The Key Literature in Medical Education podcast this weeks tackles electronic health records (EHRs) and their impact on clinical care. Even if you don’t employ an EHR in your practice, the meta-lesson from this study is important to all Clinician Educators.
At the heart of the podcast this week is the law of unintended consequences (see Locke). This study suggests that the adoption of an EHR decreases accessibility to information about a patient’s evolving condition, thus impeding the clinical reasoning process. As CEs, we should always be cognizant of how the introduction of a “new” technology may actually lead to: an unexpected benefit, unexpected side effect or perverse result (i.e. the intervention worsens the problem).
As usual, the abstract is below… but the really good stuff is on the podcast. Subscribe here.
KeyLIME Session 90 – Article under review:
View/download the abstract here.
Varpio L, Day K, Elliot-Miller P, King JW, Kuziemsky C, Parush A, Roffey T, Rashotte J. The impact of adopting EHRs: how losing connectivity affects clinical reasoning. Medical Education. 2015 May;49(5):476-86
Reviewer: Linda Snell
Electronic health records (EHRs) are becoming the norm and offer a number of advantages over paper charts. As they are adopted by teaching hospitals, their impact on med is just starting to be studied; e.g trainees not receiving sufficient guidance on how to use EHRs, EHR use affects how trainees learn to care for patients, EHRs present an array of educational opportunities that medical educators must both consider and contend with (e.g. clinical decision support systems). As clinician educators we must examine how this change impacts trainee development.
Look at 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?
Type of paper
Report of effects of a system change
Key Points on the Methods
- Pediatric academic hospital PICU
- 11 month ‘pre’ and 18 month ‘post’ EHR launch
- Looked at how implementation might affect clinical reasoning
- Specifically looked at the use of a flow sheet and its effect on conceptions of time and data interconnections, impact clinicians’ clinical reasoning, explore a phenomenon they name ‘connectivity’
- 4 data sources/types: observations, participant interviews, think aloud during and after EHR use, document review
- Analysis – constructivist grounded theory, 3 coding levels
- Underlying theories supporting: rhetorical genre studies (RGS) and visual rhetoric – posit that attention should be paid to a genre’s content and form because they do more than allow users to communicate… they teach users how to think and how to act
Impact on clinicians:
- Not knowing patient’s evolving status
- Increased cognitive load
- Loss of clinical reasoning support mechanisms – especially for more experienced clinicians
The authors suggest that clinicians’ reliance on interconnected wholes is an issue of something we label ‘connectivity’. Connectivity refers to the chronologically framed data interconnections that clinicians must make and understand in order to provide patient care, that recognizing the loss of connectivity is a mark of clinical reasoning expertise, Experts bring multiple data items into comprehensive and comprehensible ensembles called ‘bundles’, to help clinicians identify chronologically organized data interconnections in order to move patient care forward.
The common thread that links theories of bundling, narrative, RGS and visual rhetoric in relation to clinical reasoning is connectivity. Connectivity is a foundational skill our trainees require, so we must equip our trainees with skills that transfer across iterations of a genre
Spare Keys – other take home points for clinician educators
Either we must adapt to systems change or we must make the change reflect our needs.
A good example of a multidisciplinary study – MD, nurse, manager, IS expert, psychologist…
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