Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis William Ventres, MD, MA

Co-Authors – Thanks!! Sarah Kooienga, Nancy Vuckovic, Ryan Marlin, Peggy Nygren, and Valerie Stewart

Study Participants – Thanks!! 52 Logician 24

Study Participants – Thanks!! Four Primary Care Offices

Editor and Reviewers – Thanks!! Ben Crabtree, PhD Anonymous reviewers

Joint AAFP/AAFP-F Grant Program — Thanks!!

Research Committee – Thanks!!

Goals for Today Review paper: Explore your questions Methods Results and Conclusions Explore your questions

Goals for Today Review paper: Explore your questions Methods Questions Results and Conclusions Explore your questions Questions

Ethnography ?

Ethnography – Definition 1 Qualitative Research

Ethnography – Definition 2 Disciplined study of how the world appears to people who see, listen, talk, think, and act in way distinct and different from the investigator

Ethnography – Definition 3 Describing a culture

Ethnography – Definition 4 Learning from people

Ethnography

Ethnography – Tasks Observe what people do Investigate what people say they think, believe, or do Interpret what these people actually think and believe

ETHNOGRAPHIC RESEARCH PLAN Step 1. Define a research question Step 2: Interview informants Step 3. Participant observation Step 4. Analyze observations Step 5. Report results Ventres W, Frankel R. Ethnography: A stepwise approach for primary care researchers. Family Medicine. 1996;4:136-141.

RESEARCH QUESTION How do EHRs affect the encounters between physicians and their patients?

INTERVIEW INFORMANTS

Focus Group 5 Individual 75 INTERVIEW INFORMANTS Focus Group 5 Individual 75

PARTICIPANT OBSERVATION A long period of time Intense social interaction In the milieu of the informant Data collected

What do observers do? Interpret Hang out Observe Document The “story” of the informants

PARTICIPANT OBSERVATION 80 hours 29 encounters

ANALYZE OBSERVATIONS

Data Sources

Data Sources

REPORTING RESULTS Entering the cultural scene of the investigation and communicating the meanings discovered.

REPORT RESULTS

Movie Time

Results “Many mistakenly see the EHR as an updated version of the paper chart, but …

Results …behind the superficial resemblance of tabs, notes, and flow sheets is a complicated system of functions and human notions about its use in the medical setting.”

Clinician Styles High Person/ Clinician Relationship Control Biomedical Biopsychosocial Focused Informational Managerial Interpersonal Ventres W, et al. Clinician style and examination room computers: A video ethnography. Family Medicine 2005; 37(4): 276-281.

Time spent looking at ERC Actions Clinician Uses ERC Mobility Faces patient at ERC Talks gazing at ERC ERC Guides Questions Time spent looking at ERC Informational √ Managerial Interpersonal ERC = Exam Room Computer

Time spent looking at ERC Clinician Uses ERC Mobility Faces patient at ERC Talks gazing at ERC ERC Guides Questions Time spent looking at ERC Informational 42.9 36.9 Managerial 30.5 28.9 Interpersonal 24.4 23.1

Monitor Position #1 Frankel R, et al. Effects of exam-room computing on clinician–patient communication: A longitudinal qualitative study. J Gen Intern Med. 2005; 20(8): 677–682.

Monitor Position #2

EHR Notes: Cookie-cutter There are two features of EMR that contribute the increased length and decreased effectiveness of notes. The first is the automatic insertion of prion-like phrases into notes. Hirschtick RE. Copy-and-paste. JAMA. 2006;295(20):2335-2336.

EHR Notes: Cookie-cutter The patient complains that The patient has been transferred here from St. Eligious.

EHR Notes: Copy-and-Paste The copy-and paste command allows one day’s note to be copied and used as a template for the next day’s note.

Conclusions EHR 3rd party to a conversation EHRs influence multiple cognitive and social dimensions of clinical encounters EHRs produce intended and unintended consequences EHR effects will NOT be automatically and universally positive

G’Day Doc. Paul Hartigan.

Conclusion Or not. Electronic Health Records can present an opportunity for physicians to improve their patient-centered skills… Or not.

Questions Can EHR software be designed to facilitate communication between physicians and patients? What resources are available to help physicians best integrate this technology into their style of patient care as they transition to the use of the EHR? Are there examples of best practices—standard procedures or phrases—that physicians can use to assist patients as they are introduced to the EHR? When and how should medical educators introduce the EHR to students and residents, especially given the current emphasis on training patient-centered interviewing skills? What responsibilities do vendors or health care systems have to train physicians about the relational aspects of the EHR?

Tips Use mobile computer monitors Learn to type Integrate typing around patients’ needs Reserve templates for documentation Separate routine data entry/health care maintenance from patient encounters Ventres W, Kooienga S, Marlin R. EHRs in the exam room: Tips on patient-centered care. Fam Pract Management. 2006; 3:46-48.

Tips Start with your patients’ concerns Tell your patients what you are doing as you are doing it Point to the screen Encourage patients’ participation in building their charts Look at your patients

Don’t abdicate your responsibility to teach Tips Don’t abdicate your responsibility to teach

If you forget everything else: It’s not about the computer… …it’s about the patient!!

Thank you! Questions? Concerns? Problems? Stories?

Email me… Bill Ventres william.b.ventres@co.multnomah.or.us