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

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

3. Study Participants – Thanks!!52
Logician 24

4. Study Participants – Thanks!!
Four Primary Care Offices

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

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

7. Research Committee – Thanks!!

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

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

10. Ethnography ?

11. Ethnography – Definition 1
Qualitative Research

12. 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

13. Ethnography – Definition 3
Describing a culture

14. Ethnography – Definition 4
Learning from people

15. Ethnography

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

17. 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:

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

19. INTERVIEW INFORMANTS

20. Focus Group 5 Individual 75
INTERVIEW INFORMANTS
Focus
Group 5
Individual 75

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

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

23. PARTICIPANT OBSERVATION
80 hours
29 encounters

24. ANALYZE OBSERVATIONS

25. Data Sources

26. Data Sources

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

28. REPORT RESULTS

29. Movie Time

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

32. 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.”

35. 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):

36. 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

37. 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

38. 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.

39. Monitor Position #2

40. 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):

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

42. 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.

43. 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

44. G’Day Doc. Paul Hartigan.

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

49. 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?

50. 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.

51. 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

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

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

54. Thank you!
Questions?
Concerns?
Problems?
Stories?

55. me…
Bill Ventres