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

INTRODUCTION

Both the Institute of Medicine and the Future of Family Medicine project have recommended the use of information technologies and electronic medical record (EMR) systems as tools for improving the quality of care¹ and patient safety.^2,3 Recent research has shown that information technologies can reduce medication errors,⁴ improve adherence to clinical practice guidelines,⁵ and improve the delivery of preventive health services,⁶ thereby potentially improving health outcomes for patients.⁷ In addition, using an EMR that includes electronic prescribing as well as electronic charting offers substantial financial benefits to primary care organizations and the health system as a whole.⁸ Even so, relatively few primary care practices use EMRs.⁹ Reasons for not adopting EMRs may include the temporary loss of revenue associated with EMR implementation,⁸ physician perception that EMRs negatively affect workflow, and concerns about patient privacy.⁹ Even in settings where clinicians are committed to EMRs, implementation requires skilled users and a commitment to making the EMR an integral part of the organization.¹⁰ Without these personal and institutional commitments to full implementation, EMRs may actually represent a net financial drain on primary care practices and offer little or no patient care benefits.⁸

Because primary care practices are complex adaptive systems interconnected with many other organizations and made up of individuals with widely varying educational backgrounds, processes and outcomes of organizational change are largely unpredictable.^11,12 In these complex systems, the interactions between participants are nonlinear in that the behavior of the whole is not simply the sum of the behaviors of all of the participants.¹³ Accordingly, organizational-level change efforts often have implications and effects beyond the directly targeted system. The process of implementing an EMR system is one such organizational-level change wherein system-level behaviors emerge nonlinearly from the interactions of practice participants as they adapt to changes in their work and work relations necessitated by the adoption of a new technology.

Previous studies of EMR implementation have focused on the technical and organizational rather than cultural aspects of this process.¹⁴ In this article, we describe how one primary care practice implemented and used an EMR and how organizational culture and capacities affected these processes.

METHODS

We adapted the multimethod assessment process (MAP) described by Crabtree, Miller, and Stange,¹⁵ which offers the potential for triangulating data collected using different methods. A field researcher used a template of topics, adapted from previous work,^15–17 to structure observations of the practice during the course of 9 consecutive workdays in July and August of 2002, recording observations each evening in field notes expanded from jottings. The field researcher interviewed the physician owners of the practice, the office manager, the head nurse, a medical assistant, and a receptionist and asked each interviewee to describe a recent practice change, who made the decision to implement this change, and how members of the practice learned of the change. The field researcher also conducted informal key informant interviews with other practice members, including the referral specialist, another nurse, medical assistants, the front office supervisor, and other receptionists. The office manager for the practice completed a practice information form listing practice employees and their positions, giving estimates of patient demographics, and describing various aspects of the business. Although the goal of data collection was a broad understanding of organizational culture and capacities, that the practice had recently implemented a new EMR led many practice members to concentrate on this recent change in their discussions with the field researcher. Because adopting an EMR was a major recent event for this organization, the field researcher collected more data than initially planned on this topic, thereby providing sufficient data for analysis.

After the first 4 days of observation, a multidisciplinary team including the field researcher reviewed the data. The field researcher then returned to the practice to collect additional data to answer questions relating to organizational processes that arose during this review. At the end of the data collection period, the research team along with the field researcher drafted a summary report highlighting communication patterns, decision making, and information flow in the practice. The field researcher shared this report with the lead physician and then with all members of the practice at a general meeting to check and confirm our observations and interpretations. The field researcher then collected additional data 1 year later using direct observation and key informant interviews.

RESULTS

The practice was located in an upper middle-class suburban community and had a modern computer system and a laboratory for drawing blood. At the start of data collection, there were 8 health care professionals, including physicians (2 of whom owned the practice), physician’s assistants, and nurses. There were 19 other full- and part-time staff members, including an office manager, medical assistants, and administrative support staff. The turnover rate at the front desk was high; one patient voiced a typical feeling that “every time you come here there are different women working here.” We have withheld additional details regarding the practice to preserve anonymity.

Initial data analysis showed that communication patterns, decision-making processes, and conflict management processes were strong determinants of practice functioning across many areas. We focused subsequent analyses on the recent implementation and use of the EMR as an example of how organizational culture and capacities affected change processes. Direct quotes from audiotape transcripts or those recorded verbatim in field notes appear in quotation marks; additional information comes from field notes.

DISCUSSION

Inadequate communication within the practice allowed members to develop divergent understandings of why the practice adopted the EMR and what purposes it should serve. In the absence of clear communication regarding goals and objectives for the EMR, the previous practice technology for monitoring wellness and preventive health maintenance was lost. Practice communication patterns and decision-making processes also affected the organization’s ability to recognize and address serious differences in understanding regarding the purpose of the EMR. Thus, the EMR functioned much like a paper patient record but without the physician reminders that the earlier system included. Moreover, the existing interpersonal conflicts in the practice affected communication and helped block effective collaborative efforts needed to implement the EMR. Failing to address the underlying conflicts within the practice or the considerable differences in understanding among practice members limited the ability of the organization to manage complex change processes.

One important determinant of how primary care practices integrate organizational-level changes is their ability to manage the inherent diversity of practice participants and address conflict constructively by identifying and working with rather than eliminating major differences within an organization.²¹ Organizations that are better able to recognize and work simultaneously with multiple perspectives, rather than striving to achieve a consensus about the correct way to move forward with change, are best able to make improvements.^21,22 Patterns of communication and styles of decision making are important determinants of how an organization raises and addresses differences and conflicts among organization members. Inadequate communication and a heavy reliance on top-down decision making created serious organizational problems in the case described here and would likely cause problems for other organizational change initiatives. It is important to note, however, that these problems are not unique to this practice. We saw similar communication and decision-making issues in other practices participating in this program, and previous research^17,23 has found that communication patterns and other system features affect practice improvement efforts.

Because we report a case study of a single primary care practice in the northeastern United States, we cannot capture the full impact that EMR implementation may have on primary care practices. This study does show that, at a minimum, communication, decision making and conflict within practices are important issues determining the results of EMR implementation. Future studies will need to examine additional cases to identify other implementation issues in these settings.

Although EMRs hold great potential for improving the quality of patient care in primary care settings, taking advantage of this potential requires planning and communication. Further, because each primary care practice is a complex adaptive system with implementation issues specific to the initial conditions of the practice, unanticipated results are likely to emerge. Members of the practice, especially decision makers, must address these specific implementation issues through a mechanism that allows conflicts to surface safely and that encourages communication.

The effect of EMRs on patient care outcomes is not likely to be linear, leading from improved technology to improved care. Rather, because the functionality of the EMR as implemented and used derives from the interactions of practice members with each other and with the technology, the effects of this technology will likely vary. Stories such as the one that we present here may explain some of the reticence that many practice leaders have about implementing EMRs. The diffusion of this innovative technology may thus be slowed by the implicit understanding of practice leaders that implementation will require high levels of collaboration among diverse practice members and considerable change in the organizational cultures of many practices.²⁴ Thus, many may have recognized and anticipated the disruptions that are likely to accompany EMR implementation. To implement successfully the Institute of Medicine and the Future of Family Medicine recommendations for using EMR technology to improve patient care quality in primary care settings,^1,3 future research should test implementation strategies that can improve existing communication patterns, relationships, and decision-making processes in these settings.