Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis

Bill Ventres, et al, are to be commended for doing important qualitative research on the impact of the EHR on the physician-patient relationship. Anyone with life experience knows that something new will have unintended consequences. With EHRs, there are both good and bad unintended consequences. Indeed, EHRs are a disruptive technology to the traditional clinical encounter.

EHRs are here to stay, and should get better over time with Yankee ingenuity and a smarter world with taking advantage of IT tools. As one who started with an EHR in 1994, I have had much experience in making it work. Like all important parts of the process of care, there should be training to achieve proficiency and even excellence. For EHRs, let's call this: Relationship Centered Care meets the EHR. Here are a few pearls I have learned and teach students, residents, and struggling colleagues:

1. Never start an encounter with the computer. Always face the patient and interact before using the computer. 2. When attention goes to the computer, always adjust the screen so the patient can see their own record. 3. Express and demonstrate advantages of the EHR to the patient, such as the flowsheet of vital signs and lab work. 4. Show some of the "magic" of the EHR, such as "the prescription is already at the pharmacy, the requisistion is already at the lab, etc" 5. Leave the computer to connect personally with the patient, use touch when appropriate, and end the encounter without the computer. 6. Be sure the patient gets the printout of the visit including all the instructions and patient education you gave captured in print.

Competing interests:   None declared

Computers intrude into consultations in ways which remain poorly explored. Despite this uncertainty, these clinical tools are considered an essential technology to transform health care in developed countries: especially by improving preventive care and the management of long term conditions. In this edition of the Annals, Ventres and his colleagues have built on their earlier work by conducting a series of ethnographic studies which provide useful insights into the process. Their focus was on the factors influencing how physicians use the electronic health record today in order to effect future improvements. This is an impressive piece of work reporting participant observation, individual interviews, observation of videotaped material and focus groups in a manner they describe as ‘intense analysis’.

The results are presented as 14 factors which influence EHR use in four thematic categories which are plausible to this reader; well described in the text and justified by their methodology. Many of the quotes provided by study subjects will be familiar to family doctors and researchers who have explored the subject. They acknowledge the potential limitations imposed by their access to study sites and subjects. This challenges other research groups and educationalists interested in the field to replicate their findings in other contexts and take some of the issues forward which they have identified. The authors helpfully map out a list of exemplar questions in their final table.

The Oregon team will no doubt be following other leads they have identified and blazing a trail.

Refs Protti D. What can the American electronic health record (EHR) pioneers tell us about what it takes to be successful? Healthc Manage Forum.2002;15:33-5.

Sullivan F. Intruders in the consultation. Fam Pract. 1995;12:66-9.

Competing interests:   None declared