Intended for healthcare professionals

Clinical Review

The clinician's perspective on electronic health records and how they can affect patient care

BMJ 2004; 328 doi: (Published 13 May 2004) Cite this as: BMJ 2004;328:1184
  1. Stephen H Walsh (, consultant in acute medicine1
  1. 1Birmingham Heartlands and Solihull NHS Trust, Solihull Hospital, Solihull B91 2JL


    Many attempts to get clinicians to use electronic health records have failed, often because of difficulties with data entry.14 Technology should complement and improve clinical care, not impose extra burdens on already overloaded medical staff. The clinical “usability” of electronic records systems is particularly relevant with the recent appointment of service providers to implement the national Integrated Care Record Service for the NHS as usability also affects patient care. I examine important lessons learned from previous attempts to get clinicians to use computers in health care; discuss how clinicians actually work; make recommendations on designing or selecting clinical computer systems; and explore how the use of electronic health records might affect patient care.

    How clinicians work

    Use of narratives in clinical reasoning

    Patient documentation systems that try to reproduce previously accepted models of clinical reasoning (pattern recognition, algorithms, or hypothetico-deductive models) have achieved limited acceptance. According to Greenhalgh, the medical encounter consists of stories within stories.5 Kay and Purves maintain that narratives are at the heart of clinical decision making and refers to this concept as “narrative reasoning.”6 They argue that “every patient tells a story (narrative) and clinicians intuitively use narrative devices in relation to the delivery of patient care.” The patient is seen as “a page from the book of nature, a text to be read,” and the doctor becomes the author of “stories within the medical record.” Kay and Purves make a strong case for retaining information in a conceptual framework and maintain that this is best accomplished by means of narratives rather than “reducing the semantic richness and degrading the story to limited codes and weakly connected phrases.”

    Van Ginneken also states that many computerised medical record systems are rejected by clinicians because they are not based on a story metaphor.7 Frisse and colleagues state that “using conversations as …

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