on reported clinical practice. As could be expected from an EMR system that precludes the users from the paper-based medical record,13
the frequency of use of the EMR is high. Despite this fact, a majority of the physicians at most departments reported that several clinical tasks were performed more easily, and their user satisfaction scores were, on average, relatively high.
When considering the physician's frequency of use of the EMR for information retrieval, the difference between Aust-Agder Hospital and that of the reference group is distinct (). It may simply be accounted for in terms of lack of suitable alternatives to the EMR, although several informal sources of patient data are available to the physician (e.g., gathering printed excerpts from the EMR, asking the patient, or calling the patient's family practitioner). However, as pointed out previously,6
EMRs are much more useful when they are complete, leading to a higher frequency of use. This is in agreement with Bleich et al.,14
who found that a critical mass of patient data is necessary to make the physicians use the system. Also, a higher proportion of the physicians in Aust-Agder Hospital than in the reference group reported that they enter daily notes into the system (task 5, lower part of ). This suggests that the critical mass effect might also apply to documentation, a task described as difficult to computerize in other studies.15
Apart from entering daily notes, the physicians infrequently used the system for generating and storing information (, lower part). This could be due to the limited structuring and reuse of patient data in the system, forcing the user to repeatedly enter the same information. Furthermore, selecting, filling, and printing out short forms may involve more work when using the computer compared with filling it out by hand (e.g., short prescriptions, see task 12 in ).
Regarding the performance of the clinical tasks, all tasks for which the EMR really was used were generally performed more easily (). This could be due to an increased accessibility of clinical information, a finding supported by results from the interviews. On the other hand, some physicians—particularly the internists—found information retrieval more difficult to perform, indicating the opposite. A possible explanation is that although the medical record is accessible to the physicians, locating specific information in a large collection of patient data can be difficult. Furthermore, any network problems and problems regarding practical access to a computer terminal will have a negative impact on this matter.
Regarding user satisfaction, the physicians were equally satisfied with the EMR containing regular electronic data as that of the physicians in the reference group (). However, they were less satisfied regarding the EMR system as a whole (). This indicates that the changes come at a cost, and the role of the scanned document images should be considered.
The scanned document images play an essential role in making the EMR complete. However, the physicians were not satisfied with using this part of the system () and tended to avoid using it (). This could be due to poor practical availability of the information, as the images of multiple documents in continuous sections can be more than 50 pages long, and they are searchable only through manual scrolling. The internists were particularly dissatisfied () with the use of the scanned document images, presumably because their work depends more on the information contained in them. This contrasts the generally positive attitudes of the physicians, suggesting that the scanned document images are less prominent than the regular electronic data in clinical work. The negative aspects of the scanned document images may decrease with time, as the data in the old medical records become outdated and slowly lose their relevance. Possibly, a more comprehensive indexation and more efficient search functionality for the scanned multiple documents could improve the situation.
Four limitations of this study should be considered. First, the findings from evaluations of an EMR system in one hospital may not be valid for another hospital due to confounding factors such as financial and organizational differences3
as well as the variation in implemented functionality in each hospital.6
The numerous organizational changes induced by the introduction of a complete EMR system may, however, make a conventional pre–post study equally difficult to interpret. We have in this study tried to reduce the effects of confounding factors specific to each hospital by using a reference group consisting of physicians from several hospitals. Second, the one-year difference in time between this study in Aust-Agder Hospital and the study from which the reference group of hospitals is extracted might widen the differences found between the groups. However, the EMR systems in the reference hospitals have been unchanged during this time, except from minor maintenance updates. Third, we have compared the results from one whole hospital with those of selected units from several others, which means comparing samples drawn differently. However, the proportions of physicians from units in medical, surgical, and other wards were not statistically different in the two samples (χ2
p = 0.5). Fourth, this study has focused on clinical processes and has not been designed to cover patient outcomes. Although desirable, we have not considered it realistic to look for quantifiable changes in patient outcome until the effects of EMR on clinical practice in this hospital is documented.16