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

Renée R. Shield; Roberta E. Goldman; David A. Anthony; Nina Wang; Richard J. Doyle; Jeffrey Borkan

doi:10.1370/afm.1136

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Table 1.

Methods Used and Outcomes Observed in Phases of Study

	Before Implementation^a	Transition^b	After Implementation^c
EHR=electronic health record.
^aJanuary-May 2005.
^bJune 2005-March 2006
^cResidents, April-June 2006; faculty, April-November 2006.
^dObservations and conversations with nursing staff, clerical staff and physicians at nurses’ stations.
^eExtensive physician interview data to be reported at a later date.
Methods	Consultation observations	Consultation observations	Consultation observations
	Patient interviews	Patient interviews	Patient interviews
	Timed-tasks measurements	Timed-tasks measurements	Timed-tasks measurements
	Other observations^d	Other observations^d	Other observations^d
	Staff focus groups	—	Staff focus groups
	Physician Interviews^e	—	Physician Interviews^e
Outcomes	Use of patient chart	Use of patient chart	Use of patient chart
	Use of EHR	Use of EHR	Use of EHR
	Time in and out of office	Time in and out of office	Time in and out of office
	Physician body position/verbal strategies	Physician body position/verbal strategies	Physician body position/verbal strategies
	Patient/staff satisfaction	Patient/staff satisfaction	Patient/staff satisfaction

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Table 2.

Number of Clinical Encounters by Physician Type (n=170 Consultation Sessions)

Physicians	Before Implementation^a	Transition^b	After Implementation^c
^aJanuary-May 2005.
^bJune 2005-March 2006
^cResidents: April-June 2006, faculty: April-November 2006
Faculty (n=13)	17	32	26
Residents (n=13)	21	39	35
Total (n=26)	38	71	61

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Table 3.

Characteristics of Study Patients (n = 170)

Characteristic	% Male^a	% Female^b
GED=general equivalency degree.
Note: Of the 170 patients, 3 files were missing.
^an=46 (27%)
^bn=121 (71%).
Age, y
17–35	17.4	42.2
36–65	58.6	46.2
65+	21.7	9.1
Missing	2.2	2.5
Self-identified ethnicity
White or European American	71.7	67.8
African American or Hispanic	13.1	16.5
Other (Middle Eastern, Cape Verdean, American Indian)	8.7	5.0
Missing or refused to answer	6.5	10.7
Education level
<High school degree	34.8	29.8
High school degree or GED	30.4	25.6
Some college or above	30.5	41.3
Missing	4.3	3.3
Computer experience
None or little	52.2	34.7
Some or much	47.8	63.6
Missing	0.0	1.7
Computer access
None or little	47.9	37.2
Some or much	50.0	61.1
Missing	2.2	1.7

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Table 4.

Sample Patient Quotes Related to EHR Implementation

Patient Variable	Before Implementation	Transition	After Implementation
CE = computer experience; EHR = electronic health record; EMR = electronic medical records; NA = not applicable; PCP = primary care physician; PDA=personal digital assistant; VA = Veterans Administration
Aware of EHR	I guess so, yeah (female, 65 y, some CE)  Yes, at the nurses’ station (female, 24 y, extensive CE)	I hope so. My information should be in the computer (male, 32 y, no CE)  She does it on the computer…. She puts everything right on the computer when we’re talking (female, 46 y, extensive CE)  Yes he is (male, 45 y, no CE)  We’re in the 21st century. Sooner or later that paperwork is going to disappear, you know? (male, 46 y, some CE)	NA
Not aware of EHR	Not that I know of; is it that little pocket thing [PDA]? (female, 49 y, extensive CE)  I have no idea; I would think so, probably (male, 45 y, little CE)	I would probably say no (female, 25 y, some CE)  I have no idea (female, 18 y, little CE)	NA
General reactions to writing and/or EHR	I’d rather see them writing something down than just listening… and not writing anything down (male, 41 y, some CE)  She’s putting down what I’m telling her…everybody forgets things. So that way there, you put it down on paper, and you know, you don’t forget it. You can refer back to it. That’s why it don’t bother me at all (male, 70 y, some CE)  She was writing what she was saying, not what I was saying…. I didn’t like what she was writing (female, about 45 y, extensive CE)	The first day when he came with that [computer], you know, I didn’t say nothing. I think he knows what he’s doing…. To me, it was the same (female, 80 y, no CE)  She was writing down what my concerns were—I mean what her concerns were because she knows me…. Well, I think everything is going computer anyway…. The computer is fine (female, 59 y, little CE)  She does it on the computer…. She puts everything right on the computer when we’re talking…[typing is]...like a second nature thing…. Even when she’s putting things on the computer, I still feel like she’s paying attention to me (female, 46 y, extensive CE)	It seemed like it would be easier to look up when she looks at my cholesterol level, you know, click on the computer—last cholesterol level…. It didn’t make me feel like she was spending her time typing, so it didn’t feel like she was taken away by, ”Hold on, I’ve got to type this.“ She just did it. So I didn’t even realize (female, 46 y, extensive CE)
Positive reactions to EHR	[EHR helps] access the information a lot faster (female, 34 y, no CE)  Obviously to me a computer is such an added benefit because you can immediately pull information (male, 54 y, extensive CE)  They can pull it [the record] up easier (female, about 22 y, little CE)  I think it’s useful for them to have computers…so they don’t have to keep writing everything down (female, 18 y, some CE)  [EHR is] a lot easier instead of having to look through charts all the time…and maybe visits would go even quicker (female, 26 y, extensive CE)	…they could pull the record up quicker (male, 26 y, extensive CE)  It’s better for them. They can just get it that way without looking for files (female, 55 y, little CE)  I rather have that [EHR] so that if I had to go to the emergency room, and they asked me things I wouldn’t know, I would say, go look it up, and everything would be there (female, 18 y, no CE)  There ought to be less of a mound in [the landfill] someday…. I trust them [PCPs] thoroughly (female, 57 y, extensive CE)  If you’re visiting in New Hampshire, bingo, [you can get your records/health information] over the computer …I think [it] is wise (female, 55 y, little CE)	I don’t mind [the information in the computer] because they must have a system maybe to protect all the information…. It’s a good thing because like I say, you don’t have to go looking through the books. You bring everything up (male, 83 y, no CE)  It remembers more, never forgets like people do, and paper can get lost (male, 53 y, unknown CE)  [The] visit was smoother [with the EHR] (female, 35 y, extensive CE)  Paperwork is out of style, and I believe the computers will be something for the world’s future…. It’s necessary…. Why should I worry about it? I’m not telling him lies. I’m just telling him I’m sick, and I see a doctor…. So I’m not worried about whatever is in the computer…. I’m not a doctor, and I came here because I trust the doctor. And that’s enough for me. Whatever he puts in there is part of his job (male, 65 y, no CE)  The flow doesn’t change when she’s talking to me…, so like I know she’s taking notes, but I don’t really pay that much attention I guess because I’m used to it (female, 31 y, extensive CE)  Oh, that doesn’t bother me no more than really having your medical record out on the counter. I just think that it’s faster, so she has more time to talk to me (information not available)  I trust her [PCP]…anything I need to know she tells me about me. I mean she doesn’t hide anything from me (female, 56 y, unknown CE)
Concerns about EHR	It all depends who it’s made available to afterwards. You know we’re going through a period right now with the government. This here government type thing is really crazy, excuse me, with records and everything. And it makes me concerned that other people can get into your records... (male, 70 y, some CE)  [Hacking] could happen, you know, I’m sure. I mean there’s a lot of hackers out there. So anything can happen (male, 36 y, extensive CE)  I’m pretty sure the hospital has many things to make it so people can’t get at it unless it’s the right person (male, 45 y, no CE)  Sometimes it’s OK. Sometimes it’s not because, you know, now we can break into the computers (female, 31 y, some CE)	…people can take information and everything…[the] computer is another enemy…they can steal all the information from you (male, 32 y, no CE)  I’m fine just as long as nobody else gets them besides doctors to know my information (female, 32 y, extensive CE)	I just don’t want my medical records being opened up on the computer for the world to see…. Personally I would prefer the paper chart (female, 34 y, little CE)  [EHR is] OK as long as no one breaks in and gets med info. If it’s easier for docs to pull up info they need, OK. Better than searching through paper records. [Preferred paper to EHR] (female, 29 y, extensive CE)  Because if something goes wrong, anybody can get our information off of a computer. Like with the VA guys and stuff. Their data might have gotten stolen (female, 58 y, little CE)  Anybody could get to those records. The point is I don’t particularly care (information not available).

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Table 5.

Perceived Benefits and Challenges in Implementing an EHR from Clerical and Nursing Staff Focus Groups

Variable	Perceived Benefits	Perceived Challenges
Physician documentation	I think if they have the computer in there, they’ll document better (clerical staff, before implementation and during transition)  [Some doctors] do their notes electronically. And then they print them off for me (clerical staff, before implementation and during transition)  Some [physicians] will be very, very good (nurses, before implementation and during transition)  [Doctors’ notes] are more accurate now. Plus I think your notes are done more in real time now…before they used to hold onto charts forever (nurses/clerical, after implementation)  So if they want me to do refills, then I send them notes. If you don’t close your chart and finish your chart, I cannot update your med list, and hello, I can’t help you. So I think that’s helped too (nurses/clerical, after implementation)	The doctors are going to be the barriers (clerical staff, before implementation and during transition)  They don’t like transitions. Some of them don’t like change. They like to keep that piece of paper (clerical staff, before implementation and during transition)  They’re more comfortable writing instead of typing (clerical staff, before implementation and during transition)  The older ones [physicians], forget it (clerical staff, before implementation and during transition)  Some… [like to] just flip through the pages [of the paper chart] and get what they want, you know? (clerical staff, before implementation and during transition)  You’ll just have to pray they do it. Some are doing it [using the computer] more than others (nurses, before implementation and during transition)  Right now having one foot in and one foot out, how many times do we look in the chart and say...[a medication] wasn’t documented in the computer because…somebody didn’t have time, or somebody didn’t know how to do it (nurses, before implementation and during transition)  And some [physicians] will be very, very bad (nurses, before implementation and during transition)  And the very, very bad ones are going to have to get very, very good real quick (nurses, before implementation and during transition)  If [physicians] are in the chart and they haven’t finished their note, I can’t update their med list (nurses/clerical, after implementation)
Work flow	You spend so much time [now] splitting charts and repairing charts, getting them together, filing them, trying to find room for them (clerical staff, before implementation and during transition)  Everybody was nervous about [the EHR for referrals], but then when we started doing it, we all loved it (clerical staff, before implementation and during transition)  Once you start doing [computer referrals], it just gets easier as you do it (clerical staff, before implementation and during transition)  It will free up a lot of the girls from finding the charts which are always missing…it’s always right there on the computer (nurse’s aides, before implementation and during transition)  I think they [the patients] might like it…because if…they can’t find the chart, they complain… (nurse’s aides, before implementation and during transition)  It’s more accessible for the secretary (nurse’s aides, before implementation and during transition)  We’ll always have the record…and we will no longer have to worry…they can’t find it or people taking it out… (nurses, before implementation and during transition)  I can just go into the EMR and say, “Oop, this person never had another pap smear”… and I just type out a letter and off it goes (nurses, before implementation and during transition)  I don’t have to pull charts anymore. I used to pull about a hundred charts at a time, review the chart, send out letters, track them every month. And now I can do it all by Logician. I’m one of the non believers that turned to a believer (nurses, before implementation and during transition)  Now I can do it [input data] in between patients because I don’t have to worry about going and pulling charts, getting the charts back to medical records one more time that the chart could be lost because I may have kept them in my spot for days, you know? So it’s been working out really good for me (nurses, before implementation and during transition)  It’s going to save hours in the day, hours (nurses, before implementation and during transition phases)  There are fewer missing charts. Referrals it’s great for. It saves a lot of time. [Physician notes are] more legible. That’s a major thing (nurses/clerical, after implementation)  I personally think it’s wonderful. I think it’s a quick flow. We can get them [patients] right in [the rooms] (nurses/clerical, after implementation)  [for legal correspondence] Oh my gosh, all I have to do is print everything up…. You can fax it, send it, whatever (nurses/clerical, after implementation)	With slow laptops…write the vitals on scraps of paper… (nurses/clerical, after implementation)  The only thing is when the computer goes down (nurses/clerical, after implementation)  [Double entry] labs in the computer and lab slips in docs’ boxes, which then have to be filed in the chart. Also have to file MRIs and x-rays. Double the work (nurses/clerical, after implementation)
Patient safety/confidentiality/transparency	It will definitely make all of us more accountable if the patient has access to their records (nurses, before implementation and during transition)  I think patients are going to become more knowledgeable (nurses, before implementation and during transition)  It makes a patient responsible for knowing what their medications [and other medical concerns] are (nurses/clerical, after implementation)  I think having our patients being curious about what’s in their chart and what’s going on about them—it’s good. A lot of the doctors are printing off their last note and giving it to the patient…and it makes…them responsible (nurses/clerical, after implementation)  I had patients that are forging prescriptions, and so I write that in the computer…. The doctor knows it. And I tell the patient. You know, we know that your pharmacy called us, and you have copied prescriptions. That’s a felony… (nurses/clerical, after implementation)  I think parents looking at the computer is a great thing (nurses/clerical, after implementation)	But is that [patient access to their EHR] really a good thing? I mean you know when they put like a patient is noncompliant…or mildly obese (nurses, before implementation and during transition)  You’re asking me if I’m using drugs, and where are you putting this information? I mean where is it going? Who can see it? Who’s the father of my baby? Who’s going to get that information? (nurses, before implementation and during transition)  My only concern is confidentiality issues (nurse’s aides, before implementation and during transition)  You have to sign into it and sign out…because you don’t want to leave a chart open in there and anybody can go into the chart… (nurse’s aides, before implementation and during transition)  I would think people [patients] would wonder who’s going to have access to this in the hospital… (nurses, before implementation and during transition phases)  I have reservations about [putting in patient information]…. Like when they put in things about, you know, seeking drugs or… (nurses/clerical, after implementation)  It’s fine [looking at the computer] if it’s their own chart (nurses/clerical, after implementation)
Relationship		I’m afraid that when the computer is in the room, the doctor is going to be asking questions and just typing whatever the patient says. And is the doctor actually going to physically touch the patient or look at the patient anymore? (nurses, before implementation and during transition)
Other	We’re not breaking computers. We’re not losing keyboards (nurses/clerical, after implementation)  I think it’s a great thing that they’re going in there to do something. They should put something educational on there for them (nurses/clerical, after implementation)	We find kids on the Internet all the time (nurses/clerical, after implementation)  We tell them to get off, but the parents just allow them to get on the computer, and we have many adults we find on the computers (nurses/clerical, after implementation)

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Table 6.

Stopwatch Measurements Before and After Implementation of EHR

Variable	Paper Before (After)	Computer Before (After)	PValue
EHR=electronic health record; VAS=visual analog scale.
Total time, min	25.6 (14.9)	23.8 (14.4)	.45
Time spent out of room, min	5.9 (7.0)	3.2 (5.0)	.01
Physician left the room,%	53.5	59.7	.44
Time spent on computer/looking or writing in chart, min	2.8 (3.4)	4.4 (3.0)	.002
Physician talks while taking notes, %	92	97	.21
Structuring of visit by documentation system (VAS)	30.7 (24.2)	30.9 (20.5)	.96
Role of the documentation system (VAS)	21.5 (19.3)	33.8 (22.8)	.001

Additional Files

Tables

Supplemental Appendixes 1-2

Supplemental Appendix 1. Observation Protocol; Supplemental Appendix 2. Patient Interview Guide: An Ethnographic Investigation into the Impact of Information Technology in a Family Medicine Clinical Practice

Files in this Data Supplement:

Supplemental data: Appendixes 1-2 - PDF file, 6 pages
The Article in Brief

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

Renee R. Shield , and colleagues

Background Although there is considerable interest in implementation of electronic health records (EHRs), there is limited information about how doctors, staff, and patients adapt to the implementation process. This study examines the effects of EHR implementation on a medical practice, particularly on doctor-patient communication and behaviors and patients� responses.

What This Study Found During the implementation of an electronic health record, strong patient trust in the doctor-patient relationship was maintained and work flow improved. The role of the computer and the choice of where in the room it was placed had a significant effect on the doctor-patient interaction.

Implications

Gradual implementation of an electronic health record may help support the development of beneficial adaptations by doctors and staff, while maintaining positive patient-doctor relationships and fostering the sharing of medical information.