Article Figures & Data
Tables
Participants (n) Administrators Leaders/managers 18 Information technology professionals and leaders 13 Staff 4 Total 35 Physicians Physicians in practice (attendings, private practice physicians) 26 Physicians in training (interns, residents) 17 Physician leaders 4 Total 47 - Table 2. Physician and Administrator Comments from Interviews and Focus Groups Regarding the Need to Change Medical Practice to Accommodate Electronic Health Record Implementation
Representative Physician Comments Representative Administrator Comments Need to change practice style “I do almost all of my documentation and things before or after I leave the patient's room.”
“I would not document the majority of my patients as I saw them. I would leave everything ‘til the end. Once patients are out by 5 or 5:30, then I sit down and do all my paperwork. And I get home by 7:30. I'm dead and hungry and cranky.”
“It's far faster to dictate than it is to type.”
“…just the transition of going from a paper record to an electronic medical record-change. Some of our physicians, in that practice, some of them are a little bit older and you know it's not like they're 30 or 40 that had computers as part of their schooling and training.”
“And some people are better typists than others—that comes into play.”
“They've done it for all these years, it works. They know, practices would know, ‘well if I put the chart on this side of the desk it means blah, and if these were this kind, I would put them over here, and these charts I put over here on the cart.’ And over time the practice knew what all of that meant. Well if you're in electronic world, you don't have this side of the desk and the cart.”
Threat to professionalism “I've really gotten to the point that I don't do much in the patient room because what you find, you're sitting there struggling to write a prescription and the patient's looking at you like, ‘What's wrong with you?’ You know, I mean, you really, I think, lose a lot of credibility when you're struggling or getting an order written and most people are pretty understanding yet. At the same time you feel like you're not competent.”
“You become a data entry person. And I think we haven't come to terms with the fact that we have to insulate that thought process of the docs better than we are doing it.”
“We're trying to standardize the way that they conduct their patient visit because they have to go through it screen by screen in the order that we offer them. That's not something physicians are used to.”
“They're a little embarrassed, quite frankly, by some of these documents that look like the computer examines the patient, this is the computer's opinion of what's there. Their medical judgment and you know, it's an ego thing. I mean we all have our style. We all like the way to do certain things. That gets lost in the shuffle.”
“It's very hard on the physicians, not only because we're now making them data entry people but the sequence of how they examine people, how they traditionally interviewed you and assessed you, could be disrupted because the EMR goes in one linear step. It's a linear thing.”
Shift of expertise “Attendings have absolutely . . no idea what they're doing with [the EHR].”
“Some of it's being accessible, some of it's being efficient with your time and not keeping your patients waiting, and you know the whole package is what medical care to me is and I think the EMR can flip it. It flips that relationship.”
“I think we have a unique perspective on [the EHR] as opposed to everyone else in the hospital … I feel that from an [EHR] knowledge standpoint, the interns are the ones in the hospital that are most knowledgeable.”
“I actually showed one of the attendings a shortcut that I, I said, ‘You know, in our EMR stuff we can do this, this.’ He said, ‘Oh my gosh I've been using it for 4 years and I never knew that.’”
“And most of the docs, they coach each other. They're pretty good at it.”
“They sit there and say, ‘Well how am I supposed to remember everything I'm going to do if I don't have something to write it on?’ Well if you're really younger generation, you're used to working on the computer and you're used to doing that and then walk and talk to them and then … ‘oh ok,’ and go back and you're not uncomfortable with that.”
Changed interactions with patients “Even if you can position it so you're sort of looking at the screen and the patient, I think there's always the feeling that the patient is going, ‘Are they really thinking about what's on the computer or… .’ It's just a different relationship. And so I think that concerns almost every physician I've talked to.”
“I think if you don't talk and you're just on there and you're typing and you're looking in data and you're sort of internally processing all this stuff and the patients over here and they're not just watching you do that, I think they feel really alienated. Now, if you're on here and you're saying, ‘ok, well lets look at your old labs here … OK, I can see your cholesterol was … this … and oh I see we started you on this new drug and … how've you been doing on that drug?”
“You usually have a doc with their face buried in the computer because they're dealing with this new thing that they're not used to and so the patient's like, ‘Hey I'm over here’ kind of thing.”
“There are probably 1 or 2 having a really hard time where they still can't find that groove, that ‘sweet spot’ between interacting with the patient and looking on the computer. And I think they are at a disadvantage because having it right there in the room and dynamically looking at it … I mean a lot of discussions that go on are ‘well, my patient[s] feel alienated if I'm looking at my computer screen.’”
Impact on medical education “We really effectively completely learned 3 systems, outpatient, inpatient [EHR], and then whatever the old one was called within those few months. So in addition to being brand new doctors, it's a lot.”
“Oh, nobody thinks anymore. Everybody stops thinking, I mean, I think you just end up becoming automated. You just sort of go, OK did I go down my list? Did I fill all my little criteria? OK, did I do this? And you're not independently thinking anymore, you're sort of just thinking toward the computer.”
“When the student hasn't been brought up to speed with [the EMR] or doesn't have a log on, then the student's involvement is really diminished in the clinic[,] also because they can't really do their own notes or documentation and we lose a teaching opportunity there as well.”
“Some of these young new nurses have never seen a paper chart.”
Impact on clinical practice “These aren't necessarily items that can be created in smart phrases. You need to understand who's making decisions … who's able to make decisions for the patient, where is his family, who can I contact, his other providers who are providing psychiatric care. It's extremely complicated.”
“So there are some levels of detail with a family history, with a medical history where maybe the problems aren't in the available possibilities and so it become[s] a question of you look 3 or 4 times under different things and then you can't find the phrase anywhere so do you type “other” and then go and do free text over or do you just not document that problem?”
“Even though physicians are very busy, they want to give their patients time, they want to connect with them and it's difficult to do that when you're typing on a computer.”
“They've got so many issues, and they're all very complex… . They didn't become a primary care doctor and take this 30-hour-a-week job, so that they could work 50.”
EHR, electronic health record; EMR, electronic medical record.
