Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation

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.

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.

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.

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).

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.

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 responsibility^3,37 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.