Physicians, patients, and the electronic health record: an ethnographic analysis.

PURPOSE Little is known about the effects of the electronic health record (EHR) on physician-patient encounters. The objectives of this study were to identify the factors that infl uence the manner by which physicians use the EHR with patients. METHODS This ethnographic study included 4 qualitative components: 80 hours of participant observation in 4 primary care offi ces in the Pacifi c Northwest; indi- vidual interviews with 52 patients, 12 offi ce staff members, 23 physicians, and 1 nurse-practitioner; videotaped reviews of 29 clinical encounters; and 5 focus- group interviews with physicians and computer advocates. The main outcome measures were factors that infl uence how physicians use the EHR. Researchers qualitatively derived these factors through serial reviews of data. RESULTS This study identifi ed 14 factors that infl uence how EHRs are used and perceived in medical practice today. These factors were categorized into 4 the- matic domains: (1) spatial—effect of the physical presence and location of EHRs on interactions between physicians and patients; (2) relational—perceptions of physicians and patients about the EHR and how those perceptions affected its use; (3) educational—issues of developing physicians' profi ciency with and improv- ing patients' understandings about EHR use; and (4) structural—institutional and technological forces that infl uence how physicians perceived their use of EHR. CONCLUSIONS This study found that the introduction of EHRs into practice infl u- ences multiple cognitive and social dimensions of the clinical encounter. It brings into focus important questions that through further inquiry can determine how to make best use of the EHR to enhance therapeutic relationships.