With this study, we sought to examine how EHR implementation is anticipated to affect clinician-learner interactions and, in turn, impact upon educational priorities and outcomes. In doing so, we found a series of interesting dichotomies suggesting that for every unintended consequence there is potential for an equal and opposite positive reaction, reminiscent of the adage that in every crisis there is opportunity. On one hand, clinical educators worry about losing the advantage of teaching as a means of updating their clinical knowledge; on the other, some saw the possibility of improving their care by drawing on the technological sophistication of their trainees. On one hand, clinical educators worry about heightened focus on technology harming the professional identify formation and patient-centred focus of their trainees; on the other, some saw the opportunity to model resilience and the need to constantly adapt one’s practice. On one hand, clinical educators worry that the shift to an EHR will push learners to the periphery of clinical experience; on the other, it was thought to create ways for them to more readily take on central responsibilities in patient care.
In a recent time motion study performed with emergency room physicians, overall time spent doing “direct teaching” and “technical/logistical teaching” did not change pre, during, and post EHR implementation, which is a promising result . Our study, however, suggests that there is more than just the marker of time to consider as balancing the above listed dualities in the teaching dynamic are likely to need careful consideration and monitoring during EHR implementation.
At their core, these findings can be summarized as the belief that EHR implementation is expected to require educational adaptation because it is likely to alter teachers’ ability to prioritize teaching, to engage with learners in tried and tested ways, and to provide adequate coverage of the clinical skills and knowledge believed to be critical competencies derived from training in this context. Participants believed EHR implementation may change what is modelled by physicians, trainees’ involvement in the clinical workplace, and the reciprocal dynamic between trainees and physician educators. In the language of sociomateriality theory, technology and social interactions were anticipated to be integral to one another EHRs were thought likely to act as a “material” that has the capability to affect the learning environment quite unintentionally by setting priorities in ways that influence learning . This observation reinforces recent calls to study status quo workflow  and stakeholder perceptions as an important part of understanding how technology deployment might change practice because whether the technology’s effects are positive or negative, on balance, is likely to depend on the extent to which proactive planning through careful change management can shift learners’ experiences from the latter to the former.
For example, the simple presence of an EHR, and the time and cognitive resources required to navigate it, is expected to be capable of reducing the teaching physicians consider to be important (reducing feedback, direct assessment, and one-on-one time). That would be particularly disconcerting in the context of recent efforts to make curricula more competency-based (requiring physicians to be interactive with learners). This leads to the inherent risk of lessening opportunities for trainees to benefit from the experiential learning that is crucial both to skill development and professional identity formation. Given that our group of participants described themselves as those who enjoy and get fulfillment from their clinical teaching obligations, careless EHR implementation runs the risk of de-motivating the very group of clinicians who are particularly desirable to educational programs and on whom educational programs are particularly dependent. It is, therefore, imperative that clinical and educational leaders take steps to encourage and facilitate the optimism expressed by those who hoped EHR implementation could improve engagement in teaching by harnessing the technology to organize information or facilitate teaching more directly than often occurs in haphazard clinical environments.
These results, combined with a variety of theoretical concepts from education more generally, provide a framework for guiding such efforts as well as for monitoring the breadth of educational impacts that might be felt upon implementing an EHR. Here we will outline two examples.
First, prior research suggests that the implementation phase of a new technology is a particularly challenging time during which unrecognized “materials” can lead to implementation failure . In our study, the way in which records are kept, controls over who has access to such records, the need to learn how to interact with a new technology and changes to the physical orientation of the clinic were all described in ways that suggest they would “assemble” to enact change in both how teachers engage with learners and what educational outcomes are obtained. This emphasis on sociomateriality also reflects that evaluation and management of the changes experienced need to be monitored over a period of time rather than trusting that initial impacts will be felt forevermore.
Second, Lave and Wenger’s seminal work on communities of practice theory is likely to be useful to sensitize educators to the notion of enabling legitimate peripheral participation as a means to move trainees towards the centre of their chosen community through development of professional identity . In our study, the EHR was thought to create risk to this transition, but participants also provided hints as to how trainees could be helped to gain different skills through engagement in tasks that directly contribute to care both by helping the physician to keep accurate patient records and by using their own technological know-how to help their clinical preceptors continue their own professional development. The observed variety of impacts emphasizes the need to monitor an array of potential outcomes rather than focusing purely on aspects of care like medical knowledge.
In more proactive practical terms, it is worth noting that Spencer et al. reported physicians being most affected by EHR implementation when they were particularly enthusiastic teachers pre-implementation and being least affected when they were particularly comfortable with the new EHR . Combining their findings with ours suggests that, if we want to keep physicians fulfilled in their educator roles, ensuring adequate training on the EHR, as well as providing resources to help physicians cope during implementation, should be a priority. This goes for learners as well as their preceptors as our participants worried that if trainees do not have complete access to the new EHR, it would reduce their ability to be clinically independent and reduce their resultant opportunities to learn. Incorporating medical trainees into the EHR design team, as well as ensuring their adequate training and feedback could further minimize the potential for negative impacts of EHR implementation on educational outcomes .
In summary, direct implications that can be drawn from our findings include considering context, content, and processes when approaching the complex matter of change management in the context of EHR implementation. If feasible, reducing non-essential physician tasks and patient load during implementation may lead to more time for physicians to work with the new EHR, see their patients, and continue to provide teaching to learners in clinic. Incorporating the learner into the EHR implementation framework, to ensure they too have adequate access to the system, may improve their capacity to remain actively involved in clinic during and after implementation so as not to erode their learning experience.
That said, there are several limitations to this study that should be noted. First, it was conducted in a specific group of outpatient oncologists working in Canada that happened to be skewed towards female gender and, thus, the perceptions obtained may not be transferable to different groups. We attempted to maximize the heterogeneity of participants to reduce this risk, but the need to draw from a population that was anticipating EHR implementation in the near future limited the pool of participants available; why women were more likely than men to respond to the invitation (and what impact that might have had on the findings) is unclear. Second, as participants were asked to anticipate an event that has not yet happened, our data may reflect an over or underestimate (or mixture of both) of the impact EHR implementation has on teaching dynamics. They provide a strong foundation, however, from which determine factors that need to be considered during change management and for adequate evaluation of impact when implementation does occur.