Implementing an Electronic Medical Record in a Family Medicine Practice: Communication, Decision Making, and Conflict

The contribution of this qualitative case study lies in the discussion of the potential for a practice’s cultural, environmental, and conceptual environment to significantly impact an electronic medical record (EMR) implementation. Other recent studies have also discussed challenges achieving desired goals through the effective implementation and application of an EMR. Examples include an inability to achieve better population metabolic control despite increased numbers of HbA1c and LDL tests (1), absence of improved documentation of tobacco interventions,(2), and an increased hazard association with the physician-patient interactions (3). In this case, the fact that incorrect assumptions led to the disabling of key built in reminders and tracking systems, and that detrimental tensions resulted from competing EMR visions suggests that a limited view of the potential of an EMR in addition to cultural, communication, decision making, and conflict resolution factors can have significant limiting consequences in the successful implementation and use of an electronic medical record system.

Other experiences, and published reports (4,5) demonstrate that a well implemented EMR can result in practice benefits with patient communication, data management, and clinic function The results cited in the paper from Crosson and colleagues lends additional substance to our evolving understanding that the acquisition of an EMR is only one step in a transformational journey. A broad vision of an electronic system is required to even grasp what is now already available with an optimal use of electronic systems. Clinic scheduling, registration, patient data acquisition and entry, test ordering, prescribing, medication interaction checks, appropriate best practice alerts, literature searches, and patient access to their own medical record are all currently available through electronic medial record systems. But this is not enough to realize our existing potential for best care. Fundamental redesign of clinic function processes and work flows that most effectively and efficiently compliment the rapidly developing electronic clinical environment is necessary to achieve a level of patient care and experience that accurately reflects our current promise. How we achieve this transformation speaks to the larger message from Jesse Crosson, Christine Stroebel, and their colleagues. It will be the cultures that effectively nurture the required communication, collaboration, decision making, and conflict resolution techniques that will ultimately allow their organizations to reach a new level of excellence. Hardware and soft ware alone will not be sufficient without the fundamental redesign of those medical clinic processes, work flows, communication patterns, decision making structures and cultures that were the product of another age.

1. O'Connor PJ, Crain AL, Rush WA, Sperl-Hillen JM, Gutenkauf JJ, Duncan JE.: Impact of an electronic medical record on diabetes quality of care. Ann Fam Med. 2005 Jul-Aug;3(4):300-6.

2. Conroy MB, Majchrzak NE, Silverman CB, Chang Y, Regan S, Schneider LI, Rigotti NA.: Measuring provider adherence to tobacco treatment guidelines: a comparison of electronic medical record review, patient survey, and provider survey. Nicotine Tob Res. 2005 Apr;7 Suppl 1:S35-43.

3. Singh R, Servoss T, Kalsman M, Fox C, Singh G.: Estimating impacts on safety caused by the introduction of electronic medical records in primary care. Inform Prim Care. 2004;12(4):235-42.

4. Arar NH, Wen L, McGrath J, Steinbach R, Pugh JA.: Communicating about medications during primary care outpatient visits: the role of electronic medical records. Inform Prim Care. 2005;13(1):13-22.

5. Garrido T, Jamieson L, Zhou Y, Wiesenthal A, Liang L.: Effect of electronic health records in ambulatory care: retrospective, serial, cross sectional study. BMJ. 2005 Mar 12;330(7491):581.

Competing interests:   None declared

We read your article with great interest and commend you on exploring a tough but vitally important topic. Implementing health information technology in the family physician office sometimes requires a profound change in work process, job responsibilities, and interpersonal relationships. Setting up a family medicine practice in the last half of the 20th century was similar to setting up many other small businesses and required hard work, business sense, risk tolerance and a good amount of rugged individualism. Unfortunately, this often tended to naturally evolve the practice into a hierarchical power structure, with the founding doctor or doctors at the top of this structure. As your article points out, this type of management structure might not be the best model for the type of change necessary to implement health information technology solutions, and may not be well aligned with the New Model envisioned in the Future of Family Medicine Project.

In our recent investigations at the AAFP’s Center for Health Information Technology we have observed that practices are capable of implementing the same technology (e.g. one of the popular brands of EHR ) with results varying from wildly successful to moderate failures. It is also our observation that management culture and structure, relationships among staff, leadership styles, and orientation towards teamwork can have a profound effect on outcome. As we solve the technical issues surrounding health information technology, and as these systems become more affordable, leadership and management issues will become paramount. The demographics of family medicine are changing rapidly, with many more physicians being women, a tendency towards both larger groups as well as very small practices, and modified work schedules for many family physicians regardless of gender. Going forward, it’s vitally important, as you have done with this article, to examine how these demographic and sociological changes affect implementation of the New Model of family medicine in which health information technology will play a prominent role.

With very kind regards,

Physician Staff at the Center for Health Information Technology David C. Kibbe, MD MBA Louis Spikol, MD Steven Waldren, MD

Competing interests:   None declared