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In 1998, the term “narrative” was initiated by European healthcare centres (Kalitzkus, 2009). This introduction added value to EHRs since previously only structured data could be captured, and healthcare professionals' direct collection of patients’ data was not facilitated. Structured data refers to information recorded in EHRs that asks the same questions in the same format to every patient repeatedly (Abhyankar et al., 2014).

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Narratives have the potential to capture information directly from patients by allowing freedom of expression and immediate feedback which supports the reuse of information and easy communication (Johnson et al., 2008). In turn, the reuse of information and seamless communication assists the decision-making process which directly impacts health service delivery.

In 1999, narrative was developed as a medical approach by Rita Charon and Rachel Naomi Remem (Rosti, 2017). These narratives were handwritten patient stories that were physically stored in a room and thus did not guarantee patient information security or confidentiality. Securing patient information is at the core of healthcare, and the use of EHRs offers a platform that protects patient narratives (Linder, Schnipper &

Middleton, 2012). Narratives have increasingly found greater popularity. From 2001 to 2005, handwritten narratives were being converted to electronic format using advanced technology (Finn, 2015). This is referred to as electronic narratives which are the digital versions of patients’ stories recorded in video, audio and images into EHRs (Liu, Weng

& Yu, 2012). The authors added that integrating narratives in EHRs has requirements and specific guidelines to follow.

2.4.1. Requirements of integrating narrative into EHRs

Incorporating narrative into EHRs require information technology support that will allow healthcare professionals to be equipped with tablet computers in order to access EHRs (Evans, 2016). These tablet computers have functionalities that can record images, audios and videos about the patient’s health journey and their care at the hospital (Tekiner, 2017). When recording patient narrative using tablet computers, healthcare professionals have to explain why they find the patient’s story relevant and how it could benefit them and other patients. Asking the patient to fill out a consent form before starting the recording process is a fundamental requirement.

Blijleven et al. (2017) recommend that recorded information is automatically saved onto the tablet allowing for information to be edited or modified at a later stage if the patient requests so. For security purposes, healthcare professionals can upload the recorded patient narrative to a secured server and delete it off the tablet to ensure patient privacy.

In this vein, when using EHRs to share patient narratives among other healthcare

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professionals and facilities, only patients’ first names and/or diagnostic images should be used. Healthcare facilities need reliable internet connections to ease the process of recording, saving and sharing patient narratives using EHRs (Tekiner, 2017), and healthcare professionals need to be trained to work with patients’ narrative effectively.

Warner et al. (2016) indicated that although electronic narratives present positive results to support healthcare service delivery, its integration can be challenging. Issues such as trust, time-consuming recording, and legalities still make it difficult for healthcare facilities to benefit from EHRs. Birkhäuer et al. (2017) noted that changing healthcare professionals interrupts patient treatment and the communication process which may, in turn, affect the patient’s emotions, and result in the loss of trust. Furthermore, the entire process of collecting narratives - engaging with the patient, signing legal documents, writing and recording into EHRs - is time-consuming. In terms of legalities, there are rules, regulations and other jurisdictions every healthcare facility needs to abide to, and patients must reserve the rights to allow or disallow the process of electronically recording narratives.

According to Hua et al. (2011) and Warner et al. (2016), incorporating narratives in EHRs is considerably more tedious and cumbersome than recording traditional narratives (transcribed notes). Yet, the addition of electronic narratives to healthcare professionals’ decision-making process diminishes the likelihood of administering incorrect dosages of medication potentially harmful to the patient (Johnston, Banner &

Fenwick, 2016).

2.4.2. Steps of integrating narratives in EHRs

According to the American Health Association (2015) there are nine steps to follow when integrating narratives in EHRs. These phases are:

Create an implementation team: Clinical members (physicians, nurses, medical assistants and administration staff) play a crucial role in implementing new technology.

Clinical members also have the ability to teach EHRs skills to colleagues, and present daily challenges to the implementation team.

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Configure the software: The healthcare information technology team needs to closely cooperate with the health information technology vendor for the configuration of narratives in EHRs in order to meet appropriate security measures. Configuring software involves protecting computers and network systems, and customising software to optimise workflow. To customise EHR software, external elements need to be constructed and designed such as demographics, treatment protocols, computerised order entry (COE), patient’ history settings, encoded billing systems, consent forms, standing orders and medication management settings. The modification of software can be done according to the specifications of healthcare professionals to support narratives and documentation.

Identify hardware needs: Timeous understanding of hardware requirements can save healthcare professionals’ time and money. For instance, instead of logging onto the system several times a day, each healthcare professional can access the system using the laptop or tablet they carry with them. It is advisable to employ an information technology service company to assist with the system hardware.

Transfer data: It is crucial that a checklist of items entered into the new EHR system is prepared. Furthermore, the approach for migrating data from the former EHR to the new one should consider the amount of time required to transfer information.

Optimise pre-launch workflows: Healthcare professionals need to clarify optimum workflow procedures before implementing a new EHR – This will avoid inefficient workflows and insufficient staff support. Each step of the implementation should consider whether the step is necessary and whether it adds value to the patient.

Consider the room layout: The design and configuration of the exam room can impact patient care. It is therefore advisable that a semi-circular desk is used – one that allows the healthcare professional and patient to face each other. This creates the “triangle of trust”; – a virtual triangle between the healthcare professional, patient and computer facilitating communication.

Decide on the launch approach: Commencing the project can either be done in a “big bang” approach or, alternatively, on an incremental basis. With the big bang approach,

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all users directly switch to the new EHRs on the same day, and transfer all the functions and patient information to the system. This approach minimises the time and cost of managing two systems simultaneously, but it can be highly disruptive when small malfunctions occur. The incremental approach allows for the implementation to be done in a stepwise manner – activating certain functionalities step-by-step, department-by- department, and rolling out slowly to the rest of the clinic.

Develop procedures: for when the EHRs has malfunctions or experience technical issues. Procedures need to be developed to equip healthcare professionals with the necessary knowledge and skills to deal with system challenges. Training should be done on an ongoing basis.

Research done by Pérez et al. (2013) indicates that electronic narratives have been emerging in healthcare as an effective strategy to collect important patient information.

Implementing an electronic narrative approach provides a convenient way of giving and receiving information that helps to understand the patient – in contrast with the non- narrative approach. The non-narrative approach consists of patient details and information included in EHRs without adding the patient’s personal story. The incorporation of narratives into EHRs has led to the improvement of patient care, enhanced communication within medical network services and thorough decision- making processes (Johnson et al., 2008; Huang et al., 2017). In other words, despite evident deficiencies, narratives in EHRs have the ability to improve how healthcare professionals implement patient care and decision-making processes. Especially in high income countries, this trend has been observed.