title: Gradual electronic health record implementation: new insights on physician and patient adaptation.
abstract: OBJECTIVE
  Although there is significant interest in implementation of electronic health records (EHRs), limited data have been published in the United States about how physicians, staff, and patients adapt to this implementation process. The purpose of this research was to examine the effects of EHR implementation, especially regarding physician-patient communication and behaviors and patients' responses.
  
  
  METHODS
  We undertook a 22-month, triangulation design, mixed methods study of gradual EHR implementation in a residency-based family medicine outpatient center. Data collection included participant observation and time measurements of 170 clinical encounters, patient exit interviews, focus groups with nurses, nurse's aides, and office staff, and unstructured observations and interviews with nursing staff and physicians. Analysis involved iterative immersion-crystallization discussion and searches for alternate hypotheses.
  
  
  RESULTS
  Patient trust in the physician and security in the physician-patient relationship appeared to override most patients' concerns about information technology. Overall, staff concerns about potential deleterious consequences of EHR implementation were dispelled, positive anticipated outcomes were realized, and unexpected benefits were found. Physicians appeared to become comfortable with the "third actor" in the room, and nursing and office staff resistance to EHR implementation was ameliorated with improved work efficiencies. Unexpected advantages included just-in-time improvements and decreased physician time out of the examination room.
  
  
  CONCLUSIONS
  Strong patient trust in the physician-patient relationship was maintained and work flow improved with EHR implementation. Gradual EHR implementation may help support the development of beneficial physician and staff adaptations, while maintaining positive patient-physician relationships and fostering the sharing of medical information.
authors.affiliation: Department of Family Medicine, Warren Alpert Medical School of Brown University and Memorial Hospital of Rhode Island, Pawtucket, Rhode Island, USA. renee_shield@brown.edu
authors.forename: Renée R
authors.initials: RR
authors.lastname: Shield
authors.forename: Roberta E
authors.initials: RE
authors.lastname: Goldman
authors.forename: David A
authors.initials: DA
authors.lastname: Anthony
authors.forename: Nina
authors.initials: N
authors.lastname: Wang
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Doyle
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Borkan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D001292:Attitude to Computers; D005260:Female; D017144:Focus Groups; D006801:Humans; D008297:Male; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data*; D008875:Middle Aged; D010045:Outpatients / Q000706:statistics & numerical data; D010147:Pain Measurement; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D010817:Physician-Patient Relations; D010820:Physicians / Q000706:statistics & numerical data*; D011320:Primary Health Care; D036301:Qualitative Research; D012237:Rhode Island; D055815:Young Adult