title: Interventions to increase the use of electronic health information by healthcare practitioners to improve clinical practice and patient outcomes.
abstract: BACKGROUND
  There is a large volume of health information available, and, if applied in clinical practice, may contribute to effective patient care. Despite an abundance of information, sub-optimal care is common. Many factors influence practitioners' use of health information, and format (electronic or other) may be one such factor.
  
  
  OBJECTIVE
  To assess the effects of interventions aimed at improving or increasing healthcare practitioners' use of electronic health information (EHI) on professional practice and patient outcomes.
  
  
  METHODS
  We searched The Cochrane Library (Wiley), MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), and LISA (EBSCO) up to November 2013. We contacted researchers in the field and scanned reference lists of relevant articles.
  
  
  METHODS
  We included studies that evaluated the effects of interventions to improve or increase the use of EHI by healthcare practitioners on professional practice and patient outcomes. We defined EHI as information accessed on a computer. We defined 'use' as logging into EHI. We considered any healthcare practitioner involved in patient care. We included randomized, non-randomized, and cluster randomized controlled trials (RCTs, NRCTs, CRCTs), controlled clinical trials (CCTs), interrupted time series (ITS), and controlled before-and-after studies (CBAs).The comparisons were: electronic versus printed health information; EHI on different electronic devices (e.g. desktop, laptop or tablet computers, etc.; cell / mobile phones); EHI via different user interfaces; EHI provided with or without an educational or training component; and EHI compared to no other type or source of information.
  
  
  METHODS
  Two review authors independently extracted data and assessed the risk of bias for each study. We used GRADE to assess the quality of the included studies. We reassessed previously excluded studies following our decision to define logins to EHI as a measure of professional behavior. We reported results in natural units. When possible, we calculated and reported median effect size (odds ratio (OR), interquartile ranges (IQR)). Due to high heterogeneity across studies, meta-analysis was not feasible.
  
  
  RESULTS
  We included two RCTs and four CRCTs involving 352 physicians, 48 residents, and 135 allied health practitioners. Overall risk of bias was low as was quality of the evidence. One comparison was supported by three studies and three comparisons were supported by single studies, but outcomes across the three studies were highly heterogeneous. We found no studies to support EHI versus no alternative. Given these factors, it was not possible to determine the relative effectiveness of interventions. All studies reported practitioner use of EHI, two reported on compliance with electronic practice guidelines, and none reported on patient outcomes.One trial (139 participants) measured guideline adherence for an electronic versus printed guideline, but reported no difference between groups (median OR 0.85, IQR 0.74 to 1.08). One small cross-over trial (10 participants) reported increased use of clinical guidelines when provided with a mobile versus stationary, desktop computer (mean use per shift: intervention group (IG) 3.6, standard deviation (SD) 1.7 vs. control group (CG) 2.0 (SD 1.9), P value = 0.033). One cross-over trial (203 participants) reported that using a customized versus a generic interface had little impact on practitioners' use of EHI (mean difference in adjusted end-of-study rate: 0.77 logins/month/user, 95% confidence interval (CI) CI 0.43 to 1.11). Three trials included education or training and reported increased use of EHI by practitioners following training.
  
  
  CONCLUSIONS
  This review provided no evidence that the use of EHI translates into improved clinical practice or patient outcomes, though it does suggest that when practitioners are provided with EHI and education or training, the use of EHI increases. We have defined use as the activity of logging into an EHI resource, but based on our findings use does not automatically translate to the application of EHI in practice. While using EHI may be an important component of evidence-based medicine, alone it is insufficient to improve patient care or clinical practices. For EHI to be applied in patient care, it will be necessary to understand why practitioners' are reluctant to apply EHI when treating people, and to determine the most effective way(s) to reduce this reluctance.
authors.affiliation: Information Specialist, Consultant, Ottawa, Ontario, Canada.
authors.forename: Michelle
authors.initials: M
authors.lastname: Fiander
authors.forename: Jessie
authors.initials: J
authors.lastname: McGowan
authors.forename: Roland
authors.initials: R
authors.lastname: Grad
authors.forename: Pierre
authors.initials: P
authors.lastname: Pluye
authors.forename: Karin
authors.initials: K
authors.lastname: Hannes
authors.forename: Michel
authors.initials: M
authors.lastname: Labrecque
authors.forename: Nia W
authors.initials: NW
authors.lastname: Roberts
authors.forename: Douglas M
authors.initials: DM
authors.lastname: Salzwedel
authors.forename: Vivian
authors.initials: V
authors.lastname: Welch
authors.forename: Peter
authors.initials: P
authors.lastname: Tugwell
mesh_terms: D016206:Databases, Bibliographic / Q000706:statistics & numerical data; D019317:Evidence-Based Medicine / Q000706:statistics & numerical data*; D019983:Guideline Adherence / Q000706:statistics & numerical data; D063005:Health Information Systems / Q000706:statistics & numerical data*; D006282:Health Personnel / Q000706:statistics & numerical data*; D006801:Humans; D016247:Information Storage and Retrieval / Q000706:statistics & numerical data*; D005791:Patient Care; D011364:Professional Practice / Q000592:standards*; D016032:Randomized Controlled Trials as Topic