Chart biopsy: an emerging medical practice enabled by electronic health records and its impacts on emergency department-inpatient admission handoffs.

Abstract

To examine how clinicians on the receiving end of admission handoffs use electronic health records (EHRs) in preparation for those handoffs and to identify the kinds of impacts such usage may have. This analysis is part of a two-year ethnographic study of emergency department (ED) to internal medicine admission handoffs at a tertiary teaching and referral hospital. Qualitative data were gathered and analyzed iteratively, following a grounded theory methodology. Data collection methods included semi-structured interviews (N = 48), observations (349 hours), and recording of handoff conversations (N = 48). Data analyses involved coding, memo writing, and member checking. The use of EHRs has enabled an emerging practice that we refer to as pre-handoff "chart biopsy": the activity of selectively examining portions of a patient's health record to gather specific data or information about that patient or to get a broader sense of the patient and the care that patient has received. Three functions of chart biopsy are identified: getting an overview of the patient; preparing for handoff and subsequent care; and defending against potential biases. Chart biopsies appear to impact important clinical and organizational processes. Among these are the nature and quality of handoff interactions, and the quality of care, including the appropriateness of dispositioning of patients. Chart biopsy has the potential to enrich collaboration and to enable the hospital to act safely, efficiently, and effectively. Implications for handoff research and for the design and evaluation of EHRs are also discussed.