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

This is a very good and very thorough study. It does highlight the complexity of researching in this area. I see one comment on the applicability because of the setting, a teaching practice. Yet in the references are several studies in US, UK, and Australia (the Australian ones I am the author of) that do use wider settings. But the amount of data generated in these studies should not be underestimated. The research does not lend itself to simple, quantitative outcomes that can be assessed over a wide study population. Most has not taken a before and after approach. This sort of research is in it's infancy - and I applaud the authors.

Competing interests:   None declared

It's so interesting to read the human story of an implementation, and to hear people's worries -- which I believe are universal -- I have heard these concerns from patients and caregivers, from rural settings to academic health centers. With time, patients come to value the access that EMRs offer more than they fear potential privacy breaches. And health professionals overcome their misgivings about whether computers will somehow damage their relationships with patients and soon feel liberated by not having to manage cumbersome physical documents anymore.

In the end, the medical record is a repository of information used by clinicians, patients, and others (eg, family members, researchers, quality monitors, insurers), and digitizing it is the first step toward making information available where it is needed. The next step is to make it accessible online, particularly to patients, so that equal access to information can lead to truly shared decision making by patients and their doctors.

This study highlights the potential value in taking a rigorous pre- post look at practice changes, and in consulting everyone involved, including patients -- bravo.

Of course, it is physicians who must make the biggest adjustment (and often a financial investment) in the switch to electronic records. I look forward to reading the physician interview results!

Competing interests:   None declared

A 2005 article entitled, “Electronic health records: Just around the corner? Or over the cliff?” detailed the painful process of implementing electronic health records (EHR) in an internal medicine practice. The process was disruptive, expensive, and even led to low morale. However, in the end, physicians and staff members embraced the new technology and vowed never to go back to paper records. They concluded that EHR expedited work processes and created new ways to improve patient health [1].

Dr. Shield and her colleagues observe a similar pattern during EHR implementation in that initial concerns and resistance were ameliorated with improved work efficiencies. The study also adds to a growing literature that suggests EHR actually helps rather than hurts the physician–patient relationship. Most notably, patients interpreted computer usage as evidence of physicians’ caring [2].

The Shield, et al. study utilizes a thorough, mixed method approach that helps to explicate the many benefits of adopting EHR, but provides only a few hints about implementation, suggesting that a gradual approach is helpful and that some resistance from physicians and nurses should be expected. If the verdict was not in, it is now. The benefits of EHR far outweigh the various costs associated with their implementation. Even the first cost on the minds of many, the financial one, may be mitigated by a positive return on investment [3,4].

As the steady movement from paper to electronic documents in modern society would suggest, it is hard to imagine EHR implementation as anything other than inevitable, particularly in the face of mounting evidence that making the change ultimately translates into improved patient health care. Hence, it seems appropriate to focus attention on facilitating change, change management, and education.

To successfully engage in change, people need more information on ways to make it happen, and how to best implement it. For example, if a community health care organization cannot afford the initial financial cost of changing its system to EHR, government, or private economic incentives could be provided until financial gains from implementation are realized.

Employees benefit from formalized training when new technologies are introduced, leading to positive attitudes about change and increased work productivity [5]. Training modules are needed to explain the well documented benefits of EHR and how that system can complement a patient- centered approach to health care. For example, we know enough about how EHR can influence behavior in the medical interview in terms of eye contact, body positioning and patient participation, to confidently talk about more effective vs. less effective usage [6]. Moreover, medical schools already require some form of communication course for their students, and it should be relatively easy to institutionalize EHR training in the form of an educational unit in such courses.

The U.S. lags behind many parts of the world in implementing a technology that holds enormous promise for health care. Shield et al. provide more evidence that the benefits of EHR outweigh the costs, so future research should investigate concrete ways to speed up the adoption of this technology and make it universal.

[1] Baron RJ, Fabens EL, Schiffman M, Wolf E. Electronic health records: Just around the corner? Or over the cliff? Ann Intern Med. 2005 Aug 143(3): 222-26.

[2] Shield RR, Goldman RE, Anthony DA, Wang N, Doyle RJ, Borkan J. Gradual electronic health record implementation: new insights on physician and patient adaption. Ann Fam Med 2010 July/ Aug 8(4): 316-26.

[3] Wang SJ, Middleton B, Prosser LA, Bardon CG, Spurr CD, Carchidi PJ, et al. A cost-benefit analysis of electronic medical records in primary care. Am J Med 2003 114: 397-403.

[4] Grieger DL, Cohen SH, Krusch DA. A pilot study to document return on investment for implementing an ambulatory electonic health record at an academic medical center. J Am Coll Surg 2007 Jul 205(1) 89-96.

[5] Boothby D, Dufour A, Tang J. Technology adoption, training and productivity performance. Res Policy 2010 39(5): 650-61.

[6] McGrath JM, Arar NH, Pugh JA. The influence of electonic medical record usage on nonverbal communication in the medical interview. Health Informatics J 2007 13(2): 105-18.

Competing interests:   None declared

Good to see this positive report on a large EHR implementation in a family medicine residency clinic. The authors offer important lessons in the training for this development. EHRs are not optional, they are part of developing a modern information age practice. Having the EHR in the exam room with the patient is important. After all, it is the patient's record as much as the doctor's record of the patient.

Our patients are very positive about having the record in the room and we follow these simple rules:

1. The physician always greets and begins discussion with the patient away from the computer. Direct rapport is established. The computer does not enter into the visit until it is needed for information.

2. We use large screens on a swivel arm so the patient can easily see what is in their record. This is especially helpful for vital sign flow sheets, lab results (looking at them together and explaining them is powerful) and updating medication lists.

3. We are never more than 90 degress away from the patient. Our keyboards are such that we maintain direct contact with the patient and never have our back to them.

There is a spectrum of methods here from great to ugly. Plan your use of the EHR to be patient centered and not a chore for the doctor and staff. We will all have them, so implement wisely with training of all the staff and providers. Get patient feedback and if it is not positive, make changes. Using the EHR is part of being a learning practice.

Competing interests:   None declared