Working off the record: physicians' and nurses' transformations of electronic patient record-based patient information

Electronic patient records (EPRs) are increasingly being used in health care, but little is known about how EPR-based patient information is used in daily care activities, nor about its potential influence on novice training. Seventy-two physicians and nurses participated in an eight-month study on a single pediatric ward. Eighty hours of nonparticipant observations and 20 interviews were conducted. Data were analyzed using constructivist grounded theory and visual rhetoric. Three main features of participant interactions with EPR-based information were identified: (1) EPR-based information was routinely transformed into paper documents; (2) these transformations were organized by profession-specific guiding principles; and (3) transformation strategies were learned through an informal curriculum. This study describes how and why health care professionals work around EPR-based patient information, and suggests that an EPR's visual organization may be incompatible with professional activities. The study addresses the socializing implications of these activities, and highlights their educational potential.