The effects of EMR deployment on doctors’ work practices: A qualitative study in the emergency department of a teaching hospital

ObjectiveThe goal of this study was to examine the effects of medical notes (MD) in an electronic medical records (EMR) system on doctors’ work practices at an Emergency Department (ED).MethodsWe conducted a six-month qualitative study, including in situ field observations and semi-structured interviews, in an ED affiliated with a large teaching hospital during the time periods of before, after, and during the paper-to-electronic transition of the rollout of an EMR system. Data were analyzed using open coding method and various visual representations of workflow diagrams.ResultsThe use of the EMR in the ED resulted in both direct and indirect effects on ED doctors’ work practices. It directly influenced the ED doctors’ documentation process: (i) increasing documentation time four to five fold, which in turn significantly increased the number of incomplete charts, (ii) obscuring the distinction between residents’ charting inputs and those of attendings, shifting more documentation responsibilities to the residents, and (iii) leading to the use of paper notes as documentation aids to transfer information from the patient bedside to the charting room. EMR use also had indirect consequences: it increased the cognitive burden of doctors, since they had to remember multiple patients’ data; it aggravated doctors’ multi-tasking due to flexibility in the system use allowing more interruptions; and it caused ED doctors’ work to become largely stationary in the charting room, which further contributed to reducing doctors’ time with patients and their interaction with nurses.DiscussionWe suggest three guidelines for designing future EMR systems to be used in teaching hospitals. First, the design of documentation tools in EMR needs to take into account what we called “note-intensive tasks” to support the collaborative nature of medical work. Second, it should clearly define roles and responsibilities. Lastly, the system should provide a balance between flexibility and interruption to better manage the complex nature of medical work and to facilitate necessary interactions among ED staff and patients in the work environment.

► We examine direct and indirect effects of the deployment of the EMR system.
► Direct effect altered ED doctors’ workflows including increased workload and responsibility for residents and documentation location change.
► Indirect effect was a consequence of the altered workflow and indirectly affected clinical collaboration and patient care.
► Three design guidelines are suggested to be accounted for in future EMR system designs.