Scientific Production of Patient ’ s Electronic Health Record in Online Journals from Brazilian Scenario

The study aims to analyse the scientific production about patient’s Electronic Health Record (EHR) available in online journals from 2006 to 2015. This is an integrative review. The search was conducted in the Virtual Health Library and Portal Capes, considering only studies in Portuguese. The sample consisted of 17 articles. It was observed that from 2011 to 2012 is the period with the highest number of publications about the investigated issue. The majority of papers were published in journals in the area of computer science and the most common modality of publication was original article. It was found that scientific productions involving Electronic Health Record discussed about its importance and implementation in health services, as well as perceptions of health professionals about its utilization. The research evidenced the relevance of EHR in health services, emphasizing necessity for improved regulations of ethical and legal issues and creation of legal provision to concede judicial validity in Brazil. Scientific Production of Patient’s Electronic Health Record in Online Journals from Brazilian Scenario REVIEW


Introduction
The patient's health record is an administrative and technological tool of health care with numerous purposes: access services, therapeutic monitoring, communication of those involved in the health care process, decision-making and legal security of user rights.Moreover, it is an essential component able to support education and research [1].
The health records in paper format is the most traditional form of data logging about the health history of an individual.However, this type of document is vulnerable to repetition of information obtained by the various professionals involved in health care, breach of privacy and loss, becoming rather difficult to retrieve information [2].
The use of medical records in the handwritten mode has its disadvantages related to the difficulty in interpreting records due to the illegibility of letters of some of the professionals involved in health care, as well as the repeated handling and aging of this document.In addition, over time, there may be a considerable amount of information about the patient, becoming complex searching for specific data and filing documents, which could create problems related to content, format, access and availability of records [3].
Thus, patient's Electronic Health Record (EHR) emerges as an important tool that can subsidize and guide activities of professionals who use it.The electronic format of records is an agile and practical data storage system, which facilitates the dynamic of care implemented by professionals, and can be available in various sectors such as health care units, hospitals and laboratories [4].
The electronic data recording is a technological innovation associated with the contemporary advancement of the information society, which has contributed to the growing use of this resource in health, recognized by the Federal Council of Medicine, in the Resolution No. 1.639/2002, that approves the "Technical Standards for the Use of Computerized Systems for Medical Health Record Handling", enabling preparation and filing of medical records electronically [5].
The search for studies that discuss about electronic medical record, has an undeniable contribution, because it share results and experiences about the use of this technological tool, expand and enhance the comprehension of the registration of assistance care in electronic format, as well discuss its effectiveness, modes of use and application possibilities.
In light of these considerations, this study aims to analyse the national scientific production about electronic health records available in online journals in the period from 2006 to 2015.

Method
This is an integrative review, a research method that can produce a wide range of results, such as: new knowledge from the synthesis of selected studies, conceptual and theoretical elaborations; identification of connections between different areas of knowledge and central issues of a specific area; identification of theoretical and methodological approaches with greater explanatory and understanding potential; misconceptions in the studies and the need for future research [8].
The research was conducted in six stages based on the principles proposed by Ganong [9].The first stage consisted in selecting the guiding question of the study, which was developed from the theme "Electronic Health Record".Thus, it was defined for this study the following question: what is the scientific literature about electronic health record in the national scenario available in online journals from 2006 to 2015.
In the second stage, it was selected the bibliographic material that integrates the sample group of this research.Therefore, the following inclusion criteria were defined: publication type of "scientific article", published in Brazil between 2006 and 2015; and with abstracts available and indexed in databases established for this study.It was excluded reviews and studies available in the dissertation or thesis format.
The search for articles was conducted over the Internet, in the Virtual Health Library and Capes Journal Portal, during January of 2016.For the survey of researches, it was selected the Health Sciences Descriptor (DeCS) "electronic health record".
In the third stage, it was verified the information extracted from the selected studies that were ca-talogued by the authors considering the following topics: article title, paper publication year, journal that the research was published, journal qualification, study modality, formation area of researchers and identify the main results and conclusions presented by the authors.
The fourth step consisted in analytically read the selected studies, observing the approaches covered in these studies, which established two thematic categories: 1. Importance, implementation and use of EHR in health services; 2. Health professionals' perceptions about EHR.The discussion and interpretation of results, which was the fifth stage of this review, linked the findings from the reviews of each author, as well as provided suggestions for further researches through the identification of gaps in studies of this investigation.In the sixth and final stage, the integrative review was expressed completely and clearly, which allows the reader to critically question the results of this study.

Results
The sample was composed by 17 articles published from 2006 to 2015.The years 2011 and 2012 refer to the period with the highest number of publications about the studied issue, with four productions each, and followed by the years 2010, 2013 and 2014 each one with two publications.The years 2006, 2009 and 2015 obtained one publication each, as shown in Figure 1.
The studies about EHR increased emphasis over the past five years, showing the topicality of the theme.On the other hand, the chart above shows a gradual increase of annual publications in the period 2008 to 2011, stabilizing in the period between 2011 and 2012, followed by a decrease between 2013 and 2015, reaching the lowest point in only one publication.
As for the analysis of the journals, the data indicate that the Journal of Health Informatics concentrated the majority of scientific productions, discussing about registration of health care data in electronic format.In addition, it was found that journals with qualification B2 (Qualis/CAPES) in the interdisciplinary area showed higher number of researches and one study published in journal with qualification A2 (Qualis/CAPES), as shown in Table 1.
Based on the information highlighted in Table I, there is a predominance of publications involving the Electronic Health Record in journals in the field of computer science.
Regarding the publication mode, the articles were divided in three categories: original article, with 12  publications; review, with four studies; and opinion, with one publication.This distribution demonstrates the efforts of the scientific community to produce never published studies about electronic health records and collaborate with its implementation in health care services.
The profile of the academic formation of the authors, was obtained from information contained in the selected articles.The analysis revealed that the health professionals who most contributed to the publications, were nurses, doctors and dentists, with six, four and two articles, respectively, while the authors with academic formation in physiotherapy and psychology published only one article.
A diverse profile of other professionals exercising their activities in the areas of computer science, engineering and in the administrative area contributed with only one publication on the topic related to electronic health records.
Health professionals were the ones who most produced scientific articles about the subject, due to the proximity and daily use of these professionals with health record and better understanding about the needs and operational problems of health record systems.
With regard to the information included in the results and conclusions of the analysed scientific production, it was possible to separate the studies in two thematic categories: 1 -Importance and implementation of the patient's electronic health record in health services; 2 -health professionals perception about the adoption and use of the patient's electronic health record.
The first category: Importance and implementation of the Patient's Electronic Health Record in health services emphasizes the need for the use of EHR for the health care team, for the organization of work in the health service and for the health care dynamics of patient and family, as illustrated in Table 2.
The studies referred in Table II report the importance of using electronic health records because it Narrative review of the literature in national journals.
The lack of preparation of health professionals in relation to the implementation of electronic medical records interfere directly in the acceptance of required changes.Also draws attention to the concern that the use of technology should not diminish contact with the patient.
promotes greater accessibility to information, improving the process of care, thus contributing to the enhancement of assistance provided to users of the health network in the primary and specialized care context.It was also shown the importance of implementing information systems that include EHR in health institutions with adequate tools and instruments to search and storage all data about patients in order to select the most appropriate therapy to address the needs and improve the quality of the health of patients.
The advantages and disadvantages of using a computerized record system and the comparison between the use of paper and electronic records were also emphasized in studies.
Other analysed articles emphasize transparently the perception of health professionals about the adoption and use of electronic health records in health services, establishing the second category of the analysis, as shown in Table 3.
The studies that composed the empirical material provided in  Field study conducted in three hospitals with a phase of interviews and an application of questionnaires.
The results obtained suggest that there are differences in the perception of EHRs and that these are from the specificities of the users profile in different hospitals.It is necessary that health professionals agree in some aspects with the hospital manager in the way both realize the significance and importance of EHR.Pilot study It concludes that if the system adjust to the doctor's workflow in the clinic and offers something in return such as mobility, "technical simplicity" safety and other benefits, doctors use the system properly to improve the quality of patient care.

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other factors, the commitment of managers and health professionals.In addition, they focus attention to the need for training of staff.The papers also warn about the costs related to its implementation, possible errors that may interfere in accessing electronic medical records and the confidentiality of information.
According to the analysis of the articles, the degree of satisfaction in the use of EHRs is higher among nurses than among doctors and other health professionals, thus requiring further discussion about the dissemination of information among professionals who fill in medical records.

Discussion
There are several contributions from the cited studies in this investigation [10][11][12] to justify the use of EHRs by health professionals which are: the reduction in quantity of archived papers, the reduction of behavioural mistakes, greater longevity of information, prevention of repetitive procedures, greater efficiency of the health services, customer satisfaction, mobility, easiness of manipulation, safety and simultaneous access of patient's information by the health team.
As electronic health records are simple information systems and with significant degree of accuracy, this review also showed that the digitalization of medical records is essential for professionals to plan health actions [13], consequently decreasing the amount of workload in professional units by obtaining succinct data in a reasonable period of time [14].
The use of electronic health records in health facilities benefits the practice of the involved professionals, because it facilitates the access to patient information, produces faster prescriptions and controls strictly and appropriately the use of materials and medicines by patients [1].
Other studies also emphasize that the implementation of health records in electronic format, which allows the sharing and integration of information with real-time access, improves the quality of care, supports decision-making and implements more adequate therapies [10,[15][16].
Studies also stress that patient's health records in electronic format provide to health professionals Descriptive, exploratory and quantitative paper with the objective to study the use of specific EHR module by the nursing team.
The evaluated system, despite the advances, is still complex for the user who has not received training, despite having a consistent and interactive interface.
easiness, flexibility and safety in prescribing and planning their actions and enhance health services [1-2,10).In addition, legibility and constant updating of data are both advantages regarding the use of EHR [11,17].Thus, implementing electronic health records in Brazilian health services contributes to the work of the health care team and the quality of care.A successful implementation consists in the continuous participation of health professionals in all stages, from planning to the inclusion of this technology in health services.
However, some users have refuted the acceptance of electronic health records as a defensive, blocking or resistance attitude [18].Thereby, to remedy this objection and demonstrate the potential of EHRs is needed further discussion and dissemination of information among professionals to subsidize and assist in the implementation of this system in health institutions [19].
The adoption of electronic medical records in health services as an innovative technological tool requires improvement and enhancement in order to provide adequate and promising utilization, since individuals with better computer skills manipulate more easily technologies of information and communication, which is imperative for adequate training of the health staff [20].
Therefore, to establish EHR as a flexible and profitable technological resource, it should be object of intensive training.In addition to stimulate more accessible and successful utilization of EHRs, its use should be simple, clear, practical, and uncomplicated [21].
Besides the control in computing and familiarity of the team with the system, the success or failure of a system is closely related to the involvement of users in planning its various implementation stages [1].In these terms, it is inferred that technological systems can become obsolete if there is no support of professionals in large scale.In this way, the study confirms that enthusiasm and dedication of professionals are powerful components for the adequate deployment and operation of these systems [22].
The intense and adequate training of staff, added to an uncomplicated system for health professionals, the broad adhesion of these professionals, the support and the harmony of the working group, determine the success or failure in adopting and implementing an EHR system.However, some questions have to be addressed to determine whether the wide use of electronic health record is a reality.In this regard, regulatory institutions of health professionals have been concerned with the ethical and legal issues of patient's health records.A great advance was the digital certification, conferred by registry offices and instituted by the Provisional Measure 2200-2 from 2001 [23].
The study suggests that the Department of Health, as well as regulatory agencies and standardsetting organizations should allocate greater budget resources in order to strengthen the computerization policy of hospitals units and complement the Brazilian public health system [10,15].
The process of implementing a computerized record system is complex, which involves high costs and significant demand and commitment from the workforce [24].Therefore, in order to successfully deploy computerized clinical and administrative health records, it is necessary motivation, force, impetus, dynamism and responsibility of every group.

Conclusions
The implementation of EHR in hospitals may benefit greatly patients, health care professionals and institution in planning health care actions, because it improves the quality of information and patient care in order to collaborate with professionals in obtaining data about the conditions of patients providing better and more effective treatments.
In order to successfully implement an electronic health record system is crucial the participation of the health team in the stages prior to its implementation and qualification of the entire team, clarifying that the contact with the patient remains the foundation of good health care.
Electronic health record systems greatly contribute for the healthcare practice of health professionals such as: clarity, sharing and speed of information, optimization of physical space, since the file is digital and not on paper creating easeness in managing services, culminating in the improvement in the quality of care provided to the population.Nevertheless, the deployment costs related to the acquisition of equipment and computer systems and training of professionals are notable barriers.In this way, the benefits generated by the use of EHR in health institutions outweigh the listed difficulties, which can be alleviated over time.
As for the ethical and legal issues about the implementation of EHR, councils responsible for the regulation of health professionals ensure the implementation and operation of EHR by these professionals in an ethical manner.Due to the computerization of this device and the possible risk of leaking personal patient information, it is necessary to discuss and analyse the laws of ethics codes and other legislations and regulations related to ethical and legal issues of the use electronic patient record.
It is important to emphasize that this integrative review has limitations, since it consisted of a small sample of studies in the investigated period interfering in the generalization of results.Moreover, the study only analysed publications in Portuguese.Thus, it is expected that this study can create further researches and thematic discussions covering both national and international scenarios.
In general, it can be stated that this study contributed in evidencing the importance of EHR in health care units, stressing the need for better regulation of ethical and legal issues, as well as creating legal provision that concede judicial validation in Brazil.In this perspective, the theme emphasizing the Bra-zilian reality requires more debates regarding the appropriate advancement of electronic medical records.International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q2 in category Medicine.

Figure 1 :
Figure 1: Distribution of articles according to the year of publication.João Pessoa-PB, Brazil, 2016.

Table 1 .
Distribution of articles according to the title of the journal, qualis and quantity of publications.João Pessoa-PB, Brazil, 2016.

Table 2 .
Distribution of studies focusing on the importance and implementation of patient's Electronic Health Record in health services, according to title, author, purpose and conclusions.
The implementation of the educational plan in EHR was successful, since the goals were achieved such as to stimulate the systematic registration of educational actions.

Table 3 ,
argue that the adhesion and implementation of the EHR systems include, among Source: Research data, João Pessoa-PB, Brasil, 2016.

Table 3 .
Distribution of studies focusing on health professionals' perceptions about the adoption and use of Electronic Health Record, according to title, author, purpose, method and conclusions.