EHR use has less to do with doctors' tech savvy than how they deal with clinical uncertainty, suggests research.
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A new study argues that some doctors make only minimal use of electronic health records (EHRs) not because they're Luddites, but because their style of practice "absorbs" clinical uncertainty rather than trying to minimize it through the use of IT. If this is true, the widespread adoption of EHRs may not change how some doctors diagnose and treat patients.
The study, which was published in the Journal of the American Medical Informatics Association (JAMIA), used interviews and direct observations of 28 physicians in a Texas multispecialty group to explore the reasons why some doctors used the practice's EHR more than others did. The researchers showed that the physicians' perceptions of uncertainty in caring for their patients were correlated with how they used the EHR.
For the uninitiated, uncertainty is a universal attribute of medical practice, not a sign of an incompetent clinician. Good evidence supports less than half of what doctors do, and there are many clinical situations in which they don't know what they're confronting or, even if they do, what they should do about it.
Based on their observations and interviews, the researchers divided the Texas doctors into three categories: reductionists, who believed that the more structured data they recorded in the EHR, the less uncertainty they had and the better the care they were providing; absorbers of uncertainty, who spent more time conversing with patients and less time documenting information; and hybrids, who exhibited characteristics of both reductionists and absorbers.
"The distinguishing factor in categorizing physicians as uncertainty reducers was their overarching focus on information as the key driver of uncertainty management," the study said. Lead author Holly J. Lanham, assistant professor of medicine/hospital medicine at the University of Texas Health Science Center San Antonio, told InformationWeek Healthcare that this was partly because these doctors thought that their documentation would help other providers caring for the same patient.
In contrast, the study noted, the physicians with an uncertainty absorption perspective believed that their interaction with patients during a visit was the key to successful diagnosis and treatment. "Information contained in the medical record was important to these physicians, but much less so than information that was created, uncovered and emphasized during patient encounters."
Unsurprisingly, the physicians who believed that the kind of information they documented in the EHR could reduce uncertainty were much higher users of the system than the absorbers were, with the hybrids falling in between. However, Lanham emphasized, that didn't necessarily mean that the reductionists were more tech savvy. Some absorbers were highly technological, but they didn't believe that the answers to their diagnostic and treatment questions necessarily lay in the EHR.
Of the 28 physicians included in the study, 13 were classified as reductionists, five were absorbers, and 10 were hybrids. The latter believed that the information contained both in the EHR and their patient interactions were crucial to their work.
Lanham could not explain the prevalence of reductionists in the study sample. EHR adoption was voluntary in the group, she said, although there was peer pressure to use the system so that everyone could see the data and so that the practice could do quality reporting. There were no financial incentives to enter structured data in the EHR, she added. However, physicians who did more than the average amount of dictation were charged for transcription.
One physician who was still dictating many of his notes, rather than entering the data in templates, told her he was paying $800-$1,000 a month for the privilege. However, he said, he wouldn't change because that's how he practiced medicine.
The study suggested that perhaps "standardized clinical documentation could be inadvertently driving physicians toward an uncertainty reduction mindset, and thus unwittingly orchestrating the loss of alternative clinical mindsets." Lanham said that this would concern her if it resulted in "less context and less inclusion of a physician's assessment" in the medical reasoning process.
"Uncertainty reduction is helpful, and IT is already designed to help us with that," she said. "What I'm hoping is that the finding of this paper will encourage EHR developers and policy makers to recognize that uncertainty is inevitable and figure out how to help doctors and nurses cope with that uncertainty."
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