The impact of adopting EHRs: how losing connectivity affects clinical reasoning.
BACKGROUND
As electronic health records (EHRs) are adopted by teaching hospitals, educators must examine how this change impacts trainee development.


OBJECTIVE
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 EHRs 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 EHRs, 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.
Faculty of Medicine, Uniformed Services University for the Health Sciences, Bethesda, Maryland, USA; Faculty of Medicine, Academy for Innovation in Medical Education, University of Ottawa, Ottawa, Ontario, Canada.
Lara
L
Varpio
Kathy
K
Day
Pat
P
Elliot-Miller
James W
JW
King
Craig
C
Kuziemsky
Avi
A
Parush
Tyson
T
Roffey
Judy
J
Rashotte
D000046:Academic Medical Centers; D002983:Clinical Competence; D003625:Data Collection / Q000379:methods*; D057286:Electronic Health Records; D066296:Grounded Theory; D006776:Hospitals, Pediatric; D006801:Humans; D007400:Interprofessional Relations; D008137:Longitudinal Studies; D010348:Patient Care Team; D013337:Students, Medical; D013997:Time Factors