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Annals of Family Medicine 8:316-326 (2010)
© 2010 Annals of Family Medicine, Inc.
doi: 10.1370/afm.1136
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Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation

Renée R. Shield, PhD, Roberta E. Goldman, PhD, David A. Anthony, MD, Nina Wang, EdD, Richard J. Doyle, PhD and Jeffrey Borkan, MD, PhD

Department of Family Medicine, Warren Alpert Medical School of Brown University and Memorial Hospital of Rhode Island, Pawtucket, Rhode Island

CORRESPONDING AUTHOR: Renée R. Shield, PhD, Center for Gerontology and Health Care Research, Brown University, Providence, RI 02912, Shield, Box G 121(6), Brown University, Providence, RI 02912, renee_shield{at}brown.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE Although there is significant interest in implementation of electronic health records (EHRs), limited data have been published in the United States about how physicians, staff, and patients adapt to this implementation process. The purpose of this research was to examine the effects of EHR implementation, especially regarding physician-patient communication and behaviors and patients’ responses.

METHODS We undertook a 22-month, triangulation design, mixed methods study of gradual EHR implementation in a residency-based family medicine outpatient center. Data collection included participant observation and time measurements of 170 clinical encounters, patient exit interviews, focus groups with nurses, nurse’s aides, and office staff, and unstructured observations and interviews with nursing staff and physicians. Analysis involved iterative immersion-crystallization discussion and searches for alternate hypotheses.

RESULTS Patient trust in the physician and security in the physician-patient relationship appeared to override most patients’ concerns about information technology. Overall, staff concerns about potential deleterious consequences of EHR implementation were dispelled, positive anticipated outcomes were realized, and unexpected benefits were found. Physicians appeared to become comfortable with the "third actor" in the room, and nursing and office staff resistance to EHR implementation was ameliorated with improved work efficiencies. Unexpected advantages included just-in-time improvements and decreased physician time out of the examination room.

CONCLUSIONS Strong patient trust in the physician-patient relationship was maintained and work flow improved with EHR implementation. Gradual EHR implementation may help support the development of beneficial physician and staff adaptations, while maintaining positive patient-physician relationships and fostering the sharing of medical information.

Key Words: Electronic health record • physician-patient relations • patient satisfaction


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The electronic health record (EHR) may improve health care delivery1–6 by facilitating physician communication about medications,3,7 enhancing documentation,4,8,9 increasing efficiency,8–12 and fostering information sharing and responsibility with patients.10,11 Implementation is often costly,13 takes time and computer expertise,14 and has unanticipated consequences.15–17 Concerns include its negative influence on the physician-patient encounter,18–20 altering the patient’s narrative in documentation,21 reducing patient-centeredness,16,22–23 and affecting medical decision making and the physician-patient relationship.17,24–27

Even though empirical studies of the EHR have increased,8 underscoring the physical room layout14,17–18,25 and how consultation computers are "more than just pieces of furniture,"28 few mixed methods inquiries have explored the impact of EHRs on actual clinical encounters, patients’ perspectives, and physicians’ adaptive strategies. Nation-specific challenges, such as fee-for-service environments, may pose barriers to EHR implementation.14,29 A Kuwaiti example reports the experiences of clerical staff regarding EHR implementation.30 Although the impact of EHRs on physician-patient communication is controversial, more investigation is needed that compares EHR with non-EHR environments.8 Finally, longitudinal and holistic approaches to this subject are rare.

We report the perspectives and behaviors of staff, physicians, and patients elicited during a long-term, mixed methods study undertaken in a residency-based family medicine outpatient clinic. Specifically, we examined the effects of gradual EHR implementation on the clinical encounter and its milieu.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Our triangulation design, mixed methods study31 examined how computerization affected physician behaviors, physician-patient interactions, and patient perceptions of physician behaviors throughout EHR implementation. Table 1Go displays the quantitative and qualitative methods used.


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  		Table 1. Methods Used and Outcomes Observed in Phases of Study
 
Methods included participant observation of physician-patient clinical encounters and exit interviews with patients; brief conversations and observations with nurses, nurse’s aides (certified nursing assistants), and physicians at the nurses’ stations; and focus groups with front-office staff, nurses, and nurse’s aides. Two visual analog scales (VAS) were used to record the observer’s perception of how the documentation method structured the session and its overall role in the encounter. A stopwatch was used to time events in the chronology of the consultation. Extensive interviews with the physicians before and after implementation were also conducted and will be published separately. Institutional review board approval from Memorial Hospital of Rhode Island was formally granted; study participants signed a written consent and received no incentive or compensation.

Study Setting and Participants
From January 2005 through November 2006, a team anthropologist (R.R.S.) observed clinical encounters and conducted patient interviews at the Family Care Center at Memorial Hospital of Rhode Island, a teaching hospital affiliated with the Warren Alpert Medical School of Brown University; another (R.E.G.) conducted focus groups. In the 5-month period preceding installment of computers in the patient examination rooms (the preimplementation period), 10 to 12 computers were available in common work areas. During the 10-month transition period, computers were gradually installed in all 27 examination rooms and nurses’ workstations. Physicians documented their consultations in the paper chart or typed directly into the EHR. Nurses inputted blood pressure, temperature, pulse rate, weights, and other data before the physician entered the consultation room, using the paper chart before EHR implementation, using both the chart and the EHR during the transition, and using the consultation room computer after full EHR implementation. The period after implementation lasted 3 months for third-year residents (until they graduated from the residency); this phase extended to 6 months for faculty members to ensure an equal number of consultation visits. When computers were fully installed, physicians documented their consultations using the EHR only. Some physicians completed the consultation documentation by visit’s end, whereas others did not.

Data Collection
Physician participants included family medicine faculty (excluding coauthors) and second-year residents (continuing through their third year). Patient encounters were observed during clinic sessions. Patients of participating physicians were purposively sampled to maintain a similar number of patients per physician per study phase. Inclusion criteria for patients included English-speaking individuals, age 18 years or older, and a visit for an acute problem or follow-up (excluding intimate physical examinations). The clinic used Centricity (formerly called Logician), a widely utilized primary care EHR system. A separate intrainstitutional software program was available on all computers for laboratory, imaging transcription, pathology, and demographic registration reports. With the exception of 2 rooms with notebook computers, all rooms became equipped with a desktop computer with a 15-inch flat-screen monitor.

The researcher observing the clinical encounters alternated among the 3 nurses’ stations in recruiting patients. While taking an eligible patient’s temperature and blood pressure, the nurse’s aide introduced the study and asked whether the researcher might elaborate. If the patient agreed, the researcher explained the study and then obtained informed consent if the patient was willing. She returned with the physician to sit or stand silently during the consultation with a stopwatch, using a study protocol (Supplemental Appendix 1, available online at http://www.annfammed.org/cgi/content/full/8/4/316/DC1) to describe and time activities. She documented patients’ reasons for refusal and noted EHR-relevant observations and informal conversations at the nurses’ stations.

The protocol noted chronology, eye contact, physician-patient communication style, physician exits, and participants’ behaviors. The researcher recorded her perception of how much the documentation system (1) structured the visit and (2) played a role in the visit on each 10-cm VAS. Zero centimeters indicated minimal structuring or role, and 10-cm indicated maximal structuring or role.

After the consultation, the researcher conducted a brief, tape-recorded, qualitative interview with the patient, eliciting the patient’s perceptions of the physician’s documentation, communication, and quality of the encounter (Supplemental Appendix 2, available online at http://www.annfammed.org/cgi/content/full/8/4/316/DC1). Interviews were transcribed.

The researcher typed notes from each protocol within 24 hours to preserve impressions. Data were collected until saturation in all domains of observation was achieved (eg, the use of documentation in each phase by each physician).32 Handwritten nursing station observations of physicians’ and other staff interactions regarding the mechanics of documentation were also recorded in a notebook.

Focus Groups with Clinic Staff
Before implementation we held 3 focus groups with clinic nurses, nurse’s aides, and clerical staff; we held 2 focus groups after implementation. Moderated by a coauthor (R.E.G.), each focus group session lasted approximately 1 hour, was tape-recorded, and professionally transcribed.

Data Analysis
We used immersion/crystallization and other accepted methods for analysis of the data from each phase.32–34 The multidisciplinary analysis team included 2 practicing family medicine faculty, 1 physician (D.A.) and 1 physician-anthropologist (J.B.) who were both early adopters of EHR; 2 anthropologist faculty (R.R.S. and R.E.G.); and 2 additional researchers who conducted physician interviews (N.W. and R.D.). Regular, extensive analysis meetings were held to discuss observation logs and transcripts from the patients’ interviews and focus group sessions, and to iteratively consider confirming and discrepant interpretations of data until reconciliation.32 Observations and patient interview transcripts with sample quotes were abstracted by several team members onto a spreadsheet to compare cases.

In analyzing the quantitative data, visits were categorized as paper chart or EHR for the primary charting method. Total time for activities (eg, time spent out of the room) was compared among categories using 2-sided t tests. VAS scales scores were measured in millimeters and compared using t tests.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
During the study 13 faculty physicians and 13 residents participated in 170 observed clinical encounters. Approximately 170 hours of participant observation also occurred at the nurses’ stations. Each physician was observed during 4 to 9 patient encounters (faculty average 5.9; resident average 7.3) during the 3 study phases. Table 2Go displays observations of faculty and residents in each phase of EHR implementation. Twenty Family Care Center staff participated in focus groups.


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  		Table 2. Number of Clinical Encounters by Physician Type (n=170 Consultation Sessions)
 
Approximately one-half of the patients approached consented to participate in the study. Reasons for refusal included not having enough time, feeling unwell, wanting privacy with the physician, and being uninterested in participating. Table 3Go displays patient demographic characteristics.


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  		Table 3. Characteristics of Study Patients (n = 170)
 
Before Implementation (January-May, 2005)
In this phase, only problem and medication lists were recorded in the EHR. The hospital laboratory software was used for laboratory data without communication between systems. Except for 2 early adopters who used a laptop computer during consultations, other physicians recorded patient histories in the paper chart. Physicians frequently left the consultation rooms for laboratory and test results and to update clinical lists and prescriptions. Sitting facing the patient, physicians usually placed the paper chart on their laps to read and record notes—some looking at patient, others at chart, some silent, and others reading aloud while writing. Although observed physician eye contact with patients varied, patients generally expressed satisfaction in exit interviews.

Patients’ Views Patients indicated varying levels of awareness of EHR implementation. In response to whether they thought their health information was stored on the computer, this comment was not unusual: "I have no idea; I would think so, probably." Illustrative patient quotes are included in Table 4Go.


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  		Table 4. Sample Patient Quotes Related to EHR Implementation
 
Patient interview responses generally reflected approval of either documentation method, though some voiced criticism of the EHR. Patients often recalled more eye contact and less chart-writing than was observed by the researcher. One patient noted, however, "I’d rather see them writing something down than just listening." Another criticized: "She was writing what she was saying, not what I was saying...." Patients stated that the EHR improved physicians’ work, legibility, information storage and retrieval, confidentiality, accuracy, and communication among physicians, and it reduced physicians’ exits from the room. One man said: "...a computer is such an added benefit because you can immediately pull information."

Although patients were often neutral about EHR use, some noted the potential for hacking, lost records, confidentiality breaches, technological malfunction, and viruses. One 70-year-old man claimed, "It all depends who it’s made available to afterwards...it makes me concerned that other people can get into your records."

Clinical and Clerical Staff Views During the focus group sessions staff anticipated greater legibility, more accuracy, no filing, and fewer missing charts, with one saying the EHR "...will free up a lot of the girls from finding the charts which are always missing," but predicting doctors as "barriers." They were pleasantly surprised by ease of referrals: "Everybody was nervous...but then when we started doing it, we all loved it." Nurse’s aides worried about their inadequate typing abilities and children’s potential destructiveness. Nurses feared short-term double work. One said, "We’ll always have the record though. And we will no longer have to worry, you know, they can’t find it...." Table 5Go lists additional staff comments from focus groups.


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  		Table 5. Perceived Benefits and Challenges in Implementing an EHR from Clerical and Nursing Staff Focus Groups
 
Transition
During transition, computers were gradually installed in consultation rooms. Nurses entered clinical intake information in the paper and electronic records. EHR capabilities included progress notes. Physicians typed notes in the EHR, printed them for the paper chart, or continued writing them by hand. Occasional mishap and charting redundancy increased staff workload; a physician was observed waiting until the nurse closed the record to input information; another day, a laptop caught fire. Clinical staff varied in their EHR styles and abilities; differences by sex, age, or profession were not discerned.

Nurses described incomplete documentation and double entry during EHR transition as: "...having one foot in and one foot out... medication...wasn’t documented in the computer because...somebody didn’t have time, or somebody didn’t know how." They worried about eye contact ("...is the doctor actually going to physically touch the patient or look at the patient anymore?"), the consequences of patients viewing their chart ("...is that really a good thing... [writing] patient is noncompliant because they’re...mildly obese?"), confidentiality ("Who’s the father of my baby? Who’s going to get that information?"), and computer crashes. They applauded saving time, patient accountability, and just-in-time EHR reminders: "‘Oop, this person never had another Pap smear....’ I just type out a letter and off it goes." Such comments were abundant at the nurses’ stations, as when a physician noted discomfort about documenting a patient’s problems within the patient’s view.

Patients’ Views Table 4Go reflects widespread but inconsistent patient awareness of the EHR. Some patients still replied, "I have no idea," about electronic records, even when the physicians had used the computer in their presence. As did staff members, patients expressed positive perceptions about speed and access and concerns about security. Some patients were more computer savvy than the health care personnel. Some patients indicated neutrality whether documentation was electronic or written. One said, "To me, it was the same" (80-year-old woman); another noted, "Well, I think everything is going computer anyway...fine" (59-year-old woman); and another said, "Even when she’s putting things on the computer, I still feel like she’s paying attention to me" (46-year-old woman). Staff "could pull the record up quicker" (26-year-old man); "I would say, go look it up, and everything would be there..." (18-year-old woman); and paper waste would be reduced (57-year-old woman). She added, "I trust [the physicians] thoroughly."

Patients were also concerned about security, regardless of personal computer experience. One man wanted file protection because the "computer is another enemy...they can steal all the information," whereas a 32-year-old woman said, "I’m fine just as long as nobody else gets [the files] besides doctors."

Full Implementation
With full implementation all consultation rooms were equipped with computers linked to the hospital’s intranet and the Internet, and double-entry documentation was eliminated. New patient information and progress notes were inputted electronically, though physicians still examined paper charts for histories and consultation letters, and the charts often accompanied the physicians into the examination rooms. Additional EHR templates were now available for well-child examinations, prenatal visits, and complete physical examinations. Clinical staff still varied in their abilities and comfort when working with the EHR. Physicians often used the computer for referrals and just-in-time information (examples include birth control information, toxicity of a rash cream, a pain medication).

Stopwatch Measurements Table 6Go shows that physician exits to retrieve information took less time (an average of 3.2 minutes compared with 5.9 minutes before implementation, P ≤.01), and patients seemed to understand their records were maintained in the EHR. Though physicians stated concerns about losing eye contact with patients when using the EHR, and stopwatch measurements reflected more time spent on the computer than the chart (4.4 minutes vs 2.8 minutes, P =.002), patients expressed satisfaction about physicians’ eye contact and quality of visit.


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  		Table 6. Stopwatch Measurements Before and After Implementation of EHR
 
Patients’ Views Patients now exhibited full acceptance of the EHR (Table 4Go) and lauded security, access to information, efficiency, information sharing, and the "modern" way of life. An 83-year-old man believed the EHR was confidential and secure: "...they must have a system maybe to protect all the information." Another approved, "Like all you do is click click click, and I’ll have my labs." One preferred the computer because, "It ... never forgets like people do, and paper can get lost." A woman said, "I really got to see better on the computer than when they write it because it’s very hard to understand." Another approved that the physician looked up laboratory results on the computer. A 65-year-old man noted, "Paperwork is out of style," whereas a 56-year-old woman declared, "I trust [the physician]...anything I need to know she tells me about me."

Patients expressed ambivalence about computer security, however. A woman said, "I just don’t want my medical records being opened up on the computer for the world to see..." and noted anxieties about hacking. Although a 29-year-old woman said the EHR was, "OK as long as no one breaks in...," another voiced a not-infrequent opinion: "Anybody could get to those records. The point is, I don’t particularly care."

Staff focus group reactions, noted in Table 5Go, were frequently enthusiastic, echoing nursing station remarks ("I love the computer!"). They applauded efficient workflow ("I personally think it’s wonderful;" "Nobody is looking for charts"). Some said they believed the physicians’ notes were more accurate; the EHR speeded referrals and legal correspondence ("You just print it up...fax it, send it, whatever"); and new templates allowed faster physician input. A nurse appreciated the incentive for physicians to complete EHR input: "If you don’t...finish your chart, I cannot update your med list, and hello, I can’t help you." One considered that, "... having our patients being curious about what’s in their chart and what’s going on about them...makes...them responsible."

Overall Physician Adaptation Strategies
Physicians adapted to the EHR use by body position, computer placement, verbal references to the computer, and how they shared information with patients. Physicians appeared to try to decrease computer intrusiveness. The computer could still create unpleasant surprises, such as delayed log-ins, frozen screens, and computer crashes. Physicians made explicit computer references, sometimes apologizing for computer awkwardness (eg, "If this could go any slower...," or "Oww, what’d I do?... I always spell it wrong!").

During the transition, physicians would commonly sit facing the patient with the chart on their lap, stand to examine the patient, then sit to discuss findings. With implementation, physicians increasingly turned the computer monitor so the patient could view it more easily and alternated looking at the computer screen with maintaining patient eye contact. As the researcher wrote,

Physician at computer...talks to patient and asks...turns his head...toward patient...to talk.... He types and asks questions, [saying]: "I’ve just got to write this down."

Nonverbal strategies were now frequent. One physician, with an immovable keyboard and monitor before him, stretched his arm back toward the patient on the examination table, creating a symbolic link with the patient he could not directly face. Others extended a leg or angled knees toward the patient sitting beside the computer. When the patient was on the examination table, the physicians’ knees were often awkwardly perpendicular to the patient while the physician’s body faced the computer with back to the patient.

After implementation, physicians appeared more relaxed. The researcher’s notes read:

Physician...says, "Hi, sorry for the wait, " and goes to computer...says, "Bear with me for a minute for this nonsense...." She turns the screen toward the patient and has the patient pull her chair closer. She looks at the screen while typing, pauses, looks at the patient while she talks.

Some physicians repeated aloud what they read or wrote in the EHR; this activity slowed the patient’s narrative and allowed time to type and scroll through the record. "Let me just bring up your screen," and "If the computer will let me do this...," were common utterances. One physician delighted a young patient by pointing to icons on the screen, asking, "Would you like fries with that?"

Sharing Chart Information
Initially, sharing paper chart information was verbal while the chart remained out of the patient’s visual range. Although during the transition physicians rarely shared patient information on the computer, they often shared information on the screen after the implementation. The researcher’s notes read: "Physician...calls patient to the screen and shows her the labs...uses the cursor to direct the patient [saying], ‘Don’t look at me, look at this—the lab results.’" At study’s end the researcher witnessed a physician sharing the paper chart with the patient.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
As EHRs became integrated in this setting, concerns about deleterious consequences of EHR implementation were ameliorated, positive outcomes were realized, and unexpected benefits were revealed.

Increased Comfort With the Third Actor
The choice of where in the room the computer is placed28 and its role as a third actor17 alters the physician-patient interaction in a major way.22–24,27,35 We document how initially awkward physicians increased in confidence with time and became more adept. As others have noted, physicians accommodated through body language, introductions to the EHR, excuses for computer set-up delay, monitor positioning for collaborative viewing, invitations for patients to sit closer, and references to the computer as a shared burden.18,38 Repeating patients’ words while typing signaled physician attention and allowed time for correction by this "pausing."39 Just-in-time information and referrals added to efficient work flows and accompanied increased sharing of the EHR with the patient25 in contrast to the physicians’ not sharing the paper chart before EHR implementation. Though EHR multitasking may be burdensome,8,22 adjustment was noteworthy because so few physicians were early EHR adopters. This adaptation supports recommendations for preparatory discussion and gradual implementation.15,40

Trust in the Physician Relationship
Trust in the physician and the security of the therapeutic relationship appeared to override most patients’ concerns. Patients generally acknowledged exigencies of the physician’s job and expressed appreciation of less wasted time and fewer physician exits.12,25 Although patients were ambivalent about EHR security, many noted their accommodation to the benefits and anxieties of the 21st-century electronic-age reality that no system is ultimately foolproof. Although the literature asserts decreased patient-centeredness with EHR use,8,16,20,23,27,35 and clinical staff expressed concern about eye contact,16,41 these patients seemed to assume patient-centeredness in EHR use by interpreting the focus on documentation as evidence of physicians’ caring,36 and they reported no less satisfaction with the relationship.12,42 Such a positive relationship may provide the foundation to enhance patient health care responsibility3,37 as clinical information shifts from physician to joint control.

Limitations
Participating patients may have been more satisfied with their physicians than those who declined participation. Conducting exit interviews within the clinic (albeit in private rooms) may have inhibited patient criticism. Although anthropological observation contains some subjective aspects, the use of one researcher and a standard observation form and interview guide provided a uniform record to increase rigor. Extensive discussions by the analysis team facilitated consideration of alternate interpretations of findings.

Implications for Theory and Practice
EHRs in health care settings pose challenges to medical practice. Clinical staff must learn the system and coordinate efforts.15 EHR mechanics can be overwhelming, but they are ultimately surmountable.38 Curricula for EHR training are clearly necessary. In addition, physicians should learn to type well before moving to the EHR17 and be trained to improve communication.39 Computer placement in the consultation room should be considered, as it affects the patient inclusivity28 or openness39 during the physician-patient interaction. Further study should focus on how the patient record is shared; increased patient access to the patient record may lead to decreased physician authority, yet it may also enhance the physician-patient partnership and patient responsibility.37 Further outcomes research may also be warranted to examine the effects of EHR use on health and disease. In this population, our results justified the considerable expense, time, and effort expended. It is highly plausible that similar results could be obtained in comparable settings.


   ACKNOWLEDGMENTS
 
The authors wish to thank the patients, physicians, nurses, and other staff of the Family Care Center at Memorial Hospital of RI who generously agreed to participate in this research. We also acknowledge the helpful administrative support of Irene Reis and Pedro Pichardo’s assistance in the preparation of tables.


   FOOTNOTES
 
Conflicts of interest: none reported

Funding support: This research was supported by an Academic Administration Units grant from the Health Resources and Services Association, grant No. D54HP00121.

Received for publication May 20, 2009. Revision received December 18, 2009. Accepted for publication December 28, 2009.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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