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JOURNAL OF MEDICAL INTERNET RESEARCHBlijleven et alReviewWorkarounds in Electronic Health Record Systems and theRevised Sociotechnical Electronic Health Record WorkaroundAnalysis Framework: Scoping ReviewVincent Blijleven1, PhD; Florian Hoxha2, BSc; Monique Jaspers2, Prof Dr1Center for Marketing & Supply Chain Management, Nyenrode Business Universiteit, Breukelen, Netherlands2Center for Human Factors Engineering of Health Information Technology, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam,NetherlandsCorresponding Author:Vincent Blijleven, PhDCenter for Marketing & Supply Chain ManagementNyenrode Business UniversiteitStraatweg 25Breukelen, 3621 BGNetherlandsPhone: 31 630023248Email: [email protected]: Electronic health record (EHR) system users devise workarounds to cope with mismatches between workflowsdesigned in the EHR and preferred workflows in practice. Although workarounds appear beneficial at first sight, they frequentlyjeopardize patient safety, the quality of care, and the efficiency of care.Objective: This review aims to aid in identifying, analyzing, and resolving EHR workarounds; the Sociotechnical EHRWorkaround Analysis (SEWA) framework was published in 2019. Although the framework was based on a large case study, theframework still required theoretical validation, refinement, and enrichment.Methods: A scoping literature review was performed on studies related to EHR workarounds published between 2010 and 2021in the MEDLINE, Embase, CINAHL, Cochrane, or IEEE databases. A total of 737 studies were retrieved, of which 62 (8.4%)were included in the final analysis. Using an analytic framework, the included studies were investigated to uncover the rationalesthat EHR users have for workarounds, attributes characterizing workarounds, possible scopes, and types of perceived impacts ofworkarounds.Results: The SEWA framework was theoretically validated and extended based on the scoping review. Extensive support forthe pre-existing rationales, attributes, possible scopes, and types of impact was found in the included studies. Moreover, 7 newrationales, 4 new attributes, and 3 new types of impact were incorporated. Similarly, the descriptions of multiple pre-existingrationales for workarounds were refined to describe each rationale more accurately.Conclusions: SEWA is now grounded in the existing body of peer-reviewed empirical evidence on EHR workarounds and, assuch, provides a theoretically validated and more complete synthesis of EHR workaround rationales, attributes, possible scopes,and types of impact. The revised SEWA framework can aid researchers and practitioners in a wider range of health care settingsto identify, analyze, and resolve workarounds. This will improve user-centered EHR design and redesign, ultimately leading toimproved patient safety, quality of care, and efficiency of care.(J Med Internet Res 2022;24(3):e33046) doi: 10.2196/33046KEYWORDSelectronic health records; electronic medical records; framework; patient safety; unintended consequences; usability; 3046XSL FORenderXJ Med Internet Res 2022 vol. 24 iss. 3 e33046 p. 1(page number not for citation purposes)

JOURNAL OF MEDICAL INTERNET RESEARCHIntroductionElectronic health record (EHR) systems are the backbone ofmodern health care organizations. This is in pursuit of promisinggains in patient safety, quality of care, efficiency, and controlof spiraling costs by enabling value-based reimbursements.However, realizing these expected benefits is far from a givenvalue. Over the years, an overwhelming number of studies havereported that EHRs have led to a multitude of unintendedconsequences. Examples include potential patient harm resultingfrom bad EHR usability [1,2]; increased odds of burnout ofhealth care professionals [3,4]; physicians experiencing stress[5]; users spending an equal amount of time on desktop medicineas they spend on having face-to-face interaction with patients[6,7]; extensive copy and paste practices of patient notes leadingto note bloating, internal inconsistencies, and errors [8]; andthe unavailability of complete clinical information at the pointof care [9].Many causes of unintended consequences of EHR use can betraced back to discrepancies between the behavior, intentions,and expectations of EHR users and the workflows dictated byEHRs [10-15]. When EHR users experience workflowmismatches, they often create workarounds [16]. Workaroundsare practices that handle exceptions to normal workflow [17]and do not follow the rules, assumptions, workflow regulations,or intentions of systems designers [18]. Although workaroundsallow EHR users to proceed in accomplishing tasks in theirpreferred way (with or without the EHR), research shows thatworkarounds frequently jeopardize the safety, quality, andefficiency of care [19]. Given their common adverse effects,workarounds are valuable points of departure for improving theEHR design and redesign.Blijleven et al [20] developed the Sociotechnical EHRWorkaround Analysis (SEWA) framework for identifying,analyzing, and subsequently resolving EHR workarounds. Theframework was inspired by the Systems Engineering Initiativefor Patient Safety (SEIPS) framework [21]. The SEWAframework incorporates four angles: the different rationalesEHR users have for creating workarounds (eg, memory aid andrequired data entry option missing), the stakeholders affectedby a workaround (eg, patient and health care professional), theimpact of a workaround (eg, on safety and efficiency), andinherent attributes of workarounds (eg, unavoidable, repetitive,and cascading).Blijleven et alsemistructured follow-up interviews in a single large case studyin an academic hospital setting [19,22]. However, the authorsargued that the applicability of the framework in other contextsmight be limited, such as in nonacademic hospitals or inhospitals where paper-based workarounds (eg, for orderingdrugs) are still allowed. Therefore, they recommendedvalidation, refinement, and enrichment of the framework byincorporating workarounds and related rationales, attributes,possible scopes, and types of consequences identified in otherEHR workaround–related research and clinical contexts.To address these shortcomings, a scoping literature review wasperformed to identify and map the available evidence on EHRworkarounds [23]. This paper presents a revised version of theSEWA framework, with rationales, attributes, possible scopes,and types of impact described in workaround-related studies inthe EHR, electronic medical record, and computerized physicianorder entry domains in primary, secondary, and tertiary carecontexts published between 2010 and 2021.MethodsSearch StrategyThe MEDLINE, Embase, CINAHL, Cochrane, and IEEEdatabases were searched for relevant studies. We includedoriginal, full papers of research with empirical data andconference papers if there were no full papers published in thesame study. Gray literature, such as books, was not considered.The search queries included the keywords EHR, electronichealth record, and workaround(s) and their synonyms. As theaim was to identify new rationales, attributes, consequences,and scopes of EHR workarounds for the enrichment of theSEWA framework, we defined the searches as broad as possible.Pilot literature searches were conducted to check theappropriateness of the queries. During the pilot searches, theterm workflow was used as a possible synonym for workarounds.The inclusion of this term led to a much larger pool of possiblestudies. However, most of these studies were focused on careprocesses that have no relation with EHR use and were thus,out of scope. Therefore, this term was excluded from searchqueries. Furthermore, to include the complete spectrum l/patient/health care/clinical record andelectronic/digital/online was used. The results of this pilotevaluation were used to adjust the queries. The used queries areshown in Table 1.The SEWA framework [20] was based on approximately 200hours of audiovisual material of user–EHR interaction andhttps://www.jmir.org/2022/3/e33046XSL FORenderXJ Med Internet Res 2022 vol. 24 iss. 3 e33046 p. 2(page number not for citation purposes)

JOURNAL OF MEDICAL INTERNET RESEARCHBlijleven et alTable 1. Search queries used for the scoping review.Date ofsearchDatabaseQueryApril 9,2021MEDLINE([([([(((((health record*) OR medical record*) OR patient record*) OR health care record*) OR clinical record*)AND electronic] OR digital) OR digitized] OR online) OR online] OR [([Electronic Health Records (MeSH Terms)]OR electronic health record*) OR EHR] OR [([Medical Records Systems, Computerized (MeSH Terms)] OR computerized patient record) OR computerised patient record]) AND ([(workaround*) OR work around*] ORworkaround*)April 9,2021Embase(workaround OR workaround* OR workaround OR workaround*) ANDApril 9,2021CINAHL(workaround OR work around OR workarounds) AND ([(health record OR medical record OR patient record ORhealth care record OR clinical record) AND (electronic OR digital OR [online OR online] OR [digitized OR digitised])] OR [electronic health record* OR EHR OR electronic medical record* OR EMR] OR [computerized patientrecord OR computerised patient record])April 9,2021IEEE([([([(workaround*) OR work around*] OR workaround*)])] AND [([health record OR medical record OR patientrecord OR health care record OR clinical record] AND [electronic OR digital OR (online OR online) OR (digitizedOR digitised)]) OR (electronic health record* OR EHR OR electronic medical record* OR EMR) OR (computerizedpatient record OR computerised patient record)])April 9,2021Cochrane(workaround*): ti, ab,kw OR (work-around*): ti, ab, kw OR (work around*): ti, ab, kw AND ([(electronic healthrecord*): ti, ab, kw OR (health record*): ti, ab, kw OR (medical record*): ti, ab, kw OR (patient record*): ti, ab,kw OR (health care record): ti, ab, kw OR (EHR): ti, ab, kw OR (EMR):ti, ab, kw OR (clinical record):ti, ab, kwOR ([computerized patient record]: ti, ab, kw OR [computerized patient record]: ti, ab, kw)] AND [electronic]: ti,ab, kw OR [digital]: ti, ab, kw OR [online]: ti, ab, kw OR [online]: ti, ab, kw OR [digitized]: ti, ab, kw OR [digitised]:ti, ab, kw)([(health record* OR medical record* OR patient record* OR health care record* OR clinical record*) AND(electronic OR digital OR online OR online OR digitized OR digitised)] OR [electronic health record* OR ehr ORelectronic medical record* OR emr] OR [computerized patient record OR computerised patient record])Selection CriteriaThe inclusion and exclusion criteria were chosen throughdiscussions among the reviewers (FH, VB, and MJ). As thefocus of this scoping review was on workarounds in EHR use,it was decided to exclude studies focused on barcode medicationadministration systems as these systems serve only 1 purposeand cover only a small part of the medication process.Furthermore, the choice was made to exclude research focusedon EHR functionalities other than those aimed at supportingthe clinical process. To ensure data quality, a study was excludedif the research methods were not reported or in case the studyhad not been peer reviewed. Furthermore, research publishedbefore 2010 was excluded as EHRs have undergone significantchanges and improvements over the years. Finally, the inclusionand exclusion criteria were chosen.The study inclusion criteria were as follows:1.2.The health care setting of the study must be either 1 ofprimary, secondary, or tertiary care.Workarounds were studied or reported in the context ofEHR use.https://www.jmir.org/2022/3/e33046XSL FORenderX3.The article was published between 2010 and 2021.Studies were excluded if they met any of the following criteria:1.2.3.4.5.6.The research focused on EHR functionalities other thanthose aimed at supporting within the clinical process.The research focused on a barcode administrationfunctionality.The article was not written in English.There was no access to the full-text article.The article was not peer reviewed.The research methods were not reported.Article SelectionA literature search was conducted in April 2021. A total of 737potentially relevant studies were retrieved from our initial searchof electronic databases, more specifically MEDLINE (263/737,35.7%), Embase (121/737, 16.4%), CINAHL (89/737, 12.1%),IEEE (58/737, 7.9%), and Cochrane (206/737, 27.9%). Theresults of the study selection process are shown in the PRISMA(Preferred Reporting Item for Systematic Reviews andMeta-Analyses) flowchart in Figure 1.J Med Internet Res 2022 vol. 24 iss. 3 e33046 p. 3(page number not for citation purposes)

JOURNAL OF MEDICAL INTERNET RESEARCHBlijleven et alFigure 1. PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) flowchart of the study selection process. CPOE: computerizedphysician order entry; EHR: electronic health record.The retrieved 737 studies were uploaded to EndNoteX9(Clarivate), in which duplicates were first removed by bothusing EndNoteX9 and by performing a manual check (Figure1). This led to 79.6% (587/737) of unique studies. These studieswere reviewed by two independent reviewers (FH and VB).The 2 reviewers first independently screened the titles andabstracts of the eligible papers to evaluate whether they met theinclusion criteria. Of the 587 studies, 116 (19.8%) studies metthe inclusion criteria, and 471 (60.2%) studies were excluded(because of, for example, workarounds not being focused onthe EHR, not being a scientific research article, and noworkarounds mentioned). Afterward, the reviewersindependently screened the full texts of these 116 studies,https://www.jmir.org/2022/3/e33046XSL FORenderXleading to 62 (53.4%) included studies and 54 (46.6%) excludedstudies (eg, no full-text available and methods inappropriatelydescribed). After each screening phase, the two reviewers (FHand VB) discussed their findings. The next screening phase wasconducted only if a consensus was reached between the 2independent reviewers. If a disagreement between the 2reviewers could not be resolved by discussion, a thirdindependent reviewer (MJ) was involved. After consensus wasreached, interrater reliability was reported by calculating theCohen κ. The interrater agreement was also calculated to showthe extent to which the reviewers were able to reconcile throughdiscussion [24]. For the first round (title and abstract screening),the Cohen κ value was 0.958, and the interrater agreement valueJ Med Internet Res 2022 vol. 24 iss. 3 e33046 p. 4(page number not for citation purposes)

JOURNAL OF MEDICAL INTERNET RESEARCHBlijleven et alwas 0.985. For the second round (full-text screening), the Cohenκ value was 0.930, and the interrater agreement value was 0.966.ResultsData Analysis of Included ArticlesGeneral CharacteristicsDescriptive data from the included articles, such as title, authors,year of publication, study setting, functionalities of EHR studied,and research methods used, were captured in a generic overviewper study (Multimedia Appendix 1). Workaround-related datafrom the included articles, such as workaround rationales,attributes, consequences, and scope, were captured in an analyticframe per study (Multimedia Appendix 2).The general characteristics of the 62 studies are shown in Table2. There was an approximately even split in studies publishedbetween 2010 and 2015 and between 2016 and 2021. The studysettings were almost equally distributed, with most (23/62, 37%)being set in tertiary care, such as academic hospitals and specialcare units. The largest group of studies (28/62, 45%) focusedtheir research on the EHR overall. Of the 62 studies, 17 (27%)studied medication-related functionalities or EHR-integratedsystems, such as computerized physician order entries.Approximately half (28/62, 45%) used or included acombination of physicians, nurses, and other staff such aspharmacists and administrative personnel as participants. Ofthe 62 studies, 26 (42%) used a combination of methods suchas observations, interviews, and questionnaires, 15 (24%) usedinterviews as the sole method, 5 (8%) solely used questionnaires,7 (11%) solely used observational methods, and 9 (15%) usedother methods such as think-aloud protocols and documentationanalysis.The data extracted from the included articles were comparedwith the SEWA framework on a study-by-study basis. In doingso, SEWA was supplemented with new rationales, attributes,possible scopes, and types of impact of EHR workarounds thatwere not previously included. After the analysis was completed,an updated (graphical) version of the SEWA framework wascreated.https://www.jmir.org/2022/3/e33046XSL FORenderXJ Med Internet Res 2022 vol. 24 iss. 3 e33046 p. 5(page number not for citation purposes)

JOURNAL OF MEDICAL INTERNET RESEARCHBlijleven et alTable 2. General characteristics of the included studies (N 62).Study characteristicsValues, n (%)Year of publication2010-201530 (48)2016-202132 (52)Study settingPrimary care18 (29)Secondary care21 (34)Tertiary care23 (37)aFunctionalities of EHR studiedMedication-related (eg, prescribing and CPOEb)17 (27)Documentation8 (13)Overall EHR28 (45)Others (eg, alert systems and authentication process)9 (15)Type of populationPhysicians9 (15)Nurses13 (21)Others (eg, pharmacists or administrative staff such as managers,12 (19)assistants, secretary, or not mentioned)Combination of users28 (45)MethodsaObservations7 (11)Interviews15 (24)Questionnaires5 (8)Others (eg, think-aloud and documentation analysis)9 (15)Combination of 1 observation, interview, questionnaire, or other26 (42)EHR: electronic health record.bCPOE: computerized physician order entry.Validation, Refinement, and Enrichment of the SEWAFrameworkOverviewEvidence for the work system components, rationales, attributes,type of impact, and possible scopes contained in the originalSEWA framework was found in the included studies. Moreover,we refined and enriched the original framework with 7rationales, 4 attributes, and 3 types of impact. The followingsubsections elaborate on the work system components,rationales, attributes, possible scopes, and types of impact.https://www.jmir.org/2022/3/e33046XSL FORenderXWork System ComponentsSupport for all 5 work system components was found in theincluded studies, as shown in Table 3. No new work systemcomponents were identified. However, we made 1 change tothe work system component EHR system, which we renamedto EHR system and related technology. The latter wasincorporated to also cover workarounds stemming from the useof technology other than the EHR but used in parallel with theEHR, such as scanners [25].J Med Internet Res 2022 vol. 24 iss. 3 e33046 p. 6(page number not for citation purposes)

JOURNAL OF MEDICAL INTERNET RESEARCHBlijleven et alTable 3. Overview of work system components and related included studies.aWork componentsDescriptionStudiesPerson(s)Health care professionals developing and using EHRa workarounds[20,26-28]EHR system and related technology The EHR and related information technology used by health care ional conditions (eg, care directives and hospital policies) under which clinicaltasks and EHR use are performed[20,27,28,30,31]Physical environmentThe environment (eg, outpatient examination room and inpatient ward) and its conditions [20,26,27](eg, lighting and noise) in which clinical tasks are conducted by health care professionalsTask(s)Clinical tasks performed by health care professionals[20,26,28,30-32]EHR: electronic health record.RationalesThe rationales for workarounds contained in the original SEWAframework were confirmed in many studies. In addition, 7 newrationales were identified.Under the work system component person(s), one rationale wasadded: trust (Table 4). Multiple studies reported that userscreated workarounds because of insufficient trust in the (new)system or its capabilities while frequently maintaining trust inolder systems (replaced by the EHR). The related causes of alack of trust are a lack of perceived usefulness of the (new)system and insufficient confidence in (completeness) of the dataavailable in the EHR [33-39]. The description of the rationaleawareness has been refined to also cover awareness of theinformation needs of patients and not just of colleagues [40].Likewise, the description of the rationale social norms has beenrefined to make cultural [30,41] and collaborative [27,42]aspects more explicit.Although extensive support in the included studies was foundfor all rationales under the work system component EHR systemand related technology, except patient data specificity, fouradditional rationales were identified: data integration, enforcedactions, data quality, and interoperability (Table 5). Thedescription of the pre-existing rationale technical issues hasbeen refined to cover technical issues related to ancillarytechnology used in conjunction with the EHR.Multiple studies provide support for all rationales under thework system component organization except for the rationaledata migration policy (Table 6). No new rationales wereidentified.Although support was found for the pre-existing rationales undertask(s), one rationale was added: task complexity (Table 7).Approximately 3% (2/62) of studies described that the EHRdoes not always sufficiently support the execution of a complextask at hand [34-39]. Therefore, health care professionals resortto workarounds to make their workflow more digestible.Finally, the SEIPS work system component physicalenvironment was incorporated into the original SEWAframework without any rationale. However, Dudding et al [25]mentioned that a busy, fast-paced environment whereinterruptions are constant, such as the neonatal intensive careunit, gives rise to EHR workarounds. The rationale here is“fast-paced environment” and is described as “devisingworkarounds to cope with the inability to, for example, updatethe documentation in fast-paced care environments whereinterruptions are constant” [25].Table 4. Overview of rationales for the work system component person(s) and related included studies.aRationalesDescriptionStudiesDeclarative knowledgeNot knowing how to use (a part of) the EHRa to accomplish a task[20,33,34,39,43,44]Procedural knowledgeKnowing how but not being proficient enough to use a part of the EHR to accomplish a task[20,28,34,39,44]Memory aidWriting patient data down on paper (eg, keywords) or adding visual elements to parts of text in aprogress note (eg, boldfacing, italicizing, or underlining) to remind oneself[20,34,39,43,45-47]AwarenessStoring patient data that are perceived important by the EHR user for other colleagues or patientsto be noticed (frequently in a data field other than the intended field in the EHR)[20,39,40,48]Social normsFormal or informal, collaborative, and cultural understandings among health care professionals[20,29-31,45,49,50]leading to the creation and dissemination of workarounds (eg, mimicking workarounds devised bycolleagues to accomplish a task or working around the system upon as friendly requested or enforcedby a fellow clinician)Trust (new)Having insufficient trust in the (new) EHR system or its capabilities, lack of perceived usefulness,or insufficient confidence in the (completeness) of data[20,33-39]EHR: electronic health record.https://www.jmir.org/2022/3/e33046XSL FORenderXJ Med Internet Res 2022 vol. 24 iss. 3 e33046 p. 7(page number not for citation purposes)

JOURNAL OF MEDICAL INTERNET RESEARCHBlijleven et alTable 5. Overview of rationales for the work system component EHRa system and related technology and related included studies.aRationalesDescriptionStudiesUsabilityHigh behavioral user cost in accomplishing a task[20,25,28,29,31,41,42,45,46,50-56]Technical issues(A part of the) EHR or ancillary technology halting, crashing, or slowing down,hampering the EHR user in accomplishing a task[20,25,28,31-33,43,44,51-53,55-61]Data presentationPreferring a different data view (eg, visualization by means of charts or graphsrather than plain text)[20,55,62]Patient data specificityNeeding to enter or request patient data with greater or lesser specificity than of- [20]fered or enforced by the EHRData integration (new)EHR not providing or supporting the integration of patient data necessary for care [42,45]deliveryEnforced actions (new)Avoiding or overriding actions enforced by the EHR (eg, bypassing the approval [29,43,48,54,63]process of prescribing medication or using a different user account)Data quality (new)Unavailability of data, disparity in data formats (eg, the same data being stored [31,34-36,39,41,42,44,50,57,64-67]in multiple different formats in the EHR), lack of standardization, and informationgaps in the EHRInteroperability (new)Data not able to be exchanged between health care systems or institutions (eg,causing data to be unavailable at the right moment and time)[44,50,54,56,64,65]EHR: electronic health record.Table 6. Overview of rationales for the work system component organization and related included g an alternative way of accomplishing a task that improves actual efficiency [20,29,31,34,35,37,43,46,47,55,68-70]Data migration policyNot having (direct) access to required historical data because of data not having [20]been imported from previously used systems to the current EHRaEnforced data entryEHR enforcing user to enter patient data of which neither the user nor the patient [20,71,72]has knowledge ofRequired data entry option EHR not offering the required data entry option (eg, 3.75 mg rather than themissingavailable options 2.5 mg or 5 mg)a[20,32,71]EHR: electronic health record.Table 7. Overview of rationales for the work system component task(s) and related included studies.RationalesDescriptionStudiesTask interferenceInability to perform multiple tasks at once (eg, simultaneously treating a patient on[20,61]the treatment table as well as entering patient data into the EHRa)Commitment to patient inter- Valuing patient interaction over computer interaction (ie, writing things down on paper [20,34,37,41,44,55,61,73]actionand afterward entering this into the EHR)Task complexity (new)aThe high complexity of the tasks needing to be conducted[34,39]EHR: electronic health record.AttributesAlthough several studies confirmed the previously definedattributes in SEWA, several included studies also mentioned atotal of 4 new attributes (Table 8). These are concerned withwhether the user is aware of using a workaround [49]https://www.jmir.org/2022/3/e33046XSL FORenderX(awareness), whether the workaround is an individual or sharedpractice across users [49] (shared), on what medium theworkaround is conducted (eg, paper or computer) [34,41](medium), and whether the workaround is a formal or informalpractice (eg, part of a defined process or approved or promotedby management or not) [56] (formality).J Med Internet Res 2022 vol. 24 iss. 3 e33046 p. 8(page number not for citation purposes)

JOURNAL OF MEDICAL INTERNET RESEARCHBlijleven et alTable 8. Overview of workaround attributes and related included ether the workaround initiates the creation of 1 or multiple additional workarounds or is an isolated occur- [20]renceAvoidabilityWhether the workaround is required to proceed with one’s workflow or optionalAnticipatednessWhether the workaround is used at known moments in time (ie, the situation in which the workaround is used [20,74]is known beforehand) or used unexpectedlyRepetitivenessWhether the workaround is ingrained into the workflow (ie, becomes part of daily routines) or used temporar- [20,56,74]ily to overcome workflow constraintsAwareness (new)Whether the user is aware of using the workaround[49]Shared (new)Whether the workaround is a shared practice across multiple other users of the EHRa or limited to 1 user[49]Medium (new)On what medium the workaround is conducted (eg, paper, computer, verbal, or a combination)[34,41]Formality (new)Whether the use of the workaround is approved by management and part of a defined process[56][20,32,66,74]EHR: electronic health record.Types of ImpactThe previously defined types of impact in the SEWA frameworkwere confirmed by many included studies. Multiple additionaltypes of impact were also identified: privacy/security, dataquality, employee perception of EHR, financial, law/regulations,and workload (Table 9). Privacy/security relates not only to theimpact a workaround has on the security and privacy of the databut also to the patient and organization itself. Data qualityconcerns the impact on, for example, loss of data, or a lowerdata quality because of spelling or formatting mistakes in thedata. Moreover, workarounds can have a positive or negativefinancial impact [58], may jeopardize laws and regulations[63,75], and have a positive or negative impact on the workloadof the user [43].Table 9. Overview of types of impact and related included studies.aImpactDescriptionSourcePatient safetyThe impact on the safety (physical and mental) of the Effectiveness of careThe effectiveness and quality of the care process performed[20,28,43,46,54,58,59,67]Efficiency of careThe impact on the efficiency of the care process in terms of time andresources expended[20,33,55,60,64,72,76]Privacy and security (new) Impact on the security and privacy of data related to the patient or organization[32,39,51,52,56,63,68,75]Data quality (new)Impact of workarounds on data quality (eg, loss of data or decreaseddata cial (new)Financial implications because of the workaround[58]Laws and regulations(new)Legal conflicts resulting from the use of a

EHR enforcing user to enter patient data of which neither the user nor the patient [20,71,72] has knowledge of Enforced data entry EHR not offering the required data entry option (eg, 3.75 mg rather than the [20,32,71] available options 2.5 mg or 5 mg) Required data entry option missing aEHR: electronic health record. Table 7.