title: The EHR and building the patient's story: A qualitative investigation of how EHR use obstructs a vital clinical activity.
abstract: BACKGROUND
  Recent research has suggested that using electronic health records (EHRs) can negatively impact clinical reasoning (CR) and interprofessional collaborative practices (ICPs). Understanding the benefits and obstacles that EHR use introduces into clinical activities is essential for improving medical documentation, while also supporting CR and ICP.
  
  
  METHODS
  This qualitative study was a longitudinal pre/post investigation of the impact of EHR implementation on CR and ICP at a large pediatric hospital. We collected data via observations, interviews, document analysis, and think-aloud/-after sessions. Using constructivist Grounded Theory's iterative cycles of data collection and analysis, we identified and explored an emerging theme that clinicians described as central to their CR and ICP activities: building the patient's story. We studied how building the patient's story was impacted by the introduction and implementation of an EHR.
  
  
  RESULTS
  Clinicians described the patient's story as a cognitive awareness and overview understanding of the patient's (1) current status, (2) relevant history, (3) data patterns that emerged during care, and (4) the future-oriented care plan. Constructed by consolidating and interpreting a wide array of patient data, building the patient's story was described as a vitally important skill that was required to provide patient-centered care, within an interprofessional team, that safeguards patient safety and clinicians' professional credibility. Our data revealed that EHR use obstructed clinicians' ability to build the patient's story by fragmenting data interconnections. Further, the EHR limited the number and size of free-text spaces available for narrative notes. This constraint inhibited clinicians' ability to read the why and how interpretations of clinical activities from other team members. This resulted in the loss of shared interprofessional understanding of the patient's story, and the increased time required to build the patient's story.
  
  
  CONCLUSIONS
  We discuss these findings in relation to research on the role of narratives for enabling CR and ICP. We conclude that EHRs have yet to truly fulfill their promise to support clinicians in their patient care activities, including the essential work of building the patient's story.
authors.affiliation: Department of Medicine, Uniformed Services University for the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA; Academy for Innovation in Medical Education, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada. Electronic address: lara.varpio@usuhs.edu.
authors.forename: Lara
authors.initials: L
authors.lastname: Varpio
authors.affiliation: Nursing Research, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario, Canada; School of Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada. Electronic address: rashotte@cheo.on.ca.
authors.forename: Judy
authors.initials: J
authors.lastname: Rashotte
authors.affiliation: Academy for Innovation in Medical Education, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada. Electronic address: kathy.day@uottawa.ca.
authors.forename: Kathy
authors.initials: K
authors.lastname: Day
authors.affiliation: Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario, Canada. Electronic address: king@cheo.on.ca.
authors.forename: James
authors.initials: J
authors.lastname: King
authors.affiliation: Telfer School of Management, University of Ottawa, 55 Laurier Avenue East, Ottawa, Ontario, Canada. Electronic address: Kuziemsky@telfer.uottawa.ca.
authors.forename: Craig
authors.initials: C
authors.lastname: Kuziemsky
authors.affiliation: Department of Psychology, Carleton University, Loeb B550, 1125 Colonel By Drive, Ottawa, Ontario, Canada. Electronic address: Avi_Parush@carleton.ca.
authors.forename: Avi
authors.initials: A
authors.lastname: Parush
mesh_terms: D001291:Attitude of Health Personnel; D004282:Documentation / Q000379:methods*; D057286:Electronic Health Records / Q000458:organization & administration*; D055991:Health Records, Personal; D033181:Information Dissemination / Q000379:methods*; D008487:Medical History Taking / Q000379:methods*; D036301:Qualitative Research
keywords: Clinical reasoning; Electronic health records; Interprofessional team collaboration; Narrative; Patient story