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The impact of adopting EHRs: how losing connectivity affects clinical reasoning
Author(s) -
Varpio Lara,
Day Kathy,
ElliotMiller Pat,
King James W,
Kuziemsky Craig,
Parush Avi,
Roffey Tyson,
Rashotte Judy
Publication year - 2015
Publication title -
medical education
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.776
H-Index - 138
eISSN - 1365-2923
pISSN - 0308-0110
DOI - 10.1111/medu.12665
Subject(s) - grounded theory , chart , psychology , workload , data collection , health care , credibility , medical education , medicine , computer science , qualitative research , sociology , social science , statistics , mathematics , political science , law , economics , economic growth , operating system
Context As electronic health records ( EHR s) are adopted by teaching hospitals, educators must examine how this change impacts trainee development. Objectives We investigate this influence by studying clinician experiences of a hospital's move from paper charts to an EHR . We ask: how does each chart modality present conceptions of time and data interconnections? How do these conceptions affect clinical reasoning? Methods This two‐phase, longitudinal study employed constructivist grounded theory. Data were collected at a paediatric teaching hospital before (Phase 1), during and after (Phase 2) the transition from a paper chart to an EHR system. Data collection consisted of field observations (146 hours involving 300 health care providers, 22 patients and 32 patient family members), think‐aloud ( n = 13) and think‐after ( n = 11) sessions, interviews ( n = 39) and document retrieval ( n = 392). Theories of rhetorical genre studies and visual rhetoric informed analysis. Results In the paper flowsheet, clinicians recorded and viewed patient data in chronologically organised displays that emphasised data interconnections. In the EHR flowsheet, clinicians viewed and recorded individual data points that were largely chronologically and contextually isolated. Clinicians reported that this change resulted in: (i) not knowing the patient's evolving status; (ii) increased cognitive workload, and (iii) loss of clinical reasoning support mechanisms. Conclusions Understanding how patient data are interconnected is essential to clinical reasoning. The use of EHR s supports this goal because the EHR is a tool for collecting dispersed data; however, these collections often deconstruct data interconnections. Where the paper flowsheet emphasises chronology and interconnectedness, the EHR flowsheet emphasises individual data values that are largely independent of time and other patient data. To prepare trainees to work with EHR s, the ways of thinking and acting that were implicitly learned through the use of paper charts must be made explicit. To support clinical reasoning, medical educators should provide lessons in connectivity – the chronologically framed data interconnections upon which clinicians rely to provide patient care.