Examining the impact of Electronic Health Records (EHRs) on data acquisition and clinical reasoning

Posted on Thursday, August 15, 2019

By: Dr. Gary Viner

Having an abiding interest and fascination with technology, I was promptly engaged in the Ottawa Hospital implementation of Epic. As I learned more about the software though, I began to understand that it was much more than an electronic recording system, because it had various embedded artificial intelligences and I became concerned about the potential impact on developing clinical reasoning.

The Ottawa Hospital General Campus

I then conducted a background literature review: In general, Electronic Health Records (EHRs) are promoted to enhance patient safety and standardize approaches to care of clinical conditions. However, mounting evidence suggests that they have both benefits and drawbacks. Notwithstanding their known impact on physician workload and wellness, using EHRs decreased cognitive load and thus, increased efficiency, but facilitated errors and created barriers in doctor-patient interaction. The structured nature of EHRs may also have unintended impacts on doctor-patient interaction, clinical reasoning and/or data entry. The risks and benefits of using EHRs may differ for trainees and experienced family physicians. Trainees are novices who may use different clinical reasoning approaches than experienced family physicians.

Our 10-person team that came together for this project was stellar. It includes both the CIO (Dr. Glen Geiger) and VP of Education (Dr. Jerry Maniate) for the Ottawa Hospital, human factors researchers at University of Victoria (Dr. Andre Kushniruk and Dr. Helen Monkman) and six members of our own Department (Dr. Doug Archibald, Dr. Dianne Delva, Dr. Kendall Noel, Dr. John Brewer, Dr. Farhad Motamedi and Dr. Sufian Zayed).

Our proposed research questions became: Does using the EHR affect data acquisition or clinical reasoning differently between trainees and experienced physicians? In what way(s)? Do trainees have different strategies for using an EHR during encounters than experienced physicians? Do their strategies change over time?

We plan to investigate the potential impact of EHR use on data acquisition and clinical reasoning using simulated patient (SP) encounters. Trainees and experienced physicians will assess and document two SP encounters in a Family Medicine setting at two time points:

  1. 3-6 months after the EHR's initial deployment; and,
  2. 6-9 months later.

Audiovisual (AV) recordings of participants' interactions with the SPs and screen recordings of their EHR use will be examined with usability methods to identify patterns amongst the participants. Patient-centeredness will be assessed by SPs’ responses to questionnaires and reviewing recordings. The participants will have a post-encounter “think-aloud” interview to clarify their underlying clinical reasoning. We will thematically analyze the qualitative data using a combination of conventional, directed, and summative approaches. This approach will allow us to corroborate themes previously identified in the literature as well as identify emergent themes unique to our study. The questionnaire data as well as AV coding will be analyzed using quantitative approaches.

To date, we have applied for funding from three different sources, two of which were highly competitive and we were unfortunately declined. We are hopeful, however, about the response from the third source in September. In the meantime, there is some funding available to start the project and we must await the stabilization of Epic prior to commencing. We are looking forward to getting started!

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