The impact of electronic health records on collaborative work routines: A narrative network analysis.

PURPOSE: This study examined collaborative work routines and changes after the implementation of a perinatal EHR. The change process and underlying drivers were analyzed to offer insight into why changes - intended or unintended - did or did not occur and their implications for EHR design and implementation.

METHODS: This mixed-method case study included both qualitative and quantitative information. Pre- and post-implementation observations took place over an 18-month period totaling 90h. Formal and informal interviews with administrative and clinical staff, pre- and post-implementation surveys, project meeting observations, and artifact review supplemented data gathered from the observations. Workflow and narrative network analyses of work routines were used to identify changes pre- and post-EHR and to represent different perspectives of work routines.

RESULTS: EHR improved documentation efficiency and in- and out-patient information exchange, but increased variability in documentation. Some variabilities were institutionally sanctioned or tolerated, but other variabilities - while ingenious and emblematic of the generative nature of routines enabled by the EHR - were problematic. EHR's support for clinician communication and coordination was limited and its cognitive support insufficient. In some cases, EHR increased cognitive load as the unlocalized EHR scattered information, and the lengthy printouts contributed to information fragmentation and made information retrieval more difficult.

CONCLUSIONS: The process of the EHR implementation and the changes observed was the confluence of three factors: resource constraint - in particular EHR expertise and experience - not uncommon in many community hospitals; the functional properties of the EHR focusing on information aggregation, storage, and retrieval; and the extant culture and practice of healthcare emphasizing autonomy and flexibility. While collaborative and communication changes were prompted by EHR implementation, the system played a minimal role in mediating changes. Instead, changes in work routines were negotiated between the administration and clinicians, and jointly refined over time.