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Research ArticleOriginal Research

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

William Ventres, Sarah Kooienga, Nancy Vuckovic, Ryan Marlin, Peggy Nygren and Valerie Stewart
The Annals of Family Medicine March 2006, 4 (2) 124-131; DOI: https://doi.org/10.1370/afm.425
William Ventres
MD, MA
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Sarah Kooienga
FNP
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Nancy Vuckovic
PhD
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Ryan Marlin
MD, MPH
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Peggy Nygren
MA
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Valerie Stewart
PhD
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Figures

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  • Figure 1.
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    Figure 1.

    Themes and factors influencing electronic health record (EHR) use and physician-patient encounters.

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  • Appendix.
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    Table 1.

    Summary of Clinic and Participant Characteristics

    Primary SiteSecondary Sites
    CharacteristicABCD
    Note: all clinics used a Logician (Windows-based) brand EHR from GE Medical Systems Information Technologies, Hillsboro, Ore: http://www.medicalogic.com/index.html.
    FP = family physician; FNP = family nurse-practitioner; EHR = electronic health record. Functions: AC = automated charting; VR = voice recognition (trial only); R = computerized referrals; MM = mobile examination room monitor; FS = flat screen monitor; IE = internal electronic mail; HI = home Internet ; MC = mixed (paper and automated) charting; D = dictation commonly used; FM = fixed monitor; B = computerized billing; EE = external electronic mail (with patients).
    *Including videotaped and participant observations.
    Clinic
    LocationUrbanUrbanSuburban/RuralUrban
    Encounters observed5214105
    Physicians
    Professional status5 FPs,1 FNP8 FPs,1 FNP4 FPs5 Internists
    No. observed6433
    Age range, y36 – 4833 – 5334 – 4033 – 48
    Years of post-training6 – 183 – 205 – 82 – 19
    Years experience with EHRs2 – 63 – 74 – 62 – 9
    Self-reported EHR skill level average, above average, or excellentAllAllAllAll
    Patients
    Age range18 mo – 94 y5 mo – 70 y4 mo – 64 y31 – 64 y
    Male, %4474020
    Female, %56936080
    Patient complaint
    Urgent, %52364460
    Chronic, %48645640
    EHR functions available AC, VR, R, MM, FS, IE, HIMC, D, R, FM, IE, HIMC, R, FM, IE, HIAC, R, B, MM, FS, IE, EE, HI
    • View popup
    Table 2.

    Qualitative Methods and Characteristics of Participants

    Individual Interviews April–July 2001* August–October 2003†
    MethodIn-DepthBriefVideotaped Encounters August–September 2003†Focus Group Interviews April–July 2001* August–October 2003†Participant Observation April–July 2001* August–October 2003†
    * Research conducted at primary office site, A.
    † Research conducted at all office sites, A – D.
    ParticipantsSite = Clinic APhysicians = 3 (n = 15)Offices = 1 primary, 3 secondary
        Physicians815Total encounters = 29Early advocates = 1 (n = 6)
        Patients142No. of physicians = 6Resident physicians = 1 (n = 6)Clinical encounters = 52
        Office staff45Encounters/physician = 4–5
    Approximate duration1 h10 minDuration = range 1.5–27.8 min, mean 16.9 minDuration = 1 hDuration = 80 h
    • View popup
    Table 3.

    Approach to Qualitative Analysis of Data

    Data TypeAnalysis Activity Conducted ConcurrentlyProcess
    Audiotaped individual and focus-group interviews
    Step 1Reviewed transcripts and field notes independentlyEmergent factors highlighted
 Illustrative quotations recorded
    Step 2Discussed factors and themes jointly 
 Identified data to confirm or refute interpretationsInterpretations agreed upon by consensus
 Themes categorized using iterative process
    Videotapes
    Step 1Reviewed videotapes independentlyNoted characteristic practice behaviors 
 Identified factors and themes
    Step 2Reviewed representative videotaped visits jointlyShared independent interpretations 
 Interpretations agreed upon by consensus
    Step 3Reviewed notes and transcripts of the post-videotape physician interviews and questionnairesShared independent interpretations 
 Interpretations agreed upon by consensus
    Written notes from fieldwork and brief interviews
    Step 1Reviewed all notes from observations and nontranscribed interviews independentlyEmergent factors highlighted
    Step 2Reviewed notes jointlyInterpretations agreed upon by consensus 
 Themes categorized using iterative process
    Thematic results
    Step 1Results reviewed with medical anthropologist in serial meetings with researchersProbed layers of meaning about data obtained 
 Examined consensus decision-making about interpretations 
 Explored outlying interpretations
    Summarized results
    Step 1Study results reviewed by four key informantsCritiqued results in writing
    Step 2Reviewed critiquesWritten comments reviewed 
 Results adapted accordingly
    • View popup
    Table 4.

    Example Questions Generated by This Study

    EHR = electronic health record.
    Can EHR software be designed to facilitate communication between physicians and patients?
    What resources are available to help physicians best integrate this technology into their style of patient care as they transition to the use of the EHR?
    Are there examples of best practices—standard procedures or phrases—that physicians can use to assist patients as they are introduced to the EHR?
    When and how should medical educators introduce the EHR to students and residents, especially given the current emphasis on training patient-centered interviewing skills?
    What responsibilities do vendors or health care systems have to train physicians about the relational aspects of the EHR?

Additional Files

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  • The Article in Brief

    Background The electronic health record (EHR), a secure computer-based resource that includes the patient�s medical information, is often viewed as a vital tool for medical practices in the 21st century.This study explores whether and how EHRs affect patients� visits to the doctor.

    What This Study Found Use of an EHR by doctors in the examination room influences the patient visit. This study identified 14 factors that shape how EHRs are perceived and used in medical practice, including spatial factors (ways in which the physical presence and location of the EHR influences interactions between doctors and patients), relational factors (how patients� and doctors� perceptions of the EHR affect its use), educational factors (the need to help doctors learn to use the EHR and to help patients understand it), and structural factors (institutional and technological forces that influence how doctors perceive their use of an EHR).

    Implications

    • The EHR is not just a computerized version of a paper medical record. Rather, it has an identity that can influence medical care.
    • Medical practices need to consider the ways in which EHRs influence the relationship between patients and doctors.
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The Annals of Family Medicine: 4 (2)
The Annals of Family Medicine: 4 (2)
Vol. 4, Issue 2
1 Mar 2006
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Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis
William Ventres, Sarah Kooienga, Nancy Vuckovic, Ryan Marlin, Peggy Nygren, Valerie Stewart
The Annals of Family Medicine Mar 2006, 4 (2) 124-131; DOI: 10.1370/afm.425

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Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis
William Ventres, Sarah Kooienga, Nancy Vuckovic, Ryan Marlin, Peggy Nygren, Valerie Stewart
The Annals of Family Medicine Mar 2006, 4 (2) 124-131; DOI: 10.1370/afm.425
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