Factors identified as barriers or facilitators to EMR/EHR based interprofessional primary care: a scoping review

ABSTRACT

As interprofessional collaboration (IPC) in primary care receives increasing attention, the role of electronic medical and health record (EMR/EHR) systems in supporting IPC is important to consider. A scoping review was conducted to synthesize the current literature on the barriers and facilitators of EMR/EHRs to interprofessional primary care. Four online databases (OVID Medline, EBSCO CINAHL, OVID EMBASE, and OVID PsycINFO) were searched without date restrictions. Twelve studies were included in the review. Of six facilitator and barrier themes identified, the key facilitator was teamwork support and a significant barrier was data management. Other important barriers included usability related mainly to interoperability, and practice support primarily in terms of patient care. Additional themes were organization attributes and user features. Although EMR/EHR systems facilitated teamwork support, there is potential for team features to be strengthened further. Persistent barriers may be partly addressed by advances in software design, particularly if interprofessional perspectives are included. Organizations and teams might also consider strategies for working with existing EMR/EHR systems, for instance by developing guidelines for interprofessional use. Further research concerning the use of electronic records in interprofessional contexts is needed to support IPC in primary care.

KEYWORDS:

• Interprofessional collaboration
• medical informatics
• primary health care
• scoping review

Introduction

Interprofessional collaboration (IPC) in primary care involves professionals from multiple disciplines collaborating to provide high quality team-based, comprehensive, and patient-centered care (Fox et al., 2019; Seaton et al., 2021; Vanderbilt et al., 2016). IPC in practice encompasses a range of examples including professionals in multidisciplinary arrangements independently providing patient care with little communication with one another, and professionals in frequent communication working interdependently in an interdisciplinary or even transdisciplinary fashion (S. Morgan et al., 2015). IPC at all levels of health care is viewed as a basis for efficient and safe health systems, and some countries have made large strides toward integrated IPC in recent years (e.g., Canada, Australia, and Japan) (Patel & Reeves, 2018).

Primary care environments and shared team resources such as electronic medical or health record (EMR/EHR) platforms can support and reinforce collaboration and efficiency (Aboueid et al., 2020; Sangaleti et al., 2017; Supper et al., 2014). Shared communication tools bridge communicational and geographical separation (Schot et al., 2020), supporting collaboration when team members are not co-located or must travel between sites. When patients’ medical conditions require health professionals to communicate frequently and share tasks (Seaton et al., 2021), EMR/EHR systems with advanced communication features may be particularly useful.

Although EMR/EHR platforms are widely used (World Health Organization [WHO], 2016) these systems are not without challenges in interprofessional teams. Previous studies indicate that effective interprofessional collaboration requires clear team roles and responsibilities (Wranik et al., 2019) and processes for team problem solving and decision-making (Mulvale et al., 2016). Similarly, it has been suggested that teams establish protocols to guide proper EMR/EHR documentation as a team (Adamson et al., 2020).

Previous reviews found electronic records to be one among several facilitators of IPC in primary care (Mulvale et al., 2016; Sangaleti et al., 2017; Supper et al., 2014). Identifying how EMR/EHR systems hinder and support patient care provided jointly by health care providers from different professional backgrounds may contribute to the further development of EMR/EHR features that support teamwork. The purpose of this review was to synthesize the current literature on the barriers and facilitators of EMR/EHR systems to interprofessional primary care. Moreover, this review aimed to identify gaps in knowledge to provide direction for further research and inform future interventions to improve processes related to shared EMR/EHR use.

Background

Interprofessional primary care teams are well suited to support patients with complex health needs (World Health Organization, 2013, and patients of such teams report high care quality as well as improved self-efficacy and self-management (K. Morgan et al., 2020). Moreover, patients and caregivers of interprofessional primary care teams report greater care satisfaction and medication adherence compared to patients receiving usual care (McCutcheon et al., 2020. IPC in primary care is now more prevalent than solo practice in several European Union countries (OECD/EU, 2016) and is a key element of the patient’s medical home model for family practice in Canada and the United States (The College of Family Physicians of Canada, 2019); Agency for Healthcare Research and Quality (Agency for Healthcare Research and Quality [AHRQ], n.d..). In Canada, approximately half of all primary care physicians work in publicly funded interprofessional primary care models such as family health teams or primary care networks (Canadian Institute for Health Information [CIHI], 2016). However, implementation approaches (e.g., administrative structure, operational funding, remuneration arrangements) and team composition are not standardized across Canada’s 13 provinces and territories (Peckham et al., 2018). Currently there is limited evidence on the influence of these factors on the degree of interprofessional teamwork (Khan et al., 2022) and patient outcomes in Canadian practices (Donnelly et al., 2019).

Primary care teams contributed significantly to the COVID-19 pandemic response, for example by coordinating with public health to deliver COVID-related services and by increasing their use of digital strategies including remote consultations and electronic prescriptions (Kumpunen et al., 2021). During the pandemic, teams faced greater demand for mental health care services and struggled to increase accessibility by adopting approaches such as virtual care and remote triage, while at the same time contending with higher workloads and significant personal emotional distress (Ashcroft et al., 2021). Patients with post-COVID symptoms as well as those with chronic conditions that worsened during the pandemic as a result of deferred visits have highlighted the importance of team-based primary care (Pavli et al., 2021). Some European countries have seen a rapid uptake of digital tools to facilitate collaboration including shared access to patient records across providers (Kumpunen et al., 2021).

Collaborative practices vary from multiple professionals working in the same practice but in distant communication to highly communicative and integrated, based on the extent of shared information and decision making related to patient care (K. Morgan et al., 2020). A shared EMR/EHR can promote IPC in primary care by enhancing team communication and interactions (Cohen et al., 2015; Supper et al., 2014; Szafran et al., 2018). EMR/EHR use has been steadily growing (Hamade et al., 2019; Pandhi et al., 2014) to an average 93% of North American and European primary care practices in 2019 (CIHI, 2016, 2020). Within the last decade there has been a significant increase in national EHR systems, from fewer than 30 countries in 2010 to more than 50 in 2015 (World Health Organization, 2016).

Previous reviews have examined the use of EMR/EHR platforms in health care broadly, including factors influencing EMR/EHR use by health care professionals (Alanazi et al., 2020; Tsai et al., 2020), specifically physicians (de Grood et al., 2016; O’Donnell et al., 2018). The role of information and communication technology in improving interprofessional chronic disease management has also been studied in a previous review (Barr et al., 2017). However, the extent to which EMR/EHR systems support and hinder interprofessional collaboration in primary care settings has not been previously explored in a review to our knowledge.

Methods

We chose the scoping review methodology as it permits a comprehensive review and synthesis of complex areas that involve studies diverse in design and discipline (Arksey & O’Malley, 2005; Peters et al., 2015; Tricco et al., 2018). Scoping reviews may be conducted to examine key characteristics related to a specific concept, and often point to knowledge gaps in given topics (Munn et al., 2018). As such, scoping reviews serve as useful evidence to inform research as well as practice, education, and policy issues (Peterson et al., 2017). This methodology therefore fit our objectives to identify key features and functions of EMR/EHR platforms that support or hinder interprofessional primary care, and to ascertain gaps in the evidence base. This review followed the procedures outlined by Levac et al. (2010) with reporting guided by the PRISMA-ScR checklist (Tricco et al., 2018).

Identifying the research question

This review was guided by the research question: How do electronic medical or health record systems facilitate or hinder interprofessional primary care? A review protocol was not previously published. Concept definitions were followed for the purpose of identifying relevant studies (Table 1). IPC involved two or more health professionals from different disciplines (K. Morgan et al., 2020; Schot et al., 2020; Vanderbilt et al., 2016) and we employed the terms “electronic medical record” and “electronic health record” as they are often used without differentiation (Heart et al., 2017; Huang et al., 2018; World Health Organization, 2016).

Table 1. Definitions of main concepts.

Concept	Definition
Primary Care	“ … the day-to-day care that is provided by a physician or other qualified health care provider. Primary care providers are expected to be a patient’s first point of contact with the health system and should provide on-going, continuous care including referrals to other, more specialized providers, diagnostic testing and access to prescription drug therapies.” (Peckham et al., 2018)
Interprofessional collaboration (IPC)	“ … an active and ongoing partnership often between people from diverse backgrounds with distinctive professional cultures and possibly representing different organizations or sectors, who work together to solve problems or provide services.” (S. Morgan et al., 2015)
Electronic Medical Record (EMR)	“ … an office-based system that enables a health care professional, such as a family doctor, to record the information gathered during a patient’s visit. This information might include a person’s weight, blood pressure and clinical information, and would previously have been hand-written and stored in a file folder in a doctor’s office.” (Canada Health Infoway, n.d..)
Electronic Health Record (EHR)	“ … the systems that make up the secure and private lifetime record of a person’s health and health care history. These systems store and share such information as lab results, medication profiles, key clinical reports (e.g., hospital discharge summaries), diagnostic images (e.g., X-rays), and immunization history. The information is available electronically to authorized health care providers.” (Canada Health Infoway, n.d..)

Identifying relevant studies

A comprehensive search strategy based on the terms of “electronic medical records” or “electronic health records,” “interprofessional collaboration,” and “primary care” was developed by a research librarian in consultation with the first two authors. Published peer-reviewed studies were identified by searching four databases in November 2018: OVID Medline, EBSCO CINAHL, OVID EMBASE, and OVID PsycINFO. No limitations were placed on publication year. The first 200 results across three consecutive initial searches were screened to refine the search. Supplementary Table S1 provides the search strategies. A forward citation search using Google Scholar and a backward citation search of the reference lists of included studies were conducted May 2019.

Study selection

Screening was performed using Distiller SR software (Evidence Partners Inc., Ottawa, Canada) and articles retrieved with Endnote (Clarivate Analytics). Titles and abstracts were independently screened by reviewer pairs based on three main criteria: the article was peer-reviewed, the sample included interprofessional team(s) of two or more primary care providers from different professions, and EMR/EHR use was a focus of the study. Disagreements were resolved by discussion and articles were included for full-text review where agreement could not be reached. The final inclusion and exclusion criteria for full-text articles (Table 2) were determined after a calibration exercise with 50 articles by two reviewers independently. Forward and backward citation searches resulted in 19 additional articles, however none were included after independent review.

Table 2. Inclusion and exclusion criteria.

Inclusion	Exclusion
English language Peer-reviewed original research or quality improvement (QI) study (program evaluation, clinical audit, practice review, service improvement, satisfaction/knowledge survey) Study participants included primary care providers Study participants were engaged in IPC Facilitators/barriers of EMR/EHR use to IPC among primary care providers was a focus of the study	Non-English Duplicate Review or study protocol Dissertation, book, book chapter, book review, editorial, commentary, opinion letter, letter to the editor, report, conference abstract or paper Insufficient focus on IPC between primary care providers Insufficient focus on facilitators/barriers of EMR/EHR use to IPC among primary care providers

Charting the data

An initial data charting form was created in Microsoft Excel and pilot tested by two reviewers with three articles. The first author extracted: author, title, journal, publication year, country, objectives, study characteristics (design, setting, sample), and terms and descriptions representing the three main concepts. All relevant data that pertained broadly to barriers or facilitators were extracted from the articles’ results and discussion sections and charted, initially grouped as either barriers or facilitators by article.

Collating, synthesizing, and reporting results

Charted data related to facilitators and barriers were synthesized by identifying common themes across the articles using inductive thematic analysis (Braun & Clarke, 2006) which is a qualitative synthesis methodology for grouping and interpreting qualitative findings (Bearman & Dawson, 2013). Working first with the facilitator data, the first author used a recursive six-phase process of thematic analysis (Braun & Clarke, 2006) which involved 1) reviewing the charted data, 2) systematically creating preliminary codes and collating data into the codes, 3) identifying patterns and collating initial codes into themes, 4) reviewing themes against the data, 5) refining and naming themes, and 6) and final analysis. Codes and themes were constantly compared against the data to ensure the original articles were accurately represented. A similar process was followed for the charted data related to barriers, except the barrier codes were first categorized based on the facilitator subthemes, with additional subthemes developed as needed. Themes were subsequently endorsed by all authors.

Quality appraisal

A quality appraisal was completed and consensus reached independently by two reviewers using the Mixed Methods Appraisal Tool (MMAT) (Hong et al., 2018). Following MMAT guidance, no studies were excluded based on the appraisal.

Results

A total 4,847 articles were identified (Figure 1). After removing duplicates and applying the study selection process, 12 articles were included in the review.

Figure 1. PRISMA flow chart of study selection and inclusion.

Study characteristics

As shown in Supplementary Table S2, six of the studies were published in the last 6 years (Cifuentes et al., 2015; Mercer et al., 2018; O’Malley et al., 2015; Steele Gray et al., 2018; Terry et al., 2018; Woodson et al., 2018) and all were conducted in either the United States or Canada. A qualitative approach was used in nine studies (Denomme et al., 2011; Fernandopulle & Patel, 2010; MacPhail et al., 2009; Mercer et al., 2018; O’Malley et al., 2015; Saleem et al., 2014; Shachak et al., 2013; Steele Gray et al., 2019; Terry et al., 2018) and mixed methods in three (Cifuentes et al., 2015; Sockolow et al., 2012; Woodson et al., 2018). Rural or small town sites were included in half of studies (Cifuentes et al., 2015; Denomme et al., 2011; Shachak et al., 2013; Sockolow et al., 2012; Steele Gray et al., 2019; Woodson et al., 2018), however other studies may have also included rural providers without explicitly noting. Six of the studies reported participant sex; females accounted for 58% to 89% of participants (Denomme et al., 2011; Mercer et al., 2018; Saleem et al., 2014; Shachak et al., 2013; Sockolow et al., 2012; Terry et al., 2018). The number of each type of health professional participant were specified in 8 studies (Fernandopulle & Patel, 2010; MacPhail et al., 2009; Mercer et al., 2018; O’Malley et al., 2015; Saleem et al., 2014; Shachak et al., 2013; Sockolow et al., 2012; Terry et al., 2018). The number of different professionals ranged from two (Mercer et al., 2018) to eight (MacPhail et al., 2009; Sockolow et al., 2012; Steele Gray et al., 2019). Supplementary Table S3 shows how the main concepts of “primary care” “interprofessional collaboration,” and “EMR/EHR” systems were operationalized in the studies. For instance, details provided about EMR/EHRs indicate that custom-built systems were included in four studies (Cifuentes et al., 2015; MacPhail et al., 2009; O’Malley et al., 2015; Saleem et al., 2014).

Quality appraisal

Overall study quality was high (Supplementary Table S4). Two studies had limitations, as the data provided did not entirely substantiate interpretation of the results (Fernandopulle & Patel, 2010; Saleem et al., 2014). Coherence was lacking between data collection, analysis, and interpretation in one study, and it was difficult to determine whether the findings were adequately derived (Fernandopulle & Patel, 2010). All studies were included for analysis regardless of quality appraisal.

Facilitators and barriers

Six themes overall were identified in barriers and facilitators of EMR/EHR systems to interprofessional primary care (Table 3 and Supplementary Table S2). Identified in 10 studies, teamwork support was more often a facilitator than barrier (Cifuentes et al., 2015; Denomme et al., 2011; Fernandopulle & Patel, 2010; MacPhail et al., 2009; Mercer et al., 2018; O’Malley et al., 2015; Saleem et al., 2014; Shachak et al., 2013; Sockolow et al., 2012; Steele Gray et al., 2019). Likewise, organization attributes (Denomme et al., 2011; Shachak et al., 2013; Sockolow et al., 2012; Terry et al., 2018) and user features (Denomme et al., 2011; O’Malley et al., 2015; Shachak et al., 2013; Terry et al., 2018) were more often identified as facilitators than barriers. In 8 studies each, data management (Denomme et al., 2011; Fernandopulle & Patel, 2010; Mercer et al., 2018; O’Malley et al., 2015; Saleem et al., 2014; Shachak et al., 2013; Sockolow et al., 2012; Woodson et al., 2018), usability (Cifuentes et al., 2015; Fernandopulle & Patel, 2010; Mercer et al., 2018; Saleem et al., 2014; Sockolow et al., 2012; Steele Gray et al., 2019; Terry et al., 2018; Woodson et al., 2018), and practice support (Cifuentes et al., 2015; Fernandopulle & Patel, 2010; MacPhail et al., 2009; Mercer et al., 2018; O’Malley et al., 2015; Saleem et al., 2014; Shachak et al., 2013; Woodson et al., 2018) were more often cited as barriers.

Table 3. Facilitators and barriers identified in included studies.

Theme	Facilitators		Barriers
	Subtheme (number of studies)	Reference	Subtheme (number of studies)	Reference
Teamwork support	Communication (6)	2, 3, 4, 6, 7, 9	Communication	None identified
	Care coordination (6)	1, 2, 3, 4, 6, 10	Care coordination (4)	1, 3, 4, 5
	Information sharing (4)	5, 7, 8, 10	Information sharing (3)	3, 7, 9
Total studies	10		6
Data management	Data entry (4)	2, 6, 8, 12	Data entry (7)	2, 3, 6, 7, 8, 9, 12
	Data accuracy (2)	4, 7	Data accuracy (5)	3, 5, 7, 8, 9
Total studies	6		8
Usability	Ease and efficiency (4)	3, 4, 7, 8	Ease and efficiency (4)	3, 7, 9, 12
	Accessibility (3)	3, 4, 7	Accessibility (2)	9, 10
	Technical issues (1)	9	Technical issues (1)	3
	Workflow	None identified	Workflow (2)	9, 11
	Interoperability	None identified	Interoperability (4)	1, 3, 5, 10
Total studies	5		8
Practice support	Customization (3)	7, 8, 12	Customization	None identified
	Decision support (3)	4, 10, 12	Decision support (1)	4
	Patient care (2)	8, 12	Patient care (7)	3, 4, 5, 6, 7, 8, 12
	Clinical registry (1)	8	Clinical registry (3)	1, 3, 6
Total studies	5		8
Organization attributes	Practice environment (3)	2, 9, 11	Practice environment (2)	2, 10
	Training and technical support (2)	8, 9	Training and technical support (2)	2, 8
Total studies	4		3
User features	Abilities (4)	2, 6, 8, 11	Abilities (2)	2, 7
	Characteristics and perceptions (2)	2, 11	Characteristics and perceptions (1)	2
Total studies	4		2

Bolded categories were identified in 4 or more of the included studies.

References: [1] (Cifuentes et al., 2015); [2] (Denomme et al., 2011); [3] (Fernandopulle & Patel, 2010); [4] (MacPhail et al., 2009); [5] (Mercer et al., 2018) [6]; (O’Malley et al., 2015) [7]; (Saleem et al., 2014); [8] (Shachak et al., 2013); [9] (Sockolow et al., 2012); [10] (Steele Gray et al., 2018); [11] (Terry et al., 2018); [12] (Woodson et al., 2018).

Teamwork support

Communication

An internal messaging system feature was viewed as beneficial for team communication (Denomme et al., 2011; Fernandopulle & Patel, 2010; Saleem et al., 2014; Sockolow et al., 2012), as was access to patient information, chart notes, templates, and tasking across the entire team (O’Malley et al., 2015). Even when co-located, some teams used an EMR/EHR as their main communication tool (MacPhail et al., 2009). Patient communication was also enhanced when clinicians directly conveyed information to patients visually via computer screens (Saleem et al., 2014). Communication barriers were not identified.

Care coordination

EMR/EHR capacity to support care coordination was deemed essential to IPC (Cifuentes et al., 2015; Denomme et al., 2011; Fernandopulle & Patel, 2010; MacPhail et al., 2009; O’Malley et al., 2015; Steele Gray et al., 2019) and was facilitated by secure messaging and tasking functionalities (Cifuentes et al., 2015; MacPhail et al., 2009; Steele Gray et al., 2019). Tasking helped to define roles and promote autonomy (O’Malley et al., 2015). Recognizing professional responsibilities in EMR/EHRs supported use; for instance some team members used only certain sections according to their needs (O’Malley et al., 2015). Some teams found that a lack of standard EMR/EHR templates for shared care plans hindered care coordination, for instance members could not view colleagues’ tasks once they had been completed (Cifuentes et al., 2015). Also, EMR/EHR software did not allow messages to be sent simultaneously to all professionals caring for a single patient (Fernandopulle & Patel, 2010).

Information sharing

By providing access to centrally stored patient data, EMR/EHRs aided information sharing and retrieval (Mercer et al., 2018; Shachak et al., 2013). Team members were also able to view one another’s progress notes asynchronously (Saleem et al., 2014; Steele Gray et al., 2019). However, some teams reported low information sharing capacity (Fernandopulle & Patel, 2010; Saleem et al., 2014; Sockolow et al., 2012) which hindered sharing of lab results and medication orders (Sockolow et al., 2012), and did not permit simultaneous opening of notes in the same patient record (Fernandopulle & Patel, 2010).

Data management

Data entry

Consistency in data entry across members was important for successful use of EMR/EHRs (Denomme et al., 2011). Some teams standardized entry by agreeing on practices and customizing templates (Shachak et al., 2013). Others developed and continually updated guidelines, specifying individuals responsible for entry and procedures to follow (e.g., format of abbreviations) (O’Malley et al., 2015). Lack of entry consistency hindered data tracking and quality improvement (Denomme et al., 2011; O’Malley et al., 2015). Teams reported dissatisfaction with finding and documenting information (Sockolow et al., 2012) and errors from accessing multiple records simultaneously (Saleem et al., 2014). The need for audit trails required certain members to be accountable for various components of EMR/EHR data, and was a barrier to sharing and delegating entry to team members (O’Malley et al., 2015).

Data accuracy

Some team members indicated the importance of EMR/EHR data accuracy and reliability (MacPhail et al., 2009), citing capacity for error detection and record completeness as benefits (Saleem et al., 2014). Team members could verify EMR/EHR information with patients to ensure completeness, such as symptom history (Saleem et al., 2014). Some team members were dissatisfied with completeness, partly related to entering data from paper or memory after visits (Sockolow et al., 2012). Data inaccuracy was reflected in a large volume of outdated information in patients’ problem lists (Saleem et al., 2014) and incomplete or incorrect data (Fernandopulle & Patel, 2010; Mercer et al., 2018) Accuracy could be supported by standardized data entry (Shachak et al., 2013). For instance, maintaining up-to-date medication lists was critical but ultimately challenging in a team setting, as some did not accurately enter each medication at each visit, and lists could be corrupted when multiple users simultaneously made changes in a record (Fernandopulle & Patel, 2010). Medication information may include rationale for prescriptions, and when missing may hinder decisions by subsequent members (Mercer et al., 2018).

Usability

Ease and efficiency

EMR/EHR ease and efficiency was cited as a facilitator (Fernandopulle & Patel, 2010; Mercer et al., 2018; Saleem et al., 2014; Shachak et al., 2013) and barrier (Fernandopulle & Patel, 2010; Saleem et al., 2014; Sockolow et al., 2012; Woodson et al., 2018) in an equal number of studies. Teams acknowledged time-saving features such as record searchability (Saleem et al., 2014) and electronic medication lists that allowed medication orders to be quickly filled at the point of care (Fernandopulle & Patel, 2010; O’Malley et al., 2015), internal messaging that reduced phone calls (MacPhail et al., 2009), and typewritten notes that eliminated the need to decipher handwriting (Fernandopulle & Patel, 2010). In terms of barriers, some professionals found documentation burdensome (Fernandopulle & Patel, 2010; O’Malley et al., 2015; Sockolow et al., 2012; Woodson et al., 2018), and considered it time-consuming to search for specific information (Woodson et al., 2018), manually score and upload paper-based assessments (Woodson et al., 2018), and enter data after hours or a patient visit (Fernandopulle & Patel, 2010; Sockolow et al., 2012). Inefficiencies also related to time-consuming screen changes (Saleem et al., 2014; Sockolow et al., 2012), printing clinical orders (Sockolow et al., 2012), and delays caused by system slow-downs and crashes (Saleem et al., 2014).

Accessibility

Some studies noted that EMR platforms improved information accessibility (Fernandopulle & Patel, 2010; MacPhail et al., 2009; Saleem et al., 2014). Charts were available even when working remotely (Fernandopulle & Patel, 2010), and this “placeless quality” ensured informational continuity when not co-located (MacPhail et al., 2009). However, accessibility barriers hindered interprofessional care when team members used different profession-specific EMR/EHR platforms, preventing full access to patient information (Steele Gray et al., 2019). Accessibility issues were also related to difficulties navigating the EMR/EHR and physical accessibility to computers (Sockolow et al., 2012).

Technical issues

One study indicated that team members were mostly satisfied or neutral about the frequency of technical issues (Sockolow et al., 2012). However, a second study found technical issues to be a hindrance, observing repetitive software glitches (Fernandopulle & Patel, 2010).

Workflow

EMR functionality did not support clinical workflow in two studies (Sockolow et al., 2012; Terry et al., 2018). For instance, team members were required to make multiple screen changes during patient visits and were unable to quickly record certain information such as vital signs (Sockolow et al., 2012). Team members reported dissatisfaction with clinician involvement in EMR/EHR design (Sockolow et al., 2012), and characterized their system as not intuitive or reflective of the way clinicians think (Terry et al., 2018). Facilitators related to workflow were not identified.

Interoperability

Teams found that a lack of interoperability of EMR/EHR platforms prevented information exchange with other systems and devices used by teams (Cifuentes et al., 2015; Fernandopulle & Patel, 2010; Mercer et al., 2018; Steele Gray et al., 2019) and siloed professionals (Mercer et al., 2018). Workload increased as data needed to be entered and accessed across multiple systems (Steele Gray et al., 2019). In one study, interoperability issues resulted in patients and staff physically transporting prescriptions to the neighboring pharmacy resulting in loss of prescriptions and delays (Fernandopulle & Patel, 2010). Moreover, the EMR/EHR system was unable to receive electronic laboratory results, preventing electronic data capture for quality improvement purposes (Fernandopulle & Patel, 2010). Facilitators related to interoperability were not identified.

Practice support

Customization

Enabling teams to customize EMR/EHR templates resulted in documentation tools that were well suited to team context (Saleem et al., 2014). Features that allowed teams to customize templates and forms to align with their clinic workflow and patient population contributed to consistent data entry among team members (Shachak et al., 2013). One study noted that customized templates facilitated easier documentation, review, and tracking of patient goals and challenges over time (Woodson et al., 2018). Barriers related to customization were not identified.

Decision support

Decision support was an important attribute for some teams. Examples included embedded clinical guidelines and referral pathways (Steele Gray et al., 2019), drop-down diagnosis lists, speed buttons to select billing codes and make quick notes, and auto-populated information summaries (Woodson et al., 2018). Patients also received decision support via self-management tools used in collaboration with clinicians (Steele Gray et al., 2019). In terms of barriers, one study noted that where teams followed sequential care, the EMR/EHR did not flag differences in treatment decisions that occasionally emerged as patients saw different providers over time (MacPhail et al., 2009).

Patient care

Two studies noted EMR/EHR facilitators of patient care (Shachak et al., 2013; Woodson et al., 2018). Proactive patient care increased, for instance via reminders for immunizations and examinations (Shachak et al., 2013). Some teams used EMR/EHR tools to track changes in specific assessment scores over time and identify patients needing specific services (Woodson et al., 2018). Seven studies identified barriers to patient care in EMR/EHRs. At the team level, a lack of panel management tools in EMR/EHR platforms prevented identification of patterns over time and inhibited patient-centered and continuous care (Fernandopulle & Patel, 2010; Saleem et al., 2014; Woodson et al., 2018). At the individual patient level, EMR/EHRs did not provide tools for longitudinal care management to track patient goals, challenges, and strengths, which are particularly useful for patients with complex needs (MacPhail et al., 2009; O’Malley et al., 2015; Woodson et al., 2018). Important patient care functions related to medication adherence (Mercer et al., 2018) and outreach were also not available (Woodson et al., 2018) and teams cited the negative impact of reduced eye contact with patients on patient-provider communication (Saleem et al., 2014; Shachak et al., 2013; Woodson et al., 2018).

Clinical registry

By using EMR/EHRs, some teams were able to compare patient information against targets set by government (Shachak et al., 2013). However, poor clinical registry functionality was a barrier in other studies (Cifuentes et al., 2015; Fernandopulle & Patel, 2010; O’Malley et al., 2015). Teams were limited in tracking patients individually or as a group longitudinally based on specific criteria such as certain conditions, which hindered care management (O’Malley et al., 2015) and quality improvement (Cifuentes et al., 2015; Fernandopulle & Patel, 2010).

Organization attributes

Practice environment

Team members who were EMR/EHR champions or advanced users, motivated and supported use (Denomme et al., 2011; Sockolow et al., 2012; Terry et al., 2018). Champions initially encouraged colleagues and assisted with problem solving, then advocated for more advanced use (Denomme et al., 2011; Terry et al., 2018). Staff turnover was identified as an impediment to use, since team members shared their knowledge with one another as new features were learned (Denomme et al., 2011). Organizational inertia was also a barrier to using EMR/EHR systems to their full potential (Steele Gray et al., 2019).

Training and technical support

Whether provided formally by technical support staff or informally by peers (see Supplementary Table S3), receiving in-house training and support after initial training by EMR/EHR vendors facilitated template customization and development of internal user manuals (Shachak et al., 2013). Teams valued support that was timely and tailored to user skills (Shachak et al., 2013), and benefitted from “super-user” peers (Sockolow et al., 2012). In one study, a team spread across several small town clinic sites depended on mainly peer support, however support was not always available to more remote sites (Shachak et al., 2013). Continued EMR use and improvement required champions to provide ongoing training and support, without which teams may not fully use their system (Denomme et al., 2011). Additionally, five studies noted that teams had access to formal technical support either on or off-site (Fernandopulle & Patel, 2010; O’Malley et al., 2015; Shachak et al., 2013; Sockolow et al., 2012; Terry et al., 2018).

User features

Abilities

Abilities, such as computer skills, varied based on experience (Denomme et al., 2011; Shachak et al., 2013; Terry et al., 2018). While some team members had the necessary skills to work comfortably with EMR/EHR platforms, others drew on colleagues’ knowledge (Denomme et al., 2011). Variation in technological abilities was reflected in the way team members used electronic records for either basic or advanced purposes (e.g., generating referrals) (Denomme et al., 2011). A lack of proficiency in key tasks was a barrier, for instance to care coordination (Saleem et al., 2014).

Characteristics and perceptions

Although six of the studies reported participant sex, no study examined the effect of sex on EMR/EHR use. Advanced use was found to be facilitated by positive perceptions of EMR/EHR systems (Denomme et al., 2011; Terry et al., 2018) and the individual characteristic of younger age (Shachak et al., 2013). Lastly, team members in one study reported feeling “overwhelmed” at the prospect of learning numerous EMR/EHR functions (Denomme et al., 2011).

Discussion

This review examined the extent to which EMR/EHR systems support and hinder interprofessional collaboration in primary care. Limited evidence on this topic points to a need for further studies that consider the varied experiences of interprofessional primary care teams in using electronic records and the impact of EMR/EHRs on facets of collaboration for the purpose of patient care.

Teamwork support

The most cited facilitator in this review was teamwork support, which is in line with previous reviews that identified information exchange and team communication as the principal ways electronic records support IPC in primary care (Mulvale et al., 2016; Sangaleti et al., 2017; Supper et al., 2014). D. Morgan et al. (2019) noted in a recent study that rural primary care memory clinic teams are only fully functional when every member has EMR access for collaboration. In this review, teamwork was facilitated by joint access to EMR/EHRs regardless of location and accessibility of records to all members. As suggested in a recent review (Schot et al., 2020), when providers separated by geography transfer information to one another, they overcome “communication divides” that inhibit IPC. Our review also found EMR/EHR platforms contributed to reducing role ambiguity and increasing autonomy. Recent reviews demonstrated that when sharing care, it is not uncommon for professionals to face role ambiguity and overlapping responsibilities (Schot et al., 2020; Supper et al., 2014). Therefore ensuring team members contribute according to their scope of practice is key to enhancing autonomy and reducing conflict (Seaton et al., 2021). Sharing information and notes via electronic records is also essential for IPC as sharing increases opportunities for accountability and multivocality, allowing providers to “construct the context of care” (Fox et al., 2019).

Our review suggests there is potential for teamwork features of EMR/EHRs to be further developed. EMR/EHRs were initially based around the practice of physicians to support documentation and billing (Bardach et al., 2017; Furlow, 2020; O’Donnell et al., 2018; Rudin et al., 2020) and to improve the quality of patient records (Hamade et al., 2019). Benefits related to increased quality of care such as reduced adverse drug events have since been recognized (Canada Health Infoway, 2013). Moreover, electronic record implementation has been supported through national initiatives worldwide (Payne et al., 2019), such as the Health Information Technology for Economic and Clinical Health (HITECH) Act in the USA (Kataria & Ravindran, 2020) and the 2013). However, the potential for collaboration in EMR/EHR platforms is largely underdeveloped and should be explored further (Bardach et al., 2017; Furlow, 2020; Rudin et al., 2020). For instance, one solution proposed by Rudin et al. (2020) is to incorporate existing asynchronous collaboration software used in the business industry (e.g., Slack).

Data management

Issues related to data management were a central barrier in this review, and hampered decision-making and quality improvement for teams. It is possible these issues are especially salient in settings where multiple professionals share records, as they emerged in a recent review that included teams (Tsai et al., 2020) but were less apparent in previous reviews focused on individual health professionals (de Grood et al., 2016; O’Donnell et al., 2018). This barrier points to an area for improvement in EMR/EHR software design to reduce data entry fatigue. For instance,2020) noted that incorporating autocomplete and autocorrect features may prevent misspellings, and Bardach et al. (2017) proposed more interactive systems that tailor information displayed to each team member based on their past EMR/EHR usage. Incorporating the perspectives of interprofessional primary care providers in software design can potentially result in further improvement. Other studies have noted the need for organizations and teams to clarify professional roles and scopes of practice as they develop policies for EMR/EHR team use (Adamson et al., 2020; Elias et al., 2015). For example, Adamson et al. (2020) reported that the successful implementation of a hospital-based interprofessional EHR involved setting explicit guidelines for sharing and documenting clinical decisions that acknowledged the different regulatory bodies and documentation standards of each profession.

Usability

Usability was also a major barrier in this review, due mainly to poor interoperability between systems. Lack of interoperability is a recurrent theme in previous reviews (de Grood et al., 2016; O’Donnell et al., 2018; Tsai et al., 2020) and has been shown to have negative implications for care continuity in primary care (Aboueid et al., 2020; O’Donnell et al., 2018). Poor interoperability in interprofessional teams can be exacerbated when members regulated by different organizations use profession-specific platforms (Adamson et al., 2020; D. Morgan et al., 2019), or work in multiple settings that use different EMR/EHR platforms (e.g., primary and tertiary care). In terms of usability related to other issues such as efficiency, findings in the included studies were mixed with teams reporting both time savings and demands. These results suggest that experiences can vary by team and EMR/EHR implementation. Other reviews have also reported mixed findings in terms of efficiency (O’Donnell et al., 2018; Tsai et al., 2020). Current and emerging technology that may improve efficiency and reduce user fatigue include login badges in lieu of typewritten usernames and passwords (Collier, 2018); automation of tasks such as auto documentation of clinical encounters using digital or virtual scribes, artificial intelligence tools and wearable technology such as Google Glass; and platforms that integrate different systems into a single interoperable systems with a user-friendly dashboard (Bardach et al., 2017; Kataria & Ravindran, 2020; Shah et al., 2020).

Practice support

A final important barrier identified in our study was practice support, particularly challenges to patient care that were reflected in a lack of EMR/EHR tools for tracking patient information and progress longitudinally. It should be noted that positive relationships between EMR/EHR use and certain quality of care outcomes such as patient safety have been documented recently (Kataria & Ravindran, 2020; Tsai et al., 2020). Our findings point mainly to an expressed need for tools to monitor the well-being of patients with chronic or complex conditions across care encounters. This need possibly reflects a gap in teams’ understanding of the collective effect of their interventions and should be explored further.

It should be noted that some factors discussed in previous reviews did not emerge in this review, including privacy and security concerns, practice size, and cost of technology (Alanazi et al., 2020; de Grood et al., 2016; O’Donnell et al., 2018; Tsai et al., 2020). The early stages of EMR/EHR adoption and use considered in other reviews, in contrast to the post-adoption period covered by most studies in our review, may partly account for differences in influencing factors. For instance, security and cost concerns may be expected to emerge as barriers in earlier stages of uptake and initial use.

Future research

This review identified a dearth of research on the impact of electronic records on interprofessional primary care. Although IPC in primary care is recognized as important, the use of electronic records in this context is understudied compared to non-team settings. A greater understanding of the ways in which teams use electronic records in everyday practice, and the implications of team and organization characteristics for EMR/EHR integration in primary care would be useful for improving functionality. For instance, future studies may examine the role of team configuration, size, and co-location, and factors such as management, rurality, and other shared resources. Characteristics of team members might also be considered, as a previous review found EMR adoption by primary care physicians positively associated with female sex and younger age (O’Donnell et al., 2018). Further intervention studies are warranted to examine how EMR/EHRs can be used more efficiently to support IPC in primary care, for instance through training and workflow adaptations (Shah et al., 2020). Lastly, future research should assess the state of EMR/EHR advances in interprofessional contexts and perceptions of utility, such as documentation created by voice-recognition technology and digital assistants (Kataria & Ravindran, 2020).

Strengths and limitations

The strengths of this review include the development of a search strategy in collaboration with a research librarian, application of standards for conducting scoping reviews, use of concept definitions to identify relevant studies, and use of thorough and reproducible methods including a quality assessment. However, some studies may have been missed given the strict screening criteria, exclusion of non-English language and literature other than peer-reviewed original research articles, and lack of relevant studies outside North America. Therefore, it is possible that publication bias affected the generalizability of the findings. It should be noted that the size and location of participants’ organizations varied from rural practices to large urban medical centers, which possibly influenced participants’ access to resources such as technical support and their attitudes or experiences. Moreover, the included studies were published over a 9-year period during which time EMR/EHR technology evolved, such as voice recognition to assist with transcription and other automated processes to improve efficiency (Kataria & Ravindran, 2020). Such changes in technology were not accounted for in this review.

Conclusion

This review revealed key facilitators and barriers of electronic records to interprofessional primary care. It is important that electronic records support interprofessional collaboration in primary care settings, however this is an understudied area and further research is needed to understand how these factors can be addressed. We suggest that effective solutions require the involvement of teams and their organizations, as well as EMR/EHR developers.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/13561820.2023.2204890.

Additional information

Funding

This work was supported by a Canadian Institutes of Health Research Foundation Grant to DGM (grant number 148444) and the Saskatchewan Health Research Foundation through a partnership with the Canadian Institutes of Health Research, in support of the Canadian Consortium on Neurodegeneration in Aging (CCNA) (grant number 3431).

Notes on contributors

Julie Kosteniuk

Julie Kosteniuk is a Research Associate in the Canadian Centre for Health and Safety in Agriculture, College of Medicine, University of Saskatchewan, Saskatchewan.

Debra Morgan

Debra Morgan is a Professor and Chair in Rural Health Delivery at the Canadian Centre for Health and Safety in Agriculture, College of Medicine, University of Saskatchewan, Saskatchewan.

Valerie Elliot

Valerie Elliot is a Research Officer in the Canadian Centre for Health and Safety in Agriculture, College of Medicine, University of Saskatchewan, Saskatchewan.

Melanie Bayly

Melanie Bayly is a Postdoctoral Fellow in the Canadian Centre for Health and Safety in Agriculture, College of Medicine, University of Saskatchewan, Saskatchewan.

Amanda Froehlich Chow

Amanda Froehlich Chow is an Assistant Professor in the School of Public Health, University of Saskatchewan, Saskatchewan.

Catherine Boden

Catherine Boden is an Associate Librarian, Leslie and Irene Dubé Health Sciences Library, University of Saskatchewan, Saskatchewan.

Megan E. O’Connell

Megan E. O’Connell is a Professor in the Department of Psychology, University of Saskatchewan, Saskatchewan.