Table 2.

Reviewed articles (opinion-based conceptual articles (for example, essays, commentaries, reviews, editorials) are indicated by italics.

Author(s), year published	Study design	Main points for informational continuity
Aaronson et al, 200112	Qualitative survey of 219 family medicine residency directors	41% of respondents said EMRs negatively affected interactions with patients. Historical patient information is used for health maintenance/laboratory flags/problem medication/patient lists.
Bertakis and Callahan, 19929	Cross-sectional observations of doctor-patient interactions in a university family practice; 47 interactions with established patients, 36 with new patients; interactions analysed	Doctors typically ask information of established patients using valiated Davis Observation Code only when it is relevant to a new medical problem. There is less discussion of patients' family information established patient visits.
Burt et al, 200413	Qualitative retrospective audit of GP communications from 13 460 patient consultations in palliative care situations	Updating patient information is central to the doctor's role. A lack of informational continuity negatively impacts on palliative care specifically.
Desguin et al, 199430	Conceptual	Families should keep information on prescriptions and health conditions.
		Nurses can assist with updating medical records.
		Medical records are important to illness management.
		Recording social/familial information in EMRs is important.
Errington, 197431	Conceptual	Knowing a patient's peers or social group helps with understanding his/her health problems. Repeated patient visits build a cumulative picture of patients' psycho-social context for future medical care. Having access to information from previous GPs is vital to making primary care effective.
Freeman, 198432	Conceptual	Informational continuity is better when doctors ‘hand over’ records. Relying on memory alone for patient information may not be a good strategy. Rather, memory is an aid for consistency along with medical record. There is no consistency in how much information recorded in a patient's record.
Freeman et al, 200333	Conceptual	Having informational continuity can overcome the negative outcomes of lacking interpersonal continuity of care. Sometimes doctor and patient want a fresh start with regard to informational continuity (that is, a new record). Some GPs may deliberately not record contextual information so that s/he becomes the sole keeper of this information.
		Continuity is still maintained, with that practitioner only.
Freer, 198034	Conceptual	Patient health diaries used in research have been found to be more efficient than retrospective health interviews. It may be possible to use health diaries clinically, but the methods for doing this remain unclear.
Guthrie and Wyke, 200035	Conceptual	Continuity is enhanced by the use of EMRs. Chronically ill patients typically spend ten minutes explaining their health history to new GPs. Personal continuity is defined as the ongoing doctor–patient relationship and it ensures care takes account of a patient's personal/social context.
Hamilton et al, 200320	Cross-sectional retrospective case-control with cancer patients from 21 general practices	Computerised and paper records record different types of patient information. For example, some computer systems have little ‘free space’ for contextual material. Accurate records are especially needed in case of patient complaints or legal action. Information and patient follow-ups can be lost if there is no personal continuity. A hybrid system of paper records and computer records is more comprehensive (computer records have more telephone conversations recorded, paper charts have more home visits and symptoms recorded).
Hegan, 200336	Conceptual	Medical records are important as they ensure past consultations can be communicated. They should allow the person reading to re-construct the event. Effective communication with colleagues is needed for continuity of care between practitioners.
Hennen, 197537	Conceptual	Continuity of information is vital in cementing the interprofessional relationships in the office (as different professionals see patients). The medical record is the key to this.
Hjortdahl et al, 199214	Qualitative survey of 133 GPs	Prior knowledge of a patient (for example, about medical history, personality, social network) affects decision making. GPs are information coordinators. The duration and depth of doctor–patient relationship shapes accumulated knowledge; it takes at least a few years (1–5 years) to establish a good knowledge base.
Hjortdahl, 199221	Survey of 133 GPs after doctor–patient interaction	A doctor's prior knowledge of patient assists with decision making. For example, prior knowledge is ‘helpful’ in 44% of cases, ‘useful’ 66% of cases, and a ‘great help’ in 30%. In 8% of cases a lack of knowledge was deemed a ‘hindrance’.
Hjortdahl, 200138	Conceptual	Continuity builds relationships between doctor and patient. The patient needs to trust the doctor in order to establish continuity. Continuity may be used to develop a doctor's clinical knowledge/skills. Informational continuity is unlikely to replace interpersonal continuity of care. Doctors possess integrated knowledge gathered over time.
Kearley et al, 200122	Qualitative interviews and cross-sectional survey of 996 patients and 284 doctors in 18 practices	Informational continuity cannot replace interpersonal continuity in the delivery of quality of care.
Kibbe et al, 200439	Conceptual	A patient's memory is sometimes needed when reassembling information missing from the recorded record. Patients can relay EMRs between physicians. Continuous connectivity between patients, families, and doctors is an element of continuity. A portable, patient-held record (on smart-card or USB) can be a source of empowerment.
Kravitz et al, 199323	Cross-sectional survey (database data) of 1751 patients	Patients may not remember accurately what they have been told by doctors. For example, >90% of respondents remembered to take medications. Fewer remembered being told about diet and lifestyle advice. Therefore, patients' memories may be selective.
Lester et al, 200324	Cluster randomised controlled trial of 201 patients	The patient-held record is valued as a communication tool, particularly by patients with chronic stable schizophrenia. Patient-held records did not improve outcomes for patients with schizophrenia, although caseworkers/GPs found them useful.
Liaw et al, 199215	Two focus groups held with 21 randomly selected patients from family practice and walk-in clinics	Sharing information assists in establishing interpersonal continuity. Though personal qualities and competence of a doctor are important, patients felt it did not matter who the doctor was as long as medical records were available to ensure consistency. Ten patients wanted to see a regular GP who knows their personal/medical histories.
Litaker et al, 200525	Survey of retrospective cohort of a specific patient group of 3718 patients	Informational continuity provides a knowledge base accessible to all clinicians, ideally through a single electronic record accessible to all healthcare providers.
Mandl et al, 200140	Conceptual	Feelings of privacy and control will enhance a patient's sharing of information during an appointment.
Moore and Busing, 19936	Qualitative survey of 13 family medicine residency programme directors	A nurse/receptionist who coordinates information/appointments is to be the most important person in establishing continuity from the patient's view. Computer records summarise patient history/previous care.
Parchman et al, 200226	Time series (cross-sectional prospective cohort) of 256 patients	With increasing continuity, trust in doctors increases and patients are more likely to divulge information regarding the social context relevant to health. Patient recall varies according to the outcomes of the previous consultation. For example, certain recommendations made by the doctor are more or less likely to be remembered. This could influence whether or not patients give correct information to their doctors.
Risdale and Hudd, 199417	Qualitative interviews with 39 patients	Computers are an efficient tool for quickly accessing information and for cross-referencing. Information is accessed in computerised records faster than in hand-held ones.
Risdale and Hudd, 199718	Qualitative interviews with 30 patients from a specific clinic	Patients have views about what information they see as needed for the EMRs. Lifestyle information and biological risk factors are appropriate. Personal comments and serious illness are not, unless discussed in advance (mental illness is also a concern). Doctors need to develop ways patients can evaluate and access their information.
Rogers and Curtis, 198041	Conceptual	Mature knowledge pertains to information built up about the patient and his/her family. Telecommunications should be recorded on a patient's record. The patient is more likely to disclose personal information when s/he has an established record with the doctor. The patient's willingness to provide important contextual and health information is implicit with the goal of creating continuity of care.
Rowan et al, 200227	Cross-sectional survey of 134 family medicine preceptors	Coordinated medical records are important and enhance physicians' abilities to recognise information about patients' problems/therapies; problem lists, medical lists and computers help this. Looking at the correlation with longitudinality of relationships, coordinated medical records overall scored R2 0.0639, compared with, R2 0.1168 (regular medical records). GPs may need computer training to enhance informational continuity of care.
Schers et al, 200328	Cross-sectional postal survey of 873 family practice patients	Use of the computer as an information storage system may lead to more people having access to the information than the patient wants. Because of this, patients may withhold information or not disclose as much. Patients agreed that most aspects of their health histories were important for their personal GP to know, and should be accessible to the on-call GP. Older patients were more comfortable with multiple points of access to medical records. Doubts about the confidentiality of the practice may lead the patient to confide in their GP less. Access to private information should be given by patients to certain staff members. The doctor is not the only person seeing records; because of this, there may be no control over confidentiality in larger practices.
Starfield et al, 197629	Random chart pulls of 200 patients	Recording certain types of information enhances the effectiveness of care. Medical records are superior to doctors' recollections.
Starfield et al, 197910	Observations of doctor–patient interactions and chart pulls of 104 patients with return visits scheduled	Physicians routinely do not record certain types of information. Quality of the medical record is linked to the quality of care. Doctors are likely to recall important issues recorded on the health record.
The Bolton Research Group, 200019	Qualitative survey of 756 patients in 10 group practice clinics	Confidentiality allows patients to share information with doctors. Patients believed that GPs should act as gatekeepers of the medical record.
Thompson, 198942	Conceptual	Patients should have their own summary of their chart to use when travelling, when switching doctors, and when seeking acute care. The doctor should establish a patient-based record, so that when admission/intervention is needed, all the information will be there. Sometimes 6 months can elapse between the new GP getting records in a transfer situation.
Toms, 197711	Multi-qualitative method and cross-sectional case study of 30 families who had lost their family doctors	It may fall to the patient to ensure getting records transferred and thus ultimately getting continuity. There is no ‘usual practice’ of transferral of practice — each doctor is left to decide how this should be done.