Table 2.

A Selection of Quotes Per Theme

(1) PCPs describe the EHR as a medicine with side effects, for which they provide suggestions for improvements.2. So I think it increases the accuracy, I think it increases your real-time interpretation of data. Because you're doing it right then and there. You're not saying: I'll check it later, and then you forget, or, you know. So… I think it helps tremendously.
10. So, you know I think, ehm, it's an incredible tool with many flaws that make things hard, ehm, eh to sort of fully utilize it. Ehm, you know, I think the things that are … [exhales] most helpful for me. Ehm, so one is the ability to see other people's notes and to sort of easily sort through things.
12. Ehm, but I do think as a profession, we need to figure out ways to spend less time on the computer. Ehm and that's why I like these ideas of, you know, group message or group notes, whether dictation does some of it, or, you know, however we evolve to that, I think we have to, as a profession, figure out ways to spend the same amount of time with the patients, or slightly more time with the patients, but be doing eh, somebody else doing more of the documentation, or the computer doing the documentation, or pulling from somewhere and then this kind of decision support stuff, maybe being done by non-physicians.
13. I think it could become a really powerful tool, but I just don't think we're there yet.
(2) A digitally shared record raises ethical questions related to autonomy and trust.Autonomy vs. Paternalism
2. I think that's a mixed bag. Eh, what if you don't like the diagnosis of obesity? What if you don't like the diagnosis of anxiety? But they happen to be real diagnoses. Ehm, so I think that ehm … I don't know, I think it's better the way it is now, where you bring me the changes and maybe you and I need to have a talk about what obesity means, you know. So …
3. Which can happen, which does happen I would say a lot, like, people see their labs before I've replied to them and then they get very nervous about some, like, very stupid lab abnormality that is like, completely irrelevant, and then they're, you know, they're e-mailing me or calling me like: oh my gosh, I saw this, what does this mean, and they're freaking out. So, that's the only I think downside.
9. Ah … I think there's advantages and disadvantages to that and I think the devil's in the details. Ehm … there are times that a p_, I can envision a time where patients would ask that something was changed or added, that actually, probably, is: oh, that's really helpful, you know. “Oh, I actually had ehm, this surgery on my knee in 1998 and it's not in my chart”, fine, that's easy, right? [ …] If somebody says: “take out all references to me using opioids” … I don't think that we should oblige that request if it's medically appropriately there. Ehm, so, I think if we develop a system where they could do a request to change … I think that's fine. Ehm, having them go in and just edit things without anybody knowing about their edits, sounds a little bit suspect.
1. I mean, it's hard to completely trust another provider to, you know. [ …] I look up patients beforehand, and it's the same thing when I admit them as inpatients. I, I'll go through their records and, some of it is objective data that I know is true, you know, if someone got certain labs that I know, then, that, those are reliable, but at the same time I'm also looking at other people's documentations, eh, or people's documentation and their notes, and then I'm really trusting the history that they got and people don't always get a history that I would think is acceptable. So, I think it, it introduces all sorts of bias, so … You know, and I've seen that happen especially when I was a resident, ehm, you know if you were busy, you would get a page from the emergency department saying that you were gonna get a patient. And, even before, even before someone called to tell you about them, you could go onto their chart and I would go onto the chart and read everything and look at like, the labs and imaging, and the history that I could, you know, whatever they had sorted writing, and sometimes based on that I would think of a diagnosis and then talk to the patient and realize it's actually a completely different story. Ehm, so I, I would be very, very hesitant to only treat someone based on the chart.
6. I had an interesting patient, brand new to me, last week, who was very suspicious of the electronic health record. And felt like: anybody can read it. Ehm, sometimes when I encounter that, eh, I do tell them that people lose their jobs for reading–and I've seen it happen–for reading a chart that they're, shouldn't have privy to. They get caught and they get fired. But, truth be told, I bet you not everybody is caught and fired. Ehm, so I kind of understand that.
7. I go through the medication list AGAIN, because some of my medical assistants don't go through them the way they should. And sometimes I use it anyway to go through, because even if the patient says they went through it, I can't remember what they're taking.
(3) Although use of the EHR often disturbs rapport with the patient, it can also support the patient-doctor interaction when it becomes an active part of the conversation.Disturbs Rapport
6. Oftentimes when I have that paper, in, in my physical interaction with the patient, I can be standing right next to the patient and looking at this paper together. And that never happens with the computer, there is always this distance between me and the patient when I'm working with the computer.
7. So some of my patients, are here for a lot of, psychosocial issues, and usually that does not lend itself well to typing on the computer. You need to be looking at them and talking to them and I scribble notes on paper and I actually do my notes later, that takes longer.
13. But then I feel like maybe, you know, I'm not making the eye contact with the patient that I want to. Ehm, even though I still try to be very conscientious to try and make as much eye contact as I can, I'm trying to, balancing kind of the, the burden of documentation, everything I have to do with the EHR in the course of the visit, with still trying to provide like the most personal care I can. So I think that they EHR does take away from that, you know, the ideal connection that you can make with a patient.
Coping Strategies
1. So sometimes when, you know, they come in and if I want to review their lab results then I'll actually point the screen towards them and show them all the results.
5. At that moment when I turn to the computer–that is actually when I start to engage the patient. Because I open up the screen to them and we have 22 inch monitors in every one of the rooms. And I show them often their latest labs, perhaps some diagnostic studies that were recently done, ehm, and then I begin to talk to them about what I would like to do at this point. I'm talking to them and at the same time I'm entering the orders, eh, and explaining to them why I am doing that.
(4) Minor theme: A shared record may cause care providers (and their relatives) to avoid seeking help for sensitive issues.5. Eh, depending on the patient. Some people, so … for my physician professors, ehm, those people I've had a longstanding rapport of and I'll release it to them. [ …] But there is still some judgment done, eh, I mean, so there are things that I will not put in a note assuming I have a longstanding relationship with the patient that I may be misconstrued by others, or really because we, I sit in the middle of this academic center and physicians have access, have full unfettered access to charts, I may withhold from the record.
6. Eh, a lot of my patients are faculty here. So this, so I'm, I'm very cautious about that. Eh, and I will have a larger definition of what's sensitive for our faculty. [ …] So, ehm, I do offer, if there is some material that they don't wanna have included in the EHR, I am willing to keep shadow charts. But we talk about the pros and cons of that [ …] This is also, you know, someone who is a spouse of a faculty member, prominent faculty member.
8. Like recently I had a health care provider, and she was very offended when my nurse asked her in the pre-test about a certain medication that showed up on her med list, and she said: “oh no, I don't take it, I don't take it”. So the MA [medical assistant] came to me before I went in, like I said, she warned me and she said: “I was doing med reconciliation, and patient said that she's not on this medication, but it showed that she just picked up a refill”. [ …] And then I finished everything and towards the end, coming up, and I said: “Eh, just so that you're aware that it's in your chart, which is the reason we're asking that, I wanna make sure so that I can take it out of your chart”. She said: “I don't want this information in my chart”.
  • EHR, electronic health record; PCPs, primary care physicians.