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Paper may help us think better

The impact of adopting EHRs: How losing connectivity affects clinical reasoning. Varpio L et al. Medical Education 2015 (49):476-486.


Reviewed by Lolita (Maria) Alkureishi

What was the study question?
How does use of PICU flowsheets in the EMR versus paper affect clinician 1) conception of time and data interconnections and 2) clinical reasoning?

How was the study done?
Researchers collected data pre and post-EMR launch, tracking 22 patients through their PICU stays and making field observations of staff, residents, medical students, and faculty. Methods used included semi-structured patient and clinician interviews, focus groups, and analysis of paper and electronic documents. Common concepts across the dataset, patterns and interconnections among categories were studied for emerging themes. Theoretical coding enabled finalized interconnections between coding levels and related pre-existing literature.

What were the results?
Several effects resulted from changing from paper to EMR flowsheets. Clinicians experienced 1) feeling they didn’t know the patient (impeded ability to understand a patient’s evolving status, how data linked together), 2) increased cognitive workload and information overload, and 3) loss of clinical reasoning support mechanisms. Two illustrative quotes were “Instead of looking at a complete picture, it forces me to separate it” and “It’s harder to put the story together.”

What are the implications of these findings?
Making and understanding data interconnections are crucial elements of a clinician’s reasoning activity. Paper charts embody specific ways of thinking, and the EMR embodies another. It appears the EMR flowsheet deconstructs data connections and chronology, leaving experienced clinicians with massive amounts of data fragments but without an interconnected whole. Until EMR designs support more connected interfaces, providers of all levels need to be taught how to transfer these skills from one system to another.

Editors note: For me this is just one more instance of the shortcomings or necessary adjustments to be made with the introduction of EMRs or, as Abraham Verghese (My Own Country, The Tennis Partner, Cutting for Stone) says, “I hopeā€¦one of you will patent a way for us to keep the best of what is good about the EMR and toss the rest of it.” (RR)

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