Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta‐narrative Method

May combine two claims.

The authors found 11 studies in the interpretivist IS tradition, drawing on institutional theory, symbolic interactionism, organizational sense making, and soft systems action research.

“We found eleven studies in this tradition, including papers that drew on institutional theory (Currie and Guah 2007), symbolic interactionism (Prasad 1993), organizational sense making (Brown and Jones 1998;Desjardins, Lapointe, and Pozzebon 2006), and “soft systems” action research (Checkland and Holwell 1998).”

• cites Currie and Guah 2007Not checked yet

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• cites Prasad 1993Not checked yet

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• cites Brown and Jones 1998Not checked yet

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May combine two claims.

The authors found only three empirical positivist IS studies relevant to their research question, and all showed that model-based analyses of determinants of EPR success left much observed variance unexplained.

“We found only three empirical studies in positivist IS research relevant to our research question (listed in table 2), all of which demonstrated that model-based analyses of the determinants of EPR success left much of the observed variance unexplained.”

May combine two claims.

The EPR research literature is complex and heterogeneous, with diverse philosophical assumptions about ontology, epistemology, and methodology.

“We found a complex and heterogeneous literature characterized by diverse philosophical assumptions about the nature of reality (ontology), how that reality might be known (epistemology), and the preferred research approaches and study designs (methodology).”

May combine two claims.

The ninety-four primary studies outside the health informatics literature were philosophically pluralist, with 14% positivist, 19% interpretivist, 22% critical, and 55% recursive.

“The ninety-four primary studies (described in 129 papers) outside the health informatics literature were philosophically pluralist, with 14 percent positivist, 19 percent interpretivist, 22 percent critical, and 55 percent recursive.”

May combine two claims. The quote only partly states this claim.

The review's exploratory reading identified historical roots that informed later EPR research, including HCI, EBM, symbolic interactionism/ethnomethodology, workplace redesign, safety-critical systems research, social practice view of knowledge, complexity theory, and science and technology studies.

“Our exploratory reading identified a number of historical roots that informed later research on the EPR (see figure 2), including”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the implementation and use literature, until recently, neither the technology nor its social context was considered in depth.

“In the latter literature, at least until recently, neither the technology nor its social context was considered in depth.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The review considered 24 previous systematic reviews and 94 further primary studies.

“Twenty-four previous systematic reviews and ninety-four further primary studies were considered.”

May combine two claims.

The ninety-four primary studies were methodologically diverse, most using different types of case studies.

“As table 3 shows, they also were methodologically diverse, most with different types of case studies.”

May combine two claims.

In relation to the EPR, this mutual adaptation does not appear to be taking place, or at least not smoothly or unproblematically.

“In relation to the EPR, this adaptation does not appear to be taking place or, at least, not taking place smoothly or unproblematically.”

May combine two claims. The quote only partly states this claim.

Key tensions in the EPR literature centered on seven dichotomies: EPR as container or itinerary; user as information-processer or member of socio-technical network; organizational context as setting within which EPR is implemented or EPR-in-use; clinical work as decision making or situated practice; process of change as logic of determinism or logic of opposition; implementation success as objetct

“Key tensions in the literature centered on (1) the EPR (”

May combine two claims.

Key influences on the structuration process include the technology's affordances, time and space constraints, conflicting meanings attached to the EPR by different groups, patterns of human action and interaction, and how different genres of medical records are used and combined.

“Key influences on the structuration process include the affordances (see the glossary) of the technology, the constraints of time and space, the conflicting meanings attached to the EPR by different groups, the patterns of human action and interaction associated with them, and how different “genres” of medical records are used and combined in both traditional and contemporary patterns of care.”

May combine two claims.

The authors found 16 empirical studies in the change management meta-narrative, mostly single-site or multisite organizational case studies examining enabling and constraining factors on EPR implementation projects.

“We found sixteen empirical studies in this meta-narrative (for details, see table 2), most of which were single-site or multisite organizational case studies, each of which had considered the impact of a range of potential enabling or constraining factors on the fortunes of a project to implement a new EPR system.”

May combine two claims.

The authors found 11 empirical EPR studies using CSCW, and meta-narratives 7, 8, and 9 also draw on CSCW principles.

“We found eleven empirical studies on the EPR using this tradition, and in addition, meta-narratives 7, 8, and 9 draw on the principles of CSCW.”

May combine two claims.

Findings were highly consistent across interpretivist studies: users have multiple and conflicting framings of the EPR, some explained by deeply held institutional values.

“But the findings were highly consistent across studies: there are multiple and conflicting framings of the EPR by users (assumptions about it, expectations of it, versions of the problem to which it is seen as a solution), some of which are explained by deeply held institutional values”

May combine two claims.

The authors' searches identified 24 systematic reviews in the HIS tradition covering more than 2,000 primary studies, each measuring EPR impact on quality, safety, or efficiency of care.

“Our own searches found twenty-four systematic reviews in this tradition covering more than 2,000 primary studies, each of which measured the impact of the EPR on some aspect of the quality, safety, or efficiency of care.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The four philosophical positions overlap to some extent.

“These four positions, which are described in more detail in table 1, overlap to some extent.”

Probably not a substantial claim: may not pass S4 (based).

Health informatics technical design literature is separate from literature on implementation and use of systems in organizations.

“Although health informatics has a large literature on technical design, it is separate from the literature on the implementation and use of such systems in organizations.”

May combine two claims.

Successful EPR introduction requires a well-articulated vision and strategy, strong leadership, adequate resources, good project management, an enabling organizational culture, effective communication, and attention to human resource issues.

“It requires a well-articulated vision and strategy, strong leadership, adequate resources, good project management, an enabling organizational culture, effective communication, and attention to human resource issues.”

The quote only partly states this claim.

The review identified four main philosophical positions in EPR research: positivist, interpretivist, critical, and recursive (integrative).

“Adapting and extending previous taxonomies (de Vaujany 2005; Orlikowski and Baroudi 1991), we identified four main philosophical positions:”

• cites de Vaujany 2005Not checked yet

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• cites Orlikowski and Baroudi 1991Not checked yet

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Classified as probably not a substantial claim. May combine two claims.

Recursive and interpretivist traditions view context as inclusive, holistic, and fluid, an emergent property of action that is constituted by and inseparable from activity involving people and technologies.

“The recursive (and, to some extent, the interpretivist) research traditions share a more inclusive, holistic, and fluid view of context.Context is seen as an emergent property of action constituted by, and therefore inextricable from, an activity involving people and technologies.”

May combine two claims.

The authors found 22 primary research studies in the systems approaches to risk and integration tradition, plus an interdisciplinary literature review that was thorough but not explicitly systematic.

“We found twenty-two primary research studies in this tradition, along with an interdisciplinary literature review that was thorough but not explicitly systematic (Ash, Berg, and Coiera 2004).”

• cites Ash, Berg, and Coiera 2004Not checked yet

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May combine two claims.

The authors found 12 actor-network studies of the EPR, all drawing on CSCW as well as ANT, plus two empirically informed theoretical papers from ANT.

“As table 2 shows, we found twelve such studies of the EPR, all of which drew on CSCW as well as ANT, plus two empirically informed theoretical papers from ANT (Iedema 2003;Moser and Law 2006).”

• cites Iedema 2003Not checked yet

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• cites Moser and Law 2006Not checked yet

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May combine two claims.

Most tensions are between positivist studies (meta-narratives 1 and 3) and interpretivist, critical, or recursive studies (meta-narratives 2 and 4 through 9), though some traditions such as CSCW embrace more than one philosophical position.

“Most, but not all, the tensions are between studies that take a positivist worldview (broadly, meta-narratives 1 and 3) and those that take an interpretivist, critical, or recursive worldview (broadly, metanarratives 2 and 4 through 9), although some traditions (notably CSCW) embrace more than one philosophical position.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The relational view sees the EPR user as linked to wider social structures, institutions, or sociotechnical relationships and regards the collective as more than the sum of its parts.

“The relational view sees the EPR user as inextricably linked to (indeed, as embodying and reproducing) wider social structures, institutions, or sociotechnical relationships (and perhaps as “shaping” the EPR rather than “using” it) and thus regards the collective as more than the sum of its parts.”

May combine two claims.

Actor-network analyses of EPR technologies are highly regarded and extensively cited in science and technology studies but have been ignored or dismissed by most previous systematic reviews of the EPR.

“Actor-network analyses of EPR technologies are highly regarded and extensively cited in the field of science and technology studies but have been either ignored or dismissed by most previous systematic reviews of the EPR.”

May combine two claims.

When used as a formal tool with structured templates and coded data, the EPR often slows down and frustrates the clinical encounter but greatly accelerates secondary uses of clinical data.

“When used as a formal tool (e.g., with structured templates and a requirement for data to be coded), the EPR often slows down and frustrates the clinical encounter, but it greatly accelerates the secondary uses of clinical data.”

May combine two claims.

The authors found nine feminist studies and three Foucauldian studies.

“We found nine studies from a feminist perspective and three from a Foucauldian perspective.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Critical research traditions tend to treat context as an external reality composed of economic and social structures that constrain action, often unequally and oppressively.

“Critical research traditions also tend to view context as an external reality, in this case made up of economic and social structures that constrain action (and do so in an unequal and potentially oppressive way).”

Classified as probably not a substantial claim. May combine two claims.

Positivist traditions tend to view clinical work as largely reducible to a series of decisions, and conclude that decision support technologies will help clinical work if properly designed and implemented.

“Positivist traditions tend to view clinical work as largely reducible to a series of decisions, and it follows that decision support technologies will help clinical work so long as they are properly designed and implemented.”

May combine two claims.

Positivist traditions tend to take an essentialist, functionalist, and determinist view of the EPR, while nonpositivist traditions view it as a social construction or a fluid and flexible artifact that acts in situated contexts.

“Positivist traditions tend to take an essentialist, functionalist, and determinist view of the EPR (it has inherent properties that will perform certain tasks and, if implemented properly, will more or less predictably improve the process and outcome of the clinical encounter).In contrast, nonpositivist traditions view the EPR as either a social construction (something whose meaning and purpose”

Probably not a substantial claim: may not pass S3 (load-bearing).

The inseparability of the EPR from its context is a defining characteristic of literature adopting a recursive philosophy.

“Indeed, this inseparability of the EPR from its context (the fact that context is constituted by the EPR-in-use) is a defining characteristic of literature that adopts a recursive philosophy.”

Classified as probably not a substantial claim.

The biomedical literature sometimes describes information superhighways that will make clinical information instantly available in a way that transcends the context in which it was collected.

“The biomedical literature sometimes talks of “information superhighways” that will make clinical information instantly available in a way that transcends the context in which this information was originally collected (Detmer 2000).”

• cites Detmer 2000Not checked yet

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May combine two claims.

Despite concluding that the EPR is often less fit for purpose than paper, the CSCW literature does not oppose technology.

“Despite its apparently negative conclusion that the EPR is often less fit for the purpose than paper is, the CSCW literature on the EPR does not oppose technology, for three reasons.”

Classified as probably not a substantial claim.

Interpretivist and recursive traditions hold that the notion of an agreeable EPR or a single reality represented by it is problematic.

“Interpretivist and recursive traditions hold that the very notion of an “agreeable” EPR (or a single reality represented by it) is problematic.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The cognitive perspective explains nonuse of the EPR as knowledge, skills, and motivation gaps in the individual, for which the solution is information, training, and incentives.

“The former perspective explains the nonuse of the EPR as a “knowledge gap,” “skills gap,” and “motivation gap” (thus as attributes of the individual actor) for which much of the solution is the provision of information, training, and incentives.”

May combine two claims.

EPR research contains a tension between clinical work as decision making and clinical work as situated practice, and between knowledge as transferable facts and knowledge as information-in-context.

“The tension here might be expressed as “clinical work as decisionmaking” versus “clinical work as situated practice,” and between “knowledge as transferable facts” versus “knowledge as informationin-context.””

Classified as probably not a substantial claim. May combine two claims.

The synthesis considers seven key themes, each with inherent tensions.

“Next we consider seven key themes, each of which has inherent tensions.”

Probably not a substantial claim: may not pass S1 (asserted). May combine two claims.

The alternative literature suggests that quality-of-care gains from EPR systems are likely to be relatively modest, incremental, local, and based on articulations and workarounds, while still recognizing major potential efficiency savings for secondary uses.

“The alternative literature suggests that gains in the quality of care with EPR systems are likely to be relatively modest, incremental, local, and based on the study of articulations and workarounds (i.e., of the creative human work bridging the gap between technical design and clinical reality), although this view still recognizes the major potential efficiency savings that EPR systems offer for”

May combine two claims.

The three Foucauldian studies link EPR introduction with a rise in managerial surveillance and control of clinical work and draw on Foucault's panopticon concept.

“The three studies from a (broadly) Foucauldian perspective link the introduction of the EPR with the rise in managerial surveillance and control of clinical work and draw on Foucault's concept of the panopticon.”

May combine two claims.

This meta-narrative provides considerable evidence that EPRs may contain features protecting against error but also introduce new risks, including cognitive overload, loss of overview, data entry and retrieval errors, excessive trust in electronic data, and conflation of data entry with communication.

“Overall, this metanarrative provides considerable evidence that even though EPRs may contain features that protect against error, they also introduce new risks of their own, including cognitive overload, loss of overview, errors in data entry and retrieval, excessive trust in electronically held data, and the tendency to conflate data entry with communication within and among care teams (Ash et al”

• cites Ash et al. 2009Not checked yet

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• cites Weiner et al. 2007Not checked yet

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Probably not a substantial claim: may not pass S4 (based). May combine two claims.

Positivist traditions hold that the patient's condition and journey comprise a single reality to be represented in the EPR and seek a single ideal agreeable form of the record.

“Positivist traditions hold that the patient's condition and journey comprise a single reality to be represented in the EPR and so seek a single ideal and “agreeable” form of the record.”

May combine two claims.

Design is addressed very differently by positivist and interpretivist/recursive traditions, with two principal opposing philosophical positions: conventional engineering-focused design and participatory design focused on social meaning.

“One aspect of the process of change that is addressed very differently by positivist and interpretivist/recursive traditions is design.As table 1 shows, there are two principal opposing philosophical positions on design: the conventional approach (whose roots are in positivism and whose focus is on engineering) and the participatory approach (whose roots are in interpretivism and whose focus is on”

Classified as probably not a substantial claim. May combine two claims.

The logic of opposition is fluid and contingent and contains inherent, unresolvable tensions.

“The logic of opposition, in contrast, is fluid and contingent and contains inherent and unresolvable tensions.”

May combine two claims.

Much of the reviewed literature suggests that while secondary work such as audit, research, and billing may become more efficient with the EPR, primary clinical work is often made less efficient.

“(3) while secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work is often made less efficient;”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Policy decisions in many countries have accepted the bigger-is-better view and used it to justify increasingly large-scale EPR initiatives.

“Policy decisions in many countries have accepted this view and used it to justify increasingly large-scale EPR initiatives (Kreps and Richardson 2007).”

• cites Kreps and Richardson 2007Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Berg talks of growing rather than building information systems and achieving synergy among three redesign tasks: the technical system, the primary work process, and the secondary work process.

“Berg talks of “growing” rather than building information systems and working to achieve synergy among three fundamental (re)design tasks: the technical system, the primary work process (e.g., clinical care), and the secondary work process (e.g., audit, management) (Berg 2003).”

• cites Berg 2003Not checked yet

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May combine two claims.

The review found no evidence that large-scale commercial IT systems in health care produce the benefits anticipated by their architects, and a few high-quality studies suggest that they do not.

“Our review found no evidence that large-scale commercial IT systems in health care produce the benefits anticipated by their architects, and a few highquality studies suggest that they do not.”

May combine two claims.

In other cases, discipline hopping produced studies that claimed allegiance to one research tradition but operated on the assumptions of another, or used a methodological approach that sounded appropriate but was not applied rigorously or consistently.

“In other cases, discipline hopping produced a study that claimed allegiance to one research tradition but operated on the assumptions of another or that used a methodological approach that sounded appropriate but had not been applied rigorously or consistently.”

May combine two claims.

This review identified a number of studies on how actors made sense retrospectively of EPR projects, but very few published studies in which a sense-making or soft-systems approach was used prospectively in action research or comparable participatory designs.

“This review identified a number of studies on how actors made sense retrospectively of EPR projects, but we found very few published studies in which a sense-making or soft-systems approach was used prospectively in action research or comparable participatory designs.”

Probably not a substantial claim: may not pass S1 (asserted).

Critics claim that the assumption that meaning is transmitted unproblematically with data is flawed.

“but critics of this type of program claim that this is a flawed assumption (Berg 2000).”

• cites Berg 2000Not checked yet

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May combine two claims.

Much of the reviewed literature suggests that paper will not necessarily disappear because it offers a unique level of ecological flexibility, although workable paperless systems have been developed in one or two centers.

“(5) paper will not necessarily disappear, as it offers a unique level of ecological flexibility (although workable paperless systems have been developed in one or two centers);”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing).

The alternative view holds that efficiency gains and economies of scale will never be realized because of the trade-off in loss of local contextual detail and knowledge and the magnification of political disputes among stakeholders.

“The alternative view is that efficiency gains and economies of scale will never be realized because of the trade-off in loss of local, contextual detail (and thus the loss of knowledge) and the magnification of political disputes among stakeholders.”

Classified as probably not a substantial claim.

The meta-narrative approach allowed the team to identify systematically the distorted concepts and flawed reasoning contained in confused efforts at scholarship.

“While such confused efforts at scholarship are a fact of academic life these days, the meta-narrative approach allowed us to identify systematically the distorted concepts and flawed reasoning that they contained.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the determinism model, the change process is one of good project management that sets clear strategic goals and ensures all parties work systematically toward them.

“In such a model, the change process is one of “good project management” that sets clear strategic goals and ensures that all parties work systematically toward these.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Just as a project's success may be talked up for political reasons, failed projects should not be dismissed out of hand.

“Accordingly, just as the “success” of a project may be talked up for political reasons, so “failed” projects should not be dismissed out of hand (Berg 2001).”

• cites Berg 2001Not checked yet

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Classified as probably not a substantial claim. May combine two claims.

The meta-narrative method allowed the team to tease out different streams of research and show how seminal books and papers in each tradition inspired programs of theory building and empirical research, and to compare and contrast these traditions in a structured way.

“This method allowed us to tease out a number of different streams of research and show how the seminal books and papers in each tradition inspired programs of theory building and empirical research.It also allowed us to compare and contrast these traditions in a structured way, as illustrated in table 2.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

This review confirmed that even in the twenty-first century, most established scientists most of the time still operate largely within a single epistemic community and focus primarily or exclusively on research questions addressed by a relatively small group of colleagues.

“This review confirmed that even in the twenty-first century (when the work of researchers in other disciplines is readily accessible), most established scientists, most of the time, still operate largely within a single epistemic community and focus primarily or exclusively on the research questions being addressed by a relatively small group of colleagues.”

May combine two claims.

Positivist studies of collaborative clinical work view it largely as exchange of information among distributed decision makers, while interpretivist and recursive models emphasize communication, including contextualizing work.

“Thus, while positivist studies of collaborative clinical work view it as largely pertaining to the exchange of information among distributed decision makers (human and technological), interpretivist and recursive models place much greater emphasis on communication, one aspect of which is contextualizing work”

Probably not a substantial claim: may not pass S3 (load-bearing).

EPR success is generally measured by some sort of evaluation when the EPR is introduced as part of a project or program.

“The EPR tends to be introduced as part of a project or program, whose success is generally (though not always) measured by some sort of evaluation.”

May combine two claims.

These tensions are expressed in various ways, including competing institutional logics, accommodation, sense making, negotiating knowledge among communities of practice, and translation, and these approaches share conceptual common ground.

“These tensions are variously expressed as “competing institutional logics” (Scott 2001), the need for “accommodation” (Checkland and Holwell 1998), “sense making” (Weick 1995), “negotiating knowledge among different communities of practice” (Lave and Wenger 1991;Østerlund and Carlile 2005), or “translation” (Latour 1992), approaches that have much conceptual common ground (Fox 1999;Weber and Glynn”

• cites Scott 2001Not checked yet

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• cites Checkland and Holwell 1998Not checked yet

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• cites Weick 1995Not checked yet

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Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

Some papers claiming to be seminal offered little more than an incoherent list of concepts and jargon phrases.

“Some papers claiming to be seminal (and sometimes cited as such) offered little more than an incoherent list of concepts and jargon phrases.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Critical traditions argue that the success of an EPR project has an ethical dimension, including questions about who has power to define success, who sponsors the evaluation and its hidden aims, and whose interests are represented.

“Critical traditions argue that the success of an EPR project also has an ethical dimension, asking, for example, who has the power to define what counts as success, who sponsors the evaluation and what its hidden aims are, and whose interests are (and are not) represented in the evaluation (Klecun and Cornford 2005).”

• cites Klecun and Cornford 2005Not checked yet

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Classified as probably not a substantial claim.

There is a tension between the view that bigger is better and the view that small is beautiful.

“A final tension in the literature is between “the bigger the better” and “small is beautiful.””

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Progress in this meta-narrative is identified as shifting from parochial departmental HIS strategies and goals to institutional, national, and even international ones, with a concomitant need to explore new transinstitutional information system architectures and standards.

“Progress in this meta-narrative is identified as shifting from parochial departmental HIS strategies and goals to institutional, national, and even international ones and also as the concomitant need to explore new, transinstitutional information system architectures and standards (Haux 2006).”

• cites Haux 2006Not checked yet

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Classified as probably not a substantial claim. May combine two claims.

Positivist traditions generally assume that success can be measured unproblematically using metrics such as whether the technology works, uptake and usage rates, and user satisfaction, and that transferable success factors can be deduced from empirical studies.

“Positivist traditions generally assume that “success” can be measured unproblematically in terms of metrics (e.g., Does the technology work?What are its uptake and usage rates?How satisfied are users?)(Mitchell and Sullivan 2001) and that transferable “success factors” can be deduced from empirical studies.”

• cites Mitchell and Sullivan 2001Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

The HIS literature frequently expounds the view that large, integrated electronic systems have inherently greater value than small, isolated ones, a truism known as Metcalfe's law.

“The former view is frequently expounded in the HIS literature, whereas just as electronic systems are seen as inherently better than paper, so large, integrated systems are seen as having inherently greater value than small, isolated ones (a ubiquitous truism known as Metcalfe's law).”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Research conducted to date on the micro-detail of collaborative clinical work from an ethnographic perspective appears to comprise fewer than twenty studies in total.

“The research conducted to date on the microdetail of collaborative clinical work from an ethnographic perspective appears to comprise fewer than twenty studies in total.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

This alternative view runs across most of the CSCW, technology-in-practice, and ANT literature and is captured in the law of medical information.

“This view runs across most of the CSCW, technology-in-practice, and ANT literature and is captured in the law of medical information:”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Hartswood et al. provide an exposition of codesign principles and call for developing shared practice between designers and users.

“Hartswood, Procter, Rouncefield, Slack, and Voss (2003) offer a particularly eloquent exposition of the principles of codesign and call for the development of “shared practice” between designers and users.”

• cites Hartswood, Procter, Rouncefield, Slack, and Voss (2003)Not checked yet

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Classified as probably not a substantial claim.

Barley's 1986 work demonstrated that a new technology introduced into the workplace is an occasion for structuring.

“Steve Barley's classic demonstration in 1986 that a new technology introduced into the workplace is an “occasion for structuring” offered high hopes for the study of a new generation of technologies in the health care sector (Barley 1986).”

• cites Barley 1986Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Orlikowski and colleagues demonstrated that individuals working collectively around common tasks actively and explicitly shape both technologies and work routines in a mutually adaptive way.

“Orlikowski and her colleagues demonstrated that individuals, working collectively around common tasks in organizations, actively and explicitly shape both technologies and work routines in a mutually adaptive way (Orlikowski et al. 1995).”

• cites Orlikowski et al. 1995Not checked yet

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Classified as probably not a substantial claim.

Reviewers concluded that homegrown EPR interventions are by nature not widely generalisable.

“But the reviewers concluded that “these [homegrown] interventions are by nature not widely generalisable” (Kupersmith et al. 2007, p. 5).”

• cites Kupersmith et al. 2007Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Health care work is uniquely complex and dependent on coordinated practice of multiple actors.

“As the CSCW literature also has shown, health care work is uniquely complex and dependent on the coordinated practice of multiple actors.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

CSCW developed from human-computer interaction and considers collaborative use of computers by people in the workplace.

“CSCW developed from human-computer interaction and considers the collaborative use of computers by people in the workplace (Ackerman 2000;Grudin 1988).”

• cites Ackerman 2000Not checked yet

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• cites Grudin 1988Not checked yet

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May combine two claims.

Car and colleagues found that EPR benefits were inconsistent in nature and magnitude across studies, with no clear findings on maximizing benefits or opportunity cost.

“Car and colleagues found that while some primary studies and some, but not all, systematic reviews showed positive benefits from the EPR, the nature and magnitude of benefits were not consistent across studies, nor were there clear findings on how benefits might be maximized or what their opportunity cost might be.”

• cites Car et al. 2008Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

The preceding ideas, theories, and orientations provided many of the underpinning concepts for the meta-narratives of EPR research.

“The preceding ideas, theories, and orientations provided many of the underpinning concepts for the meta-narratives of EPR research summarized in table 2 and described in more detail later.”

• Also stated in: § Overview and Historical Roots · plain

  “Different meta-narratives are drawn eclectically and in different ways on all these roots.”

May combine two claims.

The sample of primary studies is skewed toward the nonbiomedical literature, so the statistics should be interpreted accordingly.

“Our sample of primary studies is thus skewed toward the nonbiomedical literature, so the following statistics should be interpreted accordingly.”

Classified as probably not a substantial claim.

Kaplan argued that systematic reviewers' selection criteria for high-quality trials led them to focus on studies where organizational context features that might explain effects had been designed out.

“Kaplan argued in 2001 that the criteria that many systematic reviewers in the HIS tradition used to select their sample of “high-quality” trials led them to focus on studies in which the very features that might explain the effect of different organizational contexts had been designed out (Kaplan 2001).”

• cites Kaplan 2001Not checked yet

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May combine two claims.

Off-the-shelf EPR systems typically failed to meet expectations and had problems fitting the detail of work practices.

“These systems typically failed to meet expectations and incurred problems of fit with the detail of work practices.”

• cites Shekelle and Goldzweig 2009Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Shekelle and Goldzweig concluded that an EPR system should be considered a complex intervention with four key components-technical, human, project management, and organisational and cultural change-all of which must be systematically studied.

“Shekelle and Goldzweig (2009) concluded that an EPR system should be considered as a complex intervention with four key components-technical, human, project management, and “organisational and cultural change”-all of which must be systematically studied.”

• cites Shekelle and Goldzweig 2009Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

IS research is a heterogeneous tradition that emerged in business schools and has a long-standing tension between positivist and nonpositivist approaches.

“Information systems (IS) research is a heterogeneous tradition that emerged in business schools to consider the role of technology in business and management.It embraces a long-standing tension between positivist and nonpositivist philosophical approaches.”

May combine two claims.

Failed EPR projects may be explained by adverse changes in temporal or spatial structuring of work, complex links between knowledge and identities or social practices, and limitations of available technology.

““Failed” EPR projects may be explained by adverse changes in the temporal or spatial structuring of work consequent on introducing new technology, the fact that knowledge is linked in complex ways to identities and social practices, and limitations of the available technology.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Car et al.'s review of reviews covered 37 previous systematic reviews.

“Of particular note is a recent 600-page “review of reviews” embracing the EPR and other information and communications technology innovations, which covered thirty-seven previous systematic reviews (Car et al. 2008).”

• cites Car et al. 2008Not checked yet

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May combine two claims.

The finding that success is not guaranteed when preconditions are present reveals known weaknesses of contingency theories, notably lack of precision and failure to explain much observed variance.

“a finding that perhaps reveals the known weaknesses of contingency theories in the study of organizational change (notably that they lack precision and fail to explain much of the observed variance).”

May combine two claims.

The health informatics tradition is predominantly positivist, quantitative, and influenced by evidence-based medicine, with randomized controlled trials as its preferred design.

“This predominantly positivist tradition was developed jointly by doctors with an interest in computers and computer scientists with an interest in medicine (Gardner et al. 2009).The tradition is rooted in quantitative approaches and came to be strongly influenced by the ideas and values of EBM, with an emphasis on experimental studies; the preferred design is the RCT.”

• cites Gardner et al. 2009Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

The interpretivist perspective holds that the use, design, and study of information systems are fundamentally a hermeneutic meaning-making process rather than a rationalistic decision-making process.

“The interpretivist perspective holds that the use, design, and study of information systems are fundamentally a hermeneutic (meaningmaking) process rather than a rationalistic, decision-making process (Boland 1979).”

• cites Boland 1979Not checked yet

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Classified as probably not a substantial claim. May combine two claims.

If the interpretivist and recursive views are accepted, the impact of introducing an EPR cannot be predicted from its essential properties, and studies seeking to determine the generalizable impact of technology X on outcome Y have limited value.

“If these last two views (built, respectively, on an interpretivist and a recursive philosophy) are accepted, it follows that the impact of introducing an EPR cannot be predicted from its essential properties and hence that studies seeking to “determine the (generalizable) impact of technology X on outcome Y” have limited value.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Alignment is achieved or attempted through translation, involving problematization, interessement, enrollment, and mobilization.

“This alignment is achieved (or, at least, attempted) through what is known as “translation,” which involves the four stages of problematization (defining a problem for which the EPR is a solution), interessement (getting others to accept this solution to the problem), enrollment (defining the key roles and practices in the network), and mobilization (engaging others in fulfilling the roles, und”

• cites Callon 1986Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Technology-in-practice draws on structuration theory, sees human identity and agency as central, and offers a sophisticated theory about what agents know, including internalized social structures.

“Technologyin-practice draws on structuration theory and sees human identity and agency as central to the analysis; it offers a sophisticated theory about what agents “know” (which, crucially, includes internalized social structures).”

Classified as probably not a substantial claim.

Because health care work is personalized, full of exceptions, and context bound, the nature of health care work sets natural limits on the possibilities of IT to revolutionize this work.

“since health care work is personalized, filled with exceptions, and context bound, “the nature of health care work sets natural limits to the possibilities of IT to revolutionize this work” (Berg 2003, p. 337).”

• cites Berg 2003Not checked yet

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May combine two claims.

The tension between standardization and contingency can never be resolved; it must be actively and creatively managed, and this gets harder as the network gets bigger.

“The tension between standardization (which helps stabilize the network) and contingency (which reflects and responds to local needs and priorities) can never be resolved; rather, it must be actively and creatively managed-and this gets harder as the network gets bigger.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Actor-network theory is built on a recursive philosophy.

“Actor-network theory (ANT) is built on a recursive philosophy (Latour 1992).”

• cites Latour 1992Not checked yet

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May combine two claims.

ANT considers agency to be a product of the network rather than intrinsic to the individual actor, so knowledgeability and motivation are only weakly and indirectly theorized.

“ANT, in contrast, considers agency to be a product of the network rather than something intrinsic to the individual actor, so such things as knowledgeability and motivation are only weakly and indirectly theorized (Mutch 2002).”

• cites Mutch 2002Not checked yet

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Classified as probably not a substantial claim. May combine two claims.

The EPR is not merely a container for information; it accumulates and transforms work and is thus an actor or actant in the network.

“The EPR is not merely a container for information; it accumulates and transforms work (is “constitutive” of it) and is thus an actor (or “actant”) in the network.”

May combine two claims.

The EPR can provide multiple views and framings of data, tolerate ambiguities inherent in interprofessional work, and make work of different professional groups more visible to others.

“Second, the EPR can provide multiple views and framings of the data and thus can tolerate (and perhaps overcome) the ambiguities inherent in interprofessional work and make the work of different professional groups more visible to others (Reddy, Dourish, and Pratt 2001).”

• cites Reddy, Dourish, and Pratt 2001Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

From the ANT perspective, EPR projects fail when elements in the network fail to align, that is, when translation efforts fail.

“Conceptualized from the ANT perspective, EPR projects “fail” when the elements in the network fail to align, that is, when efforts at translation fail.”

Classified as probably not a substantial claim.

The EPR's bodies are multiple.

“As one seminal paper put it, the EPR's bodies are multiple (Berg and Bowker 1997).”

• cites Berg and Bowker 1997Not checked yet

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May combine two claims.

Different traditions use terms such as ensemble, situated, embedded, accommodated, and networked, which share meanings and all place greater emphasis on system-level approaches than on interventions aimed at the individual.

“While different language is used in different traditions (“ensemble,” “situated,” “embedded,” “accommodated,” “networked”), these terms share many meanings, and all place greater emphasis on system-level approaches than on interventions aimed at the individual.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Critical sociology draws on feminist scholarship on power and the work of Michel Foucault.

“Critical sociology draws on the work on power by feminist scholars and the philosopher Michel Foucault (Schneider 2006;Willcocks 2006).”

• cites Schneider 2006Not checked yet

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• cites Willcocks 2006Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Critical sociology and ANT studies assume that power relationships are built into the structure and data models of the EPR.

“Critical sociology and ANT studies assume that power relationships are (at least to some extent) built into the structure and data models of the EPR.”

Probably not a substantial claim: may not pass S2 (checkable).

Because the literature is heterogeneous and based on different philosophical assumptions and worldviews, a meaningful synthesis must present tensions and conflicts among meta-narratives as higher-order data rather than merely summate findings.

“Because this heterogeneous literature is based on different philosophical assumptions and worldviews, a meaningful synthesis must not merely summate the findings of different meta-narratives but also present the tensions and conflicts among them as higher-order data.”

May combine two claims.

Creating accurate and complete clinical records requires sacrifice of time and effort by frontline clinical and administrative staff, but this is sometimes justified by benefits for efficient business processes, governance, and research.

“Rather than promising that the EPR will “save time” or “make clinical care more efficient,” a more honest message would be that creating accurate and complete clinical records requires the sacrifice of time and effort by frontline clinical and administrative staff but that this is (sometimes) justified by more benefits for efficient business processes (e.g., billing), governance, and research.”

Probably not a substantial claim: may not pass S1 (asserted).

An alternative view holds that clinical work is less about decision making than about addressing the ongoing local question of what to do next.

“The alternative view is that clinical work is less about decision making than about addressing the ongoing, local question, what to do next?(Garfinkel 1967a)”

• cites Garfinkel 1967aNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Technologies reflect the interests and values of those who produce them.

“In sum, technologies reflect the interests and values of those who produce them.”

• cites Zuboff 1988Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Much health informatics research has aimed to design EPR technologies that improve patient safety by overcoming fallible human practice.

“As described in meta-narrative 1, much of the health informatics research tradition has been oriented to designing EPR technologies that will improve patient safety by overcoming fallible human practice.”

Classified as probably not a substantial claim.

The law of medical information states that the more information must circulate across diverse contexts, the more work is required to disentangle it from the context of its production.

“The further information has to be able to circulate (i.e. the more diverse contexts it has to be usable in), the more work is required to disentangle the information from the context of its production.”

• cites Berg and Goorman 1999Not checked yet

  Not checked in the free run.

May combine two claims.

The UK NPfIT appeared to be built on six assumptions: that the EPR is primarily a container for patient information; can be integrated seamlessly into clinical work; will increase effectiveness and efficiency; will drive changes in staff interaction; should replace most paper records; and adds more value the more comprehensive and widely distributed it is.

“The UK NPfIT appeared to be built on six assumptions, that the EPR (1) is primarily a container for information about the patient; (2) can be integrated seamlessly and unproblematically into clinical work; (3) will increase the effectiveness and efficiency of clinical work;”

• Also stated in: § Discussion and Recommendations · plain

  “(4) will drive changes in how staff interact with the patient and one another; (5) should replace most, if not all, forms of paper record, which are old-fashioned and limited; and (6) the more comprehensive and widely distributed it is, the more value it will add.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The logic of determinism is technology-focused, causalist, and linear, recognizing complicatedness but not complexity.

“Taken to its extreme, the logic of determinism is focused on technology and is causalist (technology X will produce output Y, and Y can be measured) and fundamentally linear (it recognizes complicatedness but not complexity) (Plsek and Greenhalgh 2001).”

• cites Plsek and Greenhalgh 2001Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

The logic of determinism assumes that human interactions and organizational context in which technology is used operate on the same formal and predictable technical principles as the technology itself.

“It assumes that the human interactions and organizational context in which technology is used will operate on the same formal and predictable technical principles as the technology itself.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The meta-narrative method was developed by the team in a previous study to synthesize heterogeneous research literature on a complex topic.

“Our team developed the meta-narrative method in a previous study to synthesize heterogeneous research literature on a complex topic (Greenhalgh et al. 2004(Greenhalgh et al. , 2005)).”

• cites Greenhalgh et al. 2004Not checked yet

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• cites Greenhalgh et al. 2005Not checked yet

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May combine two claims.

If the logic of opposition is adopted, the change model will be neither linear nor predictable and will involve conflict.

“If this logic is adopted, it follows not merely that the change model will be neither linear nor predictable but also that there will be conflict involved.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Although the law of medical information helps explain many unsuccessful large-scale EPR initiatives, a more nuanced version may now be needed to account for uncommon examples of successful ones.

“Although this rule certainly helps explain numerous unsuccessful largescale EPR initiatives, a more nuanced version of it may now be needed to account for the uncommon examples of successful ones (see metanarrative 1).”