The EHR and building the patient’s story: A qualitative investigation of how EHR use obstructs a vital clinical activity

• Building the patient’s story is an essential part of clinical reasoning activities.
• Each clinician builds the patient’s story and, in the paper-based chart, shares their version of the patient’s story via the patient chart. This sharing supports clinicians’ ability to provide patient-centered care, within an interprofessional team, and to safeguard patient safety.
• The use of an EHR can obstruct clinicians’ ability to build the patient’s story and to disseminate it to other members of the care team. This obstruction was created by fragmenting patient data interconnections and limiting the spaces available for narrative notes.
• When an EHR impedes clinicians’ ability to build the patient’s story, interprofessional sharing of patient data interpretations, and time efficient care delivery can be compromised.

BackgroundRecent 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.MethodsThis 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.ResultsClinicians 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.ConclusionsWe 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.