The Electronic Medical Record (EMR): Work as imagined vs. work as performed

This month JC is going to take a broad look at what Robert Wears and other cognitive scientists have described as the gap between “work-as-imagined” and “work-as-done.” Work-as-imagined being the illusory ideal state that policymakers and systems designers believe should happen and work-as-done being what actually occurs in the adaptive environment of the emergency department. We have selected three articles this month that provide some insight into the challenges we all face. The first is a piece in a recent New Yorker titled: The Upgrade by Atul Gawandi who reflects on the impact of the EPIC EMR in Harvard’s healthcare system: “Three years later I’ve come to realize that a system that promised to increase my mastery over my work has, instead, increased my works mastery over me.” The second article by Ratwani describes ED interruptions and potential strategies to mitigate them. As clinicians, our Working Memory Capacity (WMC) is measurable and finite and work-flow interruptions predispose our patients (and ourselves) to harms. Our third article looks at the impact of Dragon dictation system on charting efficiency, error rates and impact on time available for direct patient care.     

Gawandi, Atul, The Upgrade,The New Yorker November 12, 2018.

Ratwani R, Emergency Physician Use of Cognitive Strategies to Manage Interruptions. Ann Emerg Med. 2017 Nov;70(5):683-687.

Dela Cruz J, Typed versus voice recognition for data entry in electronic health records: emergency physician time use and interruptions. West J Emerg Med. 2014 Jul;15(4):541-7.