Jennifer & April Edwell// Patient records have come a long way since the days of notes jotted in physician’s journals. In the bygone era of paper charting, physicians had to flip through files, deciphering scribbled numbers and words, hastily trying to (re)interpret the patient’s past. Medical residents hurried to capture patients’ ever-changing information and provide a rushed, but meaningful summary of the treatment plan–all before their hand cramped.
In the 1990s, healthcare providers began to transition from patient charts kept in beige-coloured folders to computerized records, or Electronic Health Records (EHR). Overall, the EHR is preferable to paper charts. With the EHR, a patient’s health data can be recorded with just a few clicks, and typed medical narratives are always legible (although the quality of narratives is variable). Clinical notes coalesce into a growing account of the patient’s’ medical history, and providers can preserve patients’ narratives, accumulating their stories as part of their health data. Also, the EHR synthesizes an immense amount of information, including patient demographics and medical history, communication logs, labs/images and medical scan results, as well as billing data and insurance Information. With all of this information in one place, the patient’s medical record is relatively easy to share within and across healthcare settings. Additionally, EHRs can serve as medico-legal records that provide a “paper trail” for patients’ interactions with medical systems and a source of protection against malpractice liability (Ben-Assuli 292). While digital records raise concerns about privacy and security, EHRs also open up possibilities for patients to access and control their data in new ways (Ben-Assuli 291).
Thus, there are lots of good things that come from utilizing a standard electronic record for each patient. Another example, particular to patient care, is health screenings. Check boxes in the EHR prompt providers to screen geriatric patients who might be at an increased risk of falling, teenagers who might be depressed, and women who may be in abusive relationships. These are all things that providers should inquire about–but sometimes, historically, they have fallen by the wayside. So, the EHR sends reminders. As Eugenia L. Siegler points out, medical records reflect “the cultural biases, medical theories, and therapeutic philosophies of their time and place” (671). These screening reminders reflect contemporary interest in preventative medicine.
Patient records, like other institutional documentation systems (e.g., educational transcripts), are a manifestation of particular beliefs and values. In The Digitalization of Healthcare: Electronic Records and the Disruption of Moral Orders, Ian P. McLoughlin, Karin Garrety, and Rob Wilson explore the “ethical and moral dimensions of the digitalization of healthcare” (6). These researchers demonstrate how medical records contribute to the moral “(re)ordering of healthcare” (McLoughlin, Garrety, and Wilson 56). For instance, they highlight that “records that were designed to support billing, administration, and surveillance were not necessarily optimal for individualized clinical care” (McLoughlin, Garrety, and Wilson 53). The overtone of the EHR is that healthcare is an industry, and economics matter. Charting becomes not just about capturing a patient’s story, but about generating the proper ICD-10 codes and Diagnosis Related Groups (DRGs), which indicate the severity of a patient’s condition and determine how the hospital will be reimbursed. “Document how sick a patient is, and bill at the highest level of complexity,” urges the EHR.
And the institutionalization of EHRs is a powerful force. National policy and institutional regulation influence how practitioners keep records on patients. In 2009, the Obama administration passed the HITECH (Health Information Technology for Economic and Clinical Health) Act, which utilizes an incentivising scheme to promote implementation and “meaningful use” of EHRs. On the ground, hospitals sometimes hire EHR monitors to follow doctors on rounds and interject ways to improve charting.
While the EHR can facilitate many of the goals of 21st century healthcare, it has its shortcomings. For instance, between providers and their patients, the EHR makes communication harder in many ways. In the outpatient setting, it can quite literally put a screen between providers and the patient. And in the hospital, it gives physicians a thousand more reasons to run to a desktop and not the bedside–where care (good care, anyway) happens. It’s a tether that can make providers less relational. (As an aside, we have yet to see someone follow teams around suggesting ways to improve patient-provider communication and relationships.)
However, in their daily practices, healthcare providers are not perfect users of the EHR. For example, those screening reminders mentioned above can quickly become annoying and, then, ignored. This can also happen with another EHR alert feature: automatic warning flags. For instance, after ordering a new medication for a patient, a pop-up window reminds the provider of every potential drug reaction based on what other medicines that patient is already scheduled to take. “Taking Aspirin and Plavix together increases the risk of a potentially life threatening bleed,” warns the EHR. While this cautionary reminder is well-intended, the problem is that it happens with almost every medication order. Physicians develop “flag fatigue,” skimming (if not skipping) the warning and clicking on. The extra warning screens and prompts mean a few less minutes spent doing patient care. Inattention to the EHR may be a way providers passively resist its intrusion on their work.
Providers also find ways to work with (or around) the EHR. In a study about its influence on clinical activity, Lara Varpio et al. found that many healthcare providers use EHR information to create paper-based notes. In particular, physicians and nurses pulled information from the EHR to create concise visual documents based on what the provider needed “to know” and needed “to do” (Varpoi et al. 536). Like the participants in Varpio et al.’s study, April (the MD co-authoring this post) makes “flashcards” for each patient she cares for in the Cardiac Intensive Care Unit, filtering the plethora of information contained in the EHR into a compact, practical document (often with a hand-drawn depiction of the patient’s heart).
Engaging critically with EHRs and inventing workarounds is arguably hardest for trainees, for whom these systems are part of their professional and institutional inculturation. EHRs impact how learners think about other tools and how they perceive information. For example, in the Intensive Care Unit (ICU), the EHR influences how learners talk about ventilators. During their ICU rotation, trainees learn how the mechanics of the machine interact with the physiology of the human respiratory system. However, when it’s time for the learner to present on a ventilated patient, they often recite the ventilator settings from the EHR print out–like an ingredient list. Dependent on the EHR, trainees give an inventory of decontextualized numbers, rather than connecting the support provided by the ventilator with the patient’s physiology. Additionally, trainees must learn how to differentiate types of information in the EHR, such as the distinct value and authority of a narrative note in comparison to empirical data, like a blood test or weight measurement. Lastly, under pressure to chart quickly and correctly, trainees may feel pulled away from caring for patients. Michael S. Barr encourages practitioners and administrators to focus on using the EHR “as a tool to support clinical curiosity and critical thinking rather than simply to expedite clinically meaningless documentation in order to bill higher codes” (683). It is important to teach this type of engagement to novice healthcare providers as an “early intervention” against EHR indoctrination.
Barr, Michael S. “The Clinical Record: A 200-Year-Old 21st-Century Challenge.” Annals of Internal Medicine, vol. 153, 2010, pp. 682–683. doi:10.7326/0003-4819-153-10-201011160-00015
Ben-Assuli, Ofir. “Electronic health records, adoption, quality of care, legal and privacy issues and their implementation in emergency departments” Health Policy, vol. 119, no. 3, March 2015, pp. 287-297. https://doi.org/10.1016/j.healthpol.2014.11.014
McLoughlin, Ian P., Karin Garrety, and Rob Wilson. The Digitalization of Healthcare: Electronic Records and the Disruption of Moral Orders. Vol. First edition, OUP Oxford, 2017.
Sieglerm Eugenia L. “The Evolving Medical Record.” Annals of Internal Medicine, vol. 153, 2010, pp. 671–677. doi:10.7326/0003-4819-153-10-201011160-00012
Varpio, Lara, et al. “Working Off the Record: Physicians’ and Nurses’ Transformations of Electronic Patient Record-Based Patient Information.” Academic Medicine, vol. 81, no. 10, October 2006, pp. S35-S39. doi:10.1097/01.ACM.0000237699.49711.35