Is patient care compromised by the rapidly changing computerised health information systems?" - A review of Literature Introduction The expansion of computer usage in all businesses and health services has increased exponentially over recent decades, and nurses in all care contexts in all countries now rely on computers for a range of management, communication, and care documentation purposes. Without computerization, the sustainability of most organizations and services would be in doubt, and their ability to meet mandatory reporting to funding authorities (McDonald T, 2012). The adoption of health information systems is seen world wide as one method to mitigate the widening health care demand and supply gap. In many countries, the health care sector is entering into a time of unprecedented change. Never before have there been such strong demographic trends between health care demand and supply (Ludwick, L 2008). The adoption rates of electronic medical records are on the rise. Even though popular opinion holds that the application of health informatics improves patient safety, improves physician office efficiency and mitigates shortages in health human resources, such systems can compromise short-term physician office performance, intimidate physicians and their office staff and have been shown, on occasion, to increase medical errors (Anchala, R, 2012). Previous analyses have shown that the implementation process is as important as the system itself. With particular shortages of clinicians expected in primary care in the future, it becomes imperative to understand the barriers to implementation success, so that adopters can be more successful(Kuperman, G., 2008). The objective of this research was to undertake a systematic review of the literature to identify the current state of knowledge about health information systems adoption. The goal is to understand factors and influencers from previous experiences of health information systems implementations and to respond to the question: "Is patient care compromised by the rapidly changing computerised health information systems?" Method Relevant literature was located primarily through systematic searches of electronic databases. Cinahl, Pubmed – health management systems were searched for key phrases such as "influence of computerised health information systems on patient care". Google scholar was also utilised as a tool to identify additional relevant literature which was then located through the specific journal. Articles that were peer- reviewed and utilised valid and detailed methodologies were included. These articles were predominantly qualitative in nature. The absence of articles that deal specifically with the impact of ITC (Information and technology communications) on health care systems prompted the inclusion of relevant and widely cited literature reviews. Articles published before the year 2005 were excluded. The 15 articles sourced have been systematically reviewed and synthesised in accordance with the dominant themes that emerged. Result When critically appraising the articles, they were categorized from several perspectives to gain insight into the review. Of the 20 articles reviewed, 12 pertained to enhanced results of computerized healthcare systems (Anchala, R,2012, Chang, J. 2011, Fabris, S. 2006, Fabris, S. 2006, Kuperman, G, 2007, Lester, W. 2008, Ludwick, D. 2009, McDonald, T. 2012, Sinard, J. 2015). 3 pertained to demolishing results in patient care in influence with Information and communication technology involvement in healthcare systems (Callen, J, 2007. Hagstedt, L, 2006. Wilson, A. 2007). Five articles did not pertain to any specific system. (Ulfvarson, J, 2010. Martens, J, 2008. Andersson H, 2014. Hagstedt, L, 2012, Tan, J. 2009) Articles were also categorized by the type of care setting for their implementation. Articles generally referred to implementations in hospital settings, general practice/primary care or no specific or documented setting. Although articles were found to come from a wide range of care settings, such as primary care, ambulatory care, long-term care, acute care, emergency care and community care, we did not find articles which identified unique implementation experience attributable to any one area of care. Many of the same lessons were extracted from widely differing care settings. Articles were reviewed for the major factors and issues they advocated as supporting or confounding their health information systems implementation. The majority of articles pertained to various socio-technical factors which complicated the implementations. Nine articles related to project management and financial factors and the remaining articles related to patient safety, data privacy, quality of care, liability, efficiency, training, standardization of clinical terms and other topics. Discussion: This literature review was a comprehensive systematic search of several sources to understand factors which affect implementations of health information systems in general practice. Users (health care providers) previous experiences with health information technology affected their experience with a new system, both positively and negatively. Previous experience seemed to define what was considered to be intuitive system features. The more intuitive the system or the more familiar it seemed to the user, the more likely it was to be used. Since each system is unique, training is usually required. The intensity of training, the timing of the training and the availability of training and support post-implementation all affected user experience. Access to experts on call (or "at the elbow") and post-implementation training were found to improve clinicians' experiences with the system in the first period after implementation. (Hagstedt, L, 2012) Studies reported that health information technology could affect the provider–patient dynamic. When designing the layout of an exam room, the computer monitor placement was shown to affect the interaction between provider and patient. Analysis showed that during an interview, when providers turned away from patients to enter clinical data into the system, a natural conversation breakpoint occurred. Interestingly, the study suggested that this breakpoint allowed the patient time to think about the interview and add detail to it enhancing the transfer of information between patient and provider(Callen, J, 2007). The study observed physicians showing patients their patient record to reinforce physician comments. Physicians who stopped talking when entering data used more gestures to communicate with patients, than those physicians who continued to talk while entering data. Patients did not show any signs of boredom or frustration while physicians attended to the EMR (Ulfvarson, J, 2010). One study acknowledged that systems occupy space within the exam room and advised implementers to provide appropriate physical space for systems. No studies were found that compared how provider–patient interactions in interviews were effected when providers used electronic health information systems as opposed to the paper equivalent. Several articles reported that quality of care was not adversely nor positively affected with a health information system implementation. However, one author argued that health information systems, like other interventions, should be regulated and certified. Like other forms of medical interventions (as an example, drugs), health information systems should be certified so erroneous system design or implementation do not lead to adverse medical events (Lester, W. 2008). He also advocated that health information system users should be certified to mitigate chances for adverse events due to incorrect usage. Some articles studied various dimensions of time as it pertains to implementations. Studies advocated that it takes time to implement a system and it takes time to learn how to use it. Consequently, studies observed a decline in patient throughput immediately after implementation. Although initially, clinicians believed it would take them more time to complete clinical activities after implementation, time and motion analyses found that there was a slight decrease in the time taken for common clinical documentation activities once the team was proficient with the system (Sinard, J. 2015). Aggregately, health information systems did not offer time savings, nor required more time for documentation. In one case where a time saving was encountered, that saving was put back into the encounter time for more patient care tasks. The literature search did not find articles focusing on how long it takes to stabilize workflow processes after an implementation. Expectedly, another common theme found in the search was that pertaining to financial concerns. Costs cited as deterrents to health information systems adoption were system costs, training, and lost opportunity cost due to ramp up or system down time. Narrative reviews commented that, left to their own resources, physicians would often not adopt health information systems simply because they do not see the return on investment value in them( Kuperman, G, 2007). One study did show a positive return on investment for a family practice that was organizationally connected to a hospital. Physician advocates seemed to be aggravated by benefits of systems adoption accruing largely to payers as opposed to physicians. Since payers received the benefits, physician advocates suggested that some of the costs should be supported by payers. Articles concluded that funding is required to drive adoption. Proposals from narrative review papers suggest cost sharing or financial sponsorship from government entities is required to support the high cost of adoption (Chang, J. 2011). Our review showed that adoption is influenced by financial factors to varying degrees in different jurisdictions. A more detailed investigation of financial reimbursement models for adoption and their implications to physician remuneration models is required and is the subject of our next research. Proponents of health information systems suggest that adoption leads unconditionally to a reduction in adverse medical events. One study, which has also been critically reviewed, showed adverse medical events were increased after health systems implementation (Hagstedt, L, 2006). Conclusion Health information systems are seen to be one solution to the pending problem. Such solutions can assist physicians in tracking patient medical history, interventions, encounters, lab test results as well as managing allergies and drug contraindications. But as shown above, such implementations are not simple technical projects. They come with risks, the apprehension over which can paralyze health information systems project in its tracks—or even prevent it from starting altogether.