Open research questions in Electronic Health Records Systems

What the literature leaves open

• Future work should focus on multi-site community trials, physician-supervised clinical validation of AI consultation, larger-scale prescription-format testing, integration with hospital and medical-insurance systems, rural low-connectivity adaptation and systematic privacy-compliance evaluation.

  A CLOSED-LOOP AGE-FRIENDLY MEDICAL PLATFORM: FROM AI CONSULTATION TO POST-DIAGNOSIS CARE · 2026 · DOI

• While artificial intelligence (AI)–enabled documentation tools have demonstrated potential to reduce administrative workload among practicing clinicians, little is known about their perceived feasibility or impact within residency training environments.

  Perceived Impact of a Simulated AI-Enabled EMR Autofill System on Resident Physician Burnout and Workflow Efficiency: A Research Protocol · 2026 · DOI

• The medico- legal implications of errors in AI-assisted documentation remain uncertain, particularly where documentation has been generated by an AI system but incorporated into the clinical record by a clinician.

  Exploring the Potential of Ambient AI for Inpatient Documentation: A Qualitative Study with Junior Doctors · 2026 · DOI

• Efficiency, readability, note quality, safety Up to 40% time savings, improved readability Hallucination, privacy, bias, weaker performance in complex cases…

  Autonomous Medical Documentation Pipelines: Integrating Large Language Models and Cloud Speech Services to Reduce Clinician Administrative Burden and EHR Workflow Bottlenecks · 2026 · DOI

• At the European level, these challenges are being addressed through the European Health Data Space (EHDS) initiative, which aims to enable secure, standardized, and reusable health data flows for both primary and secondary use (de la Cruz et al.). The EHDS introduces new opportunities, including the adoption of harmonized data exchange formats, such as the European Electronic Health Record Exchange Format (EEHRxF), and the adaptation of national health information systems (Murgia et al.; da Silva Carvalho et al.). Parallel to this, new digital health technologies are rapidly evolving, including artificial intelligence, wearable devices, automated decision support, and decentralized architectures. These developments create new opportunities for personalized, preventive, and data-driven healthcare, while also introducing new requirements for existing EHR systems [Ambalavanan et al.(a); Kumar et al.; Sarraf and Ghasempour]. Furthermore, ensuring that secondary data use is conducted with data protection, trust, and regulatory compliance has become increasingly critical (de la Cruz et al.; Vovk et al.). This Research Topic brings together contributions that address these challenges and opportunities from multiple perspectives and examines how EHR systems can evolve to support interoperability, secure data use, clinical effectiveness, and patient- centered healthcare.

  Editorial: Pushing boundaries in EHR implementation and innovation through advanced digital health technologies · 2026 · DOI

• We raise questions regarding the underexplored consequences of AI-assisted documentation, particularly cognitive off-loading and the potential for de-skilling, echoing historical concerns surrounding earlier cognitive technologies that externalized thought.

  Re-Centering Clinical Documentation in the Age of AI Scribes: Four Aims of the Patient Chart Note · 2026 · DOI

• Literature Review The following paragraphs discuss various approaches to overcoming the challenges of implementing a PACS system in healthcare. Most of these solutions aim to expand system functionality and resolve interoperability issues, making medical imaging and hospital management systems more usable, secure, and efficient. In 2012, Aldosari conducted a study on the adoption of PACS in Saudi Arabian hospitals, emphasizing its role in improving workflow efficiency and radiology department performance. The research highlighted that those hospitals using PACS experienced faster image retrieval, reduced diagnosis time, and better communication among medical staff. However, the study also noted challenges such as resistance from healthcare professionals and the need for proper training programmes to maximise system benefits. In 2016, Goodarzi and Khatami investigated user acceptance of PACS in emergency departments, focusing on factors influencing clinicians’ willingness to adopt the that perceived findings highlighted system. Their usefulness, ease of use, and system quality significantly affected acceptance levels among medical staff. The study 3 EAI Endorsed Transactions on Pervasive Health and Technology | Volume 11 | 2025 | R. M. Afram, N. N Khamis for emphasized that organisational readiness and adequate training programmes were essential improving satisfaction and promoting successful PACS adoption. In 2016, Khalifa & Househ assessed barriers to PACS adoption, identifying high installation costs, resistance to change among medical staff, and cybersecurity concerns as major obstacles. Their that implementing training programmes and user awareness campaigns could improve PACS acceptance and usability. findings suggested learning applications In 2017, Shen et al. provided a comprehensive analysis of deep imaging, showing that advanced neural networks can support PACS-based diagnostic processes by improving precision and reducing interpretation errors. in medical In 2017, Mohamed investigated the adoption of healthcare information systems, including PACS, in public hospitals in the Kurdistan region of Iraq. The study identified financial constraints, lack of IT expertise, and absence of standardized implementation strategies as the primary challenges facing PACS adoption in Iraq. In 2018, Al-Shorbaji et al. examined the impact of interoperability on PACS efficiency in Middle Eastern hospitals. They concluded that a lack of integration with other healthcare IT systems resulted in fragmented data storage and hindered clinical decision-making. The study emphasized the need for unified health informatics policies. In 2020, Budd et al.

  A Study to Determine User's Requirements for The Design of A PACS-Based Healthcare System in Iraq · 2026 · DOI

• for higher acuity care, suggesting appropriate patient autonomy preservation. Long-term overriding involving follow-up at 6 months showed sustained engagement with 78.4% of intervention participants continuing regular system use, indicating strong adoption and perceived value among diverse patient populations.

  Transformer-based Mobile Health Text Analytics System: Intelligent Symptom Monitoring and Alert for Pervasive Healthcare Environments · 2026 · DOI

• Our study had several strengths. First, our evaluation used a multimethod, iterative design that incorporated qualita- tive interviews and quantitative surveys at multiple stages, including the usability evaluation. Second, we engaged diverse knowledge user groups within MyJourney, includ- ing patients, nurses, pharmacists, and administrative staff, to gain a comprehensive understanding of the platform’s potential impact and areas for improvement. Third, the use of the interpretive description methodology provided detailed insights, closely grounded in participants’ experiences and clinical contexts. The integration of patient insights and provider workflow mapping into the design and rollout of the MyJourney platform at the CC helped us refine it to better align with real-world needs. Finally, interpreting our findings https://cancer.jmir.org/2026/1/e87973 through RE-AIM (phase 3) offers preliminary evidence of promising implementation and potential maintenance of MyJourney, with participants able to complete core tasks and describing the app as helpful for organizing information and coordinating aspects of their care. Patients and clinicians reported perceived reductions in documentation burden and smoother workflow coordination when using MyJourney. Limitations include a small sample confined to 2 clinics within 1 hospital, so we acknowledge that the generalizabil- ity of our findings to smaller hospitals, rural settings, or low-resource environments may be limited. However, this approach allowed us to observe both a mature implementa- tion (ie, the BDC clinic) and an early-stage adoption (CC) of MyJourney within the same institution. Nevertheless, we acknowledge that the implementation of innovations such as MyJourney is dependent on institutional readiness, leader- ship buy-in, and interoperability capacity. There is also a possibility that our purposive sampling strategy to identify eligible patients, providers, and staff introduced selection bias, as our recruitment methods incorporated convenience and self-selection (eg, posters, prior consent lists, and voluntary participation by staff). This may limit the trans- ferability of our findings. However, we included nearly all MyJourney users in our sample. Phase 2 interviews did not include oncologists or surgeons, reflecting their limited routine use of the CC Clinical Navigation Tool at this stage; future work should more directly incorporate physi- cian perspectives, as the platform scales and physician-facing components are further integrated. Another related limitation was that the patient participants in phase 1 were predomi- nantly English-speaking, highly educated, and reported higher income, which does not reflect the North York community. In future evaluations, we will ensure the recruitment of patients with diverse intersecting identities, including gender identity, race, language, and accessibility needs. Outcomes are primarily perceptual and descriptive at this stage of technology evaluation (particularly for describing workflow efficiency), and integration with external systems has not been tested. We did not collect objective use or long-term sustainability metrics (eg, log-in frequency and time-on-task) for the BDC implementation; therefore, our assessment of implementation “success” is based on user-reported usability, perceived utility, and integration into workflows. As such, our results should be interpreted as evidence of early implementa- tion success rather than definitive proof of sustained adoption (ie, they should be understood as descriptive and percep- tual indicators of implementation success and anticipated sustainability). Future work should incorporate objective workflow and clinical metrics, as well as measures (eg, time-motion or productivity metrics), and longer follow-up to more rigorously assess efficiency and maintenance over time.

  Supporting Patients With Breast Cancer and Providers Through Treatment and Survivorship: Multimethod Implementation Study of the MyJourney Platform. · 2026 · DOI

• This study is cross-sectional; therefore, causal inference is not supported, and the mediation should be interpreted as a statistical partitioning of associations rather than a temporal mechanism. All measures (DHC, UI, UX) were self-reported at one time point, which increases susceptibility to common method variance, social desirability, and ceiling effects. In addition, scale alignment remains a concern: pragmatic UI and UX items may (e.g., perceived ease/clarity/ partially overlap conceptually satisfaction apparent elements), potentially the proximity of UI to UX. While instruments were applied consistently, further evidence of instrument validity in this setting is needed, especially discriminant validity between UI and UX and measurement invariance across professions and hospital types, because item interpretation may differ by role and context, and DHC may reflect general digital confidence rather than task- and system-specific competency. inflating Statistical and design features also restrict interpretation. The prespecified models assume correct functional form and omit potentially important confounders (e.g., system vendor/version/ intensity, shift module, patterns, and local support arrangements), which may bias estimates or mask true effects (particularly for DHC).

  Person-centered hospital care in Indonesia: the role of digital health competency, user interface quality, and user experience in a multi-hospital study · 2026 · DOI

• This study draws on primary data from healthcare professionals directly involved in patient care and health information management across multiple public hospitals, providing practical insight into real-world experiences with Electronic Health Records (EHR) implementation. The relatively large and diverse sample enhanced the robustness of the findings, while the use of both descriptive and inferential analyses enabled a comprehensive assessment of implementation patterns and associated factors. However, the cross-sectional design limits causal inference between observed variables. The reliance on self-reported data introduces the potential for social desirability and recall bias, particularly regarding knowledge and prior EHR experience. Although statistical adjustments were made, unmeasured institutional factors may have influenced the results. In addition, the absence of qualitative data limited deeper contextual interpretation, and the focus on selected public hospitals may restrict generalisability to other settings. PRACTICAL IMPLICATIONS The findings highlight the need for sustained investment in ICT infrastructure, continuous capacity building for healthcare workers, and the establishment of strong institutional support systems to enhance the effective implementation of Electronic Health Records (EHR). Strengthening training programmes, improving system reliability, and ensuring ongoing technical support will help maximise the benefits of EHR use in routine healthcare delivery. In addition, aligning EHR systems with clinical workflows and fostering positive user engagement across different professional groups are essential for improving utilisation and 35 Article DOI: 10.52589/IJPHP-KHUZLFQV DOI URL: https://doi.org/10.52589/IJPHP-KHUZLFQV International Journal of Public Health and Pharmacology (IJPHP) ISSN: 2997-6014 Volume 6, Issue 2, 2026 (pp. 19-39) www.abjournals.org reducing resistance to digital systems. Addressing identified barriers such as infrastructural gaps, limited technical skills, and organisational constraints will further enhance system performance and user acceptance. Importantly, this study provides context-specific evidence from Calabar Metropolis, contributing to a better understanding of how EHR implementation is shaped by workforce and institutional factors within public healthcare settings. These insights can inform policy, planning, and implementation strategies aimed at strengthening digital health systems in similar resource-constrained environments.

  Determinants of Electronic Health Record Implementation in Government-owned Hospitals across Calabar Metropolis, Cross River State, Nigeria · 2026 · DOI

• Policy reformers and hospital administrators should aim to develop competency and confidence in nurses via regular, holistic EHR training initiatives that address nurse’s needs. An IT infrastructure & technical support teams breaks for minimizing system downtime and high user satisfaction. System developers for EHR shall invest in User-friendliness and Customizability to tailor as per nurses’ workflows and preferences. In-depth user experiences should be elicited through longitudinal and mixed-methods design for future research to study causal relationships. To address the positive attitude toward EHR for potential adoption, organizational intervention can include team dynamics and professional motivation besides functional technologies. Shift patterns and workload management should be taken into consideration to make the best out of nurse welfare as well as technology usage. https://doi.org/10.62486/pc2026169 Ghanayem H, et alISSN: 3121-2212 SAP Primary Care.

  Training, usability, and technical support as predictors of electronic health record–associated workflow efficiency and job satisfaction among nurses: evidence from Palestine · 2026 · DOI

• The cross-sectional design is not capable of making claims about causation between EHR use and downstream events workflow efficiency and satisfaction. All findings are associational only. The use of nonprobability convenience sampling limits the generalizability of our findings to all nurses in Palestinian governmental hospitals. Although we recruited from multiple hospitals and shifts, selection bias may have been introduced, and caution is needed when extrapolating results to other settings or populations. Nonresponder bias could not be assessed, as no data were collected on the 20 nonresponders. The exclusion of nurses working in wards with mixed documentation (paperbased and electronic) was intentional to avoid confounding, as prior research has shown that hybrid systems produce different workflow patterns compared to fully electronic or fully paper environments. However, this decision reduces the generalizability of our findings to the substantial proportion of Palestinian hospital wards that still operate hybrid documentation systems. Caution is therefore warranted when applying these results to mixeddocumentation settings. Data were obtained by selfreported questionnaires, which are subject to recall bias and social desirability bias. To mitigate this, the survey was anonymous (no names or employee IDs collected), and participants were assured that individual responses would not be shared with employers. Nevertheless, some bias may remain. Singlemethod (quantitative only) design: We lack qualitative insights into why usability, training, or technical support matter to nurses. Mixed methods would better explain the mechanisms behind our associations. No objective measure of workflow efficiency (e.g., timemotion studies, EHR log data). Our selfreported efficiency scores may not perfectly reflect actual time savings or task completion accuracy. The study was limited to Palestine governmental hospitals and may not be generalizable to other private healthcare or even other sectors. Several key potential confounders (e.g., organizational culture; leadership support for digital and individual technology attitudes) were inadequately explored. The technical problems and operational variables were rated based on subjective impressions instead of on system performance attributes.

  Training, usability, and technical support as predictors of electronic health record–associated workflow efficiency and job satisfaction among nurses: evidence from Palestine · 2026 · DOI

• A strength of the study is its novelty in exploring expe- riences of using patient portals as adolescents in mental health care. However, since this is a new area of research, the questions asked were broad and general. Subsequent studies have the opportunity to include more specific questions to further investigate some of the identified topics in more detail. A potential limitation is that informants up until age 27 were included, as this might impact the experiences remembered when informants retold and reflected upon their patient portal use as adolescents. Additionally, their current and more mature perspectives may shape how they remember past experiences. However, only 3 of the 14 informants were older than 24, and the mean age of the included informants was 20. Another poten- tial limitation is that the informants´ experiences reflect the use of patient portals available in Norway. Adoles- cents in other countries may have access to different solutions, which can lead to other experiences. However, since several findings from this study align with previous research on adults in mental health care and adolescents in somatic health care, it seems that many of the identi- fied themes are relevant across different contexts.

  Experiences of using patient portals as adolescents in mental health care - a qualitative study · 2026 · DOI

• Although electronic medical records (EMR) are introduced in many different settings, yet little is known about the readiness, effectiveness and progress of a centralized information system like NUMR across United Arab Emirates.

  Health care Expert’s readiness to implement National Unified Medical Records (NUMR) system in the United Arab Emirates; A Qualitative study · 2021 · DOI

• Despite the fact that EHRs can help to achieve better health, there is lack of evidence explaining national and sub-national EHR development in the limited resource settings.

  Electronic health records for better health in the lower- and middle-income countries · 2020 · DOI

• Mandating intensive technical cybersecurity disaster training for every emergency physician is not feasible nor a tremendously beneficial use of limited physician resources. However, department leadership and disaster-oriented physicians can lead cyber disaster preparedness efforts. We propose specific recommendations for emergency physicians for cyber disaster preparedness. The first thing to implement is regular ED and hospitalwide cyber disaster drills, simulating a technical failure of all digital systems. An even easier way to accomplish this task is to use your institution’s next scheduled electronic health record downtimes to practice effective nondigital patient care procedures. Members of your information technology and information services teams should participate in the crafting of these drills as well. To further accelerate your preparedness goals, introduce and develop a cyber disaster task force that includes technical, clinical, and organizational leadership. You then can share best practices with other health care delivery organizations. If and when a cybersecurity threat affects your hospital, participate in health care interorganizational threat sharing by using existing international mechanisms, such as the Health Information Sharing and Analysis Center. And finally, some of the simplest ways an emergency physician can safeguard his or her hospital from a cyber threat is to practice good cyber hygiene.24 (cid:1) Create longer unique pass phrases instead of a password found in dictionaries. (cid:1) Do not share passwords or pass phrases. (cid:1) Avoid using the same password or pass phrase for multiple accounts and services. (cid:1) Avoid sharing information on social media that can be used to answer security questions. (cid:1) Deploy multifactor authentication. (cid:1) Avoid accessing systems clinical environments such as coffee shops and airports. (cid:1) Avoid opening malicious e-mails. (cid:1) Avoid connecting environments. rogue flash drives from untrusted to clinical (cid:1) Encrypt digital data storage. (cid:1) Avoid disclosing sensitive information to unverified persons who may be impersonating authorized users.

  Cyber Disaster Medicine: A New Frontier for Emergency Medicine · 2020 · DOI

• These findings suggest that information technology systems designed for interoperability and secondary data also need to be designed in ways that support the qualculative practices of data workers in order to succeed, including making future uses of data clear to data workers and finding ways to minimize conflicting data before data workers encounter it.

  The qualculative dimension of healthcare data interoperability · 2019 · DOI

• METHODS: First we discuss EHR educational capabilities that have not been reviewed in sufficient detail in the literature and expand our discussion for each educational activity with examples.

  Electronic Health Records as an Educational Tool: Viewpoint · 2018 · DOI

• Furthermore, there were no standards develop by the relevant ministry and this had led to the lack of interoperability, information silos, and failure to preserve, migrate and share information across different platforms The study recommends the establishment of technical committees to develop, implement and overseer the eHealth standardisation process in Zimbabwe.

  National standardisation for eHealth information initiatives in hospitals in Bulawayo, Zimbabwe · 2018

• This paper examines the status and challenges of clinical informatics in the South African health care sector, In a recent survey of major international research databases such as Scopus, it was observed that there is a gap in knowledge on clinical informatics particularly as related to the status and challenges in the country’s healthcare facilities.

  The status and challenges of clinical informatics development in South Africa · 2016 · DOI

• It was discussed that hospital personnel exhibit nomadic work behaviour. Hence ubiquitous and uninterrupted ac- cess to existing information is a means for enhancing their work situation. Advanced information visualization is the means for effectively presenting information to the user. Context aware systems, featuring advanced information vi- sualization may successfully address many shortcomings of the current routing of nomadic users in a clinical en- vironment. We have presented a system, which was in- troduced in the domain of cultural heritage and is generic enough to be applied in the clinical routine supporting mo- bile devices for medical staff. We have presented a set of functions supported by the platform intGuide, as well as in- dicative use cases, showing the added value for the clini- cal environment emerging from the introduction of such a system. A necessary prerequisite for the successful introduction of such a system is the interoperability with existing legacy systems in the clinical environment. Health level 7 (HL7) is one of the things that come to mind in this context. The HL7 information exchange is thus far not supported by the system. If the system is to be introduced as a success- ful extension to existing legacy systems and not an island solution, HL7 is one of the major priorities of the adap- tation to the clinical routine. The main focus will be the connectivity to the EPR system. Additional helpful features may occur by extending the workflow control system to cover for additional activities. One example in this direction is the monitoring of progress of registered activities, e.g., status of laboratory tests for 127 Athanasios M. Demiris and Nicolaos Ioannidis individual patients. Other examples of important extension are the accessing of an e-library of the hospital or even an extranet of health.

  Context awareness and nomadic devices featuring advanced information visualization in clinical routine · 2005 · DOI

• We conclude that published standards in the distance education literature can provide valuable guidance to Web CME providers, and there is a clear need for additional research into questions about what works in Web-based education and why.

  Setting quality standards for web-based continuing medical education · 2004 · DOI

• While they are typically used to evaluate a single patient record, their application for a linked maternal infant chart has not been extensively explored.

  Design and implementation of maternal-infant clinical trial recruitment alert using linked electronic medical records, and evaluation of researcher-perceived alert usability · 2026 · DOI

• Background: Physician clinical information-seeking behavior has been studied in high-income settings but remains poorly characterized in Latin America.

  Clinical Information Needs Among Latin American Physicians: A Multi-Country Analysis of Semantic Clinical Search · 2026 · DOI

Most-cited papers in Electronic Health Records Systems

• Digital transformation in healthcare: Analyzing the current state-of-research · Journal of Business Research · 2020 · 737 citations
• Clinical Information Technologies and Inpatient Outcomes · Archives of Internal Medicine · 2009 · 266 citations
• Implications of large language models such as <scp>ChatGPT</scp> for dental medicine · Journal of Esthetic and Restorative Dentistry · 2023 · 262 citations
• A review of evaluation outcomes of web‐based continuing medical education · Medical Education · 2005 · 239 citations
• Artificial Intelligence–Generated Draft Replies to Patient Inbox Messages · JAMA Network Open · 2024 · 221 citations
• The impact of nuance DAX ambient listening AI documentation: a cohort study · Journal of the American Medical Informatics Association · 2024 · 144 citations
• Digital navigators to implement smartphone and digital tools in care · Acta Psychiatrica Scandinavica · 2020 · 141 citations
• Patient Privacy in the Era of Big Data · Balkan Medical Journal · 2017 · 115 citations
• Impact of Electronic Health Record Use on Cognitive Load and Burnout Among Clinicians: Narrative Review · JMIR Medical Informatics · 2024 · 96 citations
• Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews · Journal of Advanced Nursing · 2018 · 93 citations

Most recent work

• Rule-based natural language processing to extract clinical trial and research study enrollment history from unstructured notes · Health Informatics Journal · 2026
• The MediVoice implementation journey: ambient artificial intelligence for clinical documentation · Frontiers in Digital Health · 2026
• From Clinical Encounter to Draft Documentation: A Mechanistic Narrative Review of Ambient Scribe Technology (Preprint) · 2026
• Online Medicine Ordering & Doctor Appointment Booking Platform with Digital Health Records · International Journal for Research in Applied Science and Engineering Technology · 2026
• Asclepius: Novel Concept in Health Care System · INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH IN ENGINEERING AND MANAGEMENT · 2026
• AI-Powered Medical Scribe System: Real-Time Clinical Documentation Using Large Language Models and Automatic Speech Recognition · International Scientific Journal of Engineering and Management · 2026
• An evaluation of ambient artificial intelligence scribes at two academic medical centers · Discover Artificial Intelligence · 2026
• Deploying the Medical Informatics Platform for cross-border federated analytics in FERES and eCREAM · Frontiers in Disaster and Emergency Medicine · 2026
• Medical students’ intention to adopt electronic health records to improve the quality of healthcare · International Journal of Health Care Quality Assurance · 2026
• Data exchange is not information continuity · Open MIND · 2026

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