JMIR Publications

ABSTRACT

We thank the letter’s author for the critical comment on the positive impact of digital interventions [1]. It would be an ultimate success of medical informatics research to be recognized by hospital executives and managers. However, we are not convinced that the previous national initiatives for the implementation of electronic records were evidence-based, neither in England, Germany nor the United States. Following the scene of electronic records for 30 years, recognizing the literature of 50 years, and been responsible for the selection and management of electronic records in hospitals, our view was truthfully impartial. We were willing to accept scientific evidence independently of preexisting opinions even if the clear result was a surprise [2]. Firstly, we want to clarify that we did not evaluate digital interventions in general, which the letter ‘s headline indicates. In our study, we sought to focus on electronic medical records (EMRs) as specific types of electronic records. However, we were confronted with several challenges concerning the definition and specification of the technology, as partly addressed in the letter. Excluding studies focusing on CPOE on the one hand did not mean to exclude studies on EMRs that offer CPOE support on the other hand for example. It would be a step forward to have a standard not only for the reporting of results such as PRISMA but also for the labelling of digital interventions. Concerning the results of the included studies, we aimed at drawing utmost benefits from details. This could mean overriding the studies‘ conclusions, as stated in our limitations. In case of [3] we probably overweighted the improved efficiency in the post meaningful use period (2010/2011). We apologize if we did not meet the common appraisal in all cases. However, the results of [3] fully support the conclusions from the whole set of included studies with a clear positive effect on the quality of care and an ambigouos economical implication. The appropriate evaluation criteria of EMRs should be put up for discussion. It may be unreasonable to expect a reduction of mortality from its implementation. We would be honored if our series of reviews contribute to realistic expectations towards the effects of EMRs on different types of quality criteria. Secondly, other points of criticism are related to the context of the EMR implementation. Studies about effects of EMRs are faced with a double complexity [4]. The implementation of an EMR will involve the whole organization of hospital care, will alter the health care processes, and will include a wide range of functionalities (EMR as complex intervention). The setting of the implementation of an EMR is complex, too, with different professions, different specialties, different levels of care etc. (complexity of the context). For example, the readiness for change and the management of change might be more important for the success of an EMR implementation than specific technological issues [5]. It could be argued, that well prepared organizations will benefit more from an EMR than less prepared organizations. In extreme cases, less prepared organizations will get worse with the same EMR solution that helped well-prepared organization to further improve patient outcome. We agree with the letter’s author that there could be a coexistence effect in the secondary data studies. Hospitals attempting to improve care by implementing an EMR should be advised to analyze thoroughly their current state, to eliminate reasons for inappropriate care in advance, and to be well prepared for the technology. Medical informatics science is confronted with the digitization of health care independently from its input and participation. Due to the high penetration of electronic records, interventional studies will no longer be possible for this technology in developed countries. Nevertheless, at times, society will seek help from medical informatics science, especially if political expectations failed. Frequently, low hanging fruits determined the reaction of researchers in the past. It would be a major step forward if medical informatics science is willing to act as a collective community grounded on scientific evidence. With this regard, we express our appreciation for the letter’s author feedback.