Electronic Patient Records, Real-Time Clinical Documentation and Burden: An Umbrella Review
Clinical Snapshot
PICO Framework
| P — Population | Clinicians working in hospital and primary care settings using electronic patient records |
| I — Intervention | Electronic patient records (EPRs) and real-time clinical documentation systems |
| C — Comparator | Not explicitly defined - umbrella review examining documentation burden across different EPR implementations |
| O — Outcomes | Documentation burden, barriers to real-time documentation, technological solutions, clinician workload |
Bottom Line
This umbrella review systematically examines the documentation burden clinicians experience with electronic patient records across hospital and primary care settings. Using Donabedian's framework, it maps structural causes, process barriers, and outcome measures related to real-time clinical documentation. While the methodology appears robust with JBI guidelines and comprehensive database searching, the abstract provides limited detail about specific findings or quantitative results. The research addresses a critical issue for Australian healthcare, where EPR implementation continues to expand. Understanding documentation burden is essential for optimising clinician workflow, reducing burnout, and improving patient care quality. However, without access to the full results, it's difficult to assess the strength of evidence or specific practice implications. The findings may inform EPR vendor selection, implementation strategies, and workflow redesign in Australian healthcare settings.
Key Findings
P Value: Not applicable for umbrella review
Effect Size: Not reported in abstract
Primary Outcome: Documentation burden associated with electronic patient records
Nnt Or Sensitivity: Not applicable - descriptive synthesis of causes, barriers, and solutions
Confidence Interval: Not reported
Clinical Application
High relevance given widespread EPR implementation across Australian healthcare Directly applicable to Australian Digital Health Strategy and My Health Record implementation. Relevant for RACGP digital health guidelines and hospital EPR optimisation initiatives All clinicians using electronic health records in Australian hospitals and primary care practices
Abstract
This umbrella review synthesises evidence from reviews on clinicians' documentation burden (DB) associated with electronic patient records (EPRs) in hospital and primary care settings. Guided by Donabedian's model (structure, process, outcomes), it maps causes of burden, barriers to real-time documentation, and technological solutions. Following the Joanna Briggs Institute (JBI) methodology, searches across six databases identified 2,739 records, with 166 under full-text review. Findings of this review will inform strategies to optimise real-time EPR use while minimising DB.
References
- 1.Rathnayake, S., Karunathilake, N., Odo, C., Parisi, V., Pink, J., Tu, J., Zhao, W., & Randell, R. (2026). Electronic Patient Records, Real-Time Clinical Documentation and Burden: An Umbrella Review. Studies in Health Technology and Informatics. https://doi.org/10.3233/SHTI260583
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