Further considerations in EMR adoption

Dear Sir, The recently published review article by Najaftorkaman, Ghapanchi, Talaei-Khoei, and Ray (2015) is a significant advance on our understanding of the historic influences on the electronic medical record (EMR). Their research represents a thorough review of what has gone before and highlights several areas of fruitful ongoing work. I would like to draw attention to the idea that a review of past work, even such a thorough one, does not reflect on what is missing from past research endeavors and what new areas might yield new innovative and important advances. Thus the Najaftorkaman et al. study’s taxonomy, although thoroughly grounded in evidence-based prior studies, only extends into the future those things that have arisen from the past. Much of my own work has been to do with technology use by people with cognitively diminished capacity (Burmeister, 2010, 2016; Pakrasi, Burmeister, McCallum, Coppola, & Loeb, 2015; Teipel et al., 2016), and I wish to use that as an example of the need to look beyond past work alone. For instance, Najaftorkaman et al. (p. 584) looked at the effects of computer literacy on EMR adoption, but in so doing did not consider the EMR needs of people whose cognitive limitations make such literary competence difficult to achieve. Another consideration arises from page 594, where they state that little attention has been given to “behavioral changes.” Although they exemplify, people with dementia are an example. As the disease progresses, personality can change and with it changes in emotional states, which result in behavioral changes (Lin et al., 2014; Teipel et al., 2016). One limitation of the Najaftorkaman et al. study is that no consideration was given to carers. They assumed that people whose health requires use of EMR are all capable of looking after themselves. But aside from people with cognitive impairments, there are many other situations in which carers are involved (guardians of minors, or people with physical limitations). In the context of my work in Australia I have repeatedly encountered situations where the carers of people with diminished cognitive abilities are discriminated against. Future EMR research should look at better ways to include the carers. Still another situation arises from pages 582–583, in which the need for autonomy is discussed, such as “user autonomy is one of the key individual factors that have an impact on EMR adoption. For instance, physicians would like to have the freedom to carry out appropriate treatments for their patients based on their best judgment.” (page 583). That autonomy for the health professional is important is clear from their research. However, what about the autonomy of the client? Current state of the art in regards to assistive technology for people with dementia attempts to maximize autonomy, while ensuring safety, such that technology assistants do not take over complete function, but facilitate as much as possible the use of the user’s remaining cognitive function (Burmeister, 2016; Teipel et al., 2016). Finally, in their Implications for Practice section (pages 595–596), they highlight the need for customization. I hope that the aforementioned examples for people with diminished cognitive abilities gives a further, concrete example that supports that need for customization. Thus my recommendation for the extension of the excellent work by Najaftorkaman et al. (2015) is that EMR adoption research also learn from current work in other areas, such as with people who have diminished cognitive abilities and yet need to enjoy the benefits that the rest of society enjoys through the advances in EMR.