Deskilling and adaptation among primary care physicians using two work innovations

BACKGROUND: The U.S. health care system has innovated over the past decade in ways aimed at improving quality of care while increasing managerial control over how medicine is practiced. Two key issues in examining innovation implementation is the extent to which physicians may experience deskilling as part of innovation use and to what extent they actively participate in this deskilling through adaptations they make to accommodate and take advantage of the innovations in their everyday work. METHODOLOGY: Interviews with 78 U.S. primary care physicians were conducted. Data were transcribed and computer analyzed through an interactive process of open coding, theoretical sampling, vignette construction, and pattern recognition that proceeded in several stages. The two innovations examined were the use of electronic medical records and clinical guidelines. FINDINGS: Primary care physicians perceive and experience the use of electronic medical records and clinical guidelines in ways that indicate deskilling outcomes. The deskilling outcomes identified include decreased clinical knowledge, decreased patient trust, increased stereotyping of patients, and decreased confidence in making clinical decisions. Physicians are actively involved in the deskilling process through the adaptive choices made when incorporating the innovations into their everyday work. The existing primary care business model exacerbates the deskilling effects of the two innovations examined in the study. PRACTICE IMPLICATIONS: Primary care physicians perceive and experience deskilling as a tangible outcome of using particular health care innovations. However, such deskilling is, in part, a function of physicians' own actions as well as extant pressures in the surrounding work context. Health care organizations and managers have a productive role to play in attempting to mitigate these pressures and lessen the deskilling outcomes associated with them. This study supports closer examination of the total costs and benefits deriving from using different health care innovations while portraying innovation use as a negotiated set of outcomes.