Implementing an Electronic Medical Record in a Family Medicine Practice: Communication, Decision Making, and Conflict

Abstract

PURPOSE Electronic medical record (EMR) systems offer substantial opportunities to organize and manage clinical data in ways that can potentially improve preventive health care, the management of chronic illness, and the fi nancial health of primary care practices. The functionality of EMRs as implemented, however, can vary substantially from that envisaged by their designers and even from those who purchase the programs. The purpose of this study was to explore how unique aspects of a family medicine offi ce culture affect the initial implementation of an EMR. METHODSAs part of a larger study, we conducted a qualitative case study of a private family medicine practice that had recently purchased and implemented an EMR. We collected data using participant observation, in-depth interviews, and key informant interviews. After the initial data collection, we shared our observations with practice members and returned 1 year later to collect additional data.RESULTS Dysfunctional communication patterns, the distribution of formal and informal decision-making power, and internal confl icts limited the effective implementation and use of the EMR. The implementation and use of the EMR made tracking and monitoring of preventive health and chronic illness unwieldy and offered little or no improvement when compared with paper charts.CONCLUSIONS Implementing an EMR without an understanding of the systemic effects and communication and the decision-making processes within an offi ce practice and without methods for bringing to the surface and addressing confl icts limits the opportunities for improved care offered by EMRs. Understanding how these common issues manifest within unique practice settings can enhance the effective implementation and use of EMRs. INTRODUCTIONB oth the Institute of Medicine and the Future of Family Medicine project have recommended the use of information technologies and electronic medical record (EMR) systems as tools for improving the quality of care 1 and patient safety. 2,3 Recent research has shown that information technologies can reduce medication errors, 4 improve adherence to clinical practice guidelines, 5 and improve the delivery of preventive health services, 6 thereby potentially improving health outcomes for patients. 7 In addition, using an EMR that includes electronic prescribing as well as electronic charting offers substantial fi nancial benefi ts to primary care organizations and the health system as a whole. 8 Even so, relatively few primary care practices use EMRs. 9 Reasons for not adopting EMRs may include the temporary loss of revenue associated with EMR implementation, 8 physician perception that EMRs negatively affect workfl ow, and concerns about patient privacy. 9 Even in settings where clinicians are committed to EMRs, implementation requires skilled users and a commitment to making the EMR an integral part of the 10 Without these personal and institutional commitments to full implementation, EMRs may actually represent a net fi nancial drain on primary care pr...

The Medical Home: Growing Evidence to Support a New Approach to Primary Care

“…101 A qualitative study of family medicine practices suggests that approximately a year after implementation, practices with electronic records initiate but struggle with effective tracking of clinical outcomes data. 102 At 5 years, practices with electronic records document more frequent testing of glycosylated hemoglobins and lipid levels but do not achieve better control. 103 High quality primary care groups find having an electronic medical record a useful tool but not essential to meeting guidelines.…”

Do electronic medical record (EMR) demonstrations change attitudes, knowledge, skills or needs?

“…1 Both the Future of Family Medicine Project and the Institute of Medicine recommend using EMR technology to improve patient care quality in primary care settings. [2][3][4] There is a national momentum in family medicine and primary care in the USA towards making the transition to EMRs. In a qualitative study, Crosson et al explored how the unique aspects of a family medicine office culture affect the initial implementation of an EMR, and concluded that future research should test implementation strategies that can improve existing communication patterns, relationships and decision-making processes.…”

Barriers to ambulatory EHR: who are 'imminent adopters' and how do they differ from other physicians?

“…20,24 Other previously identified barriers to EHR adoption include a disruption to the office workflow, lack of training and knowledge, discomfort with the use of computers, and a perceived shift in the doctor-patient relationship. 19,21,[25][26][27] Recent evidence also suggests that the large number of EHR products in the marketplace makes it difficult, especially for smaller practices, to identify which vendor best meets their needs and will be in business for future technical support that will be needed. 28 To overcome some of these barriers, numerous organisations, including the US Federal government, have begun to incentivise EHR adoption among physicians.…”