Implementation of a comprehensive electronic health record system within a patient-centered medical home: Practice changes and challenges

Background: A network of federally-qualified health centers in New York State implemented a comprehensive electronic health record (EHR) beginning in 2002, with development continuing during its transition to a patient-centered medical home in 2009. Objective/purpose: This study focuses on understanding EHR implementation and use, with a primary emphasis on implementation processes and resultant organizational changes. Methods: Within a larger mixed-methods study, qualitative open-ended interviews were conducted with physicians, nurses, behavioral health providers, administrators, practice managers and patient service representatives (n=33). Topics included implementation, practice changes, barriers, facilitators, and satisfaction. Transcripts and notes were coded and analyzed using pre-identified themes, as well as themes emerging from the data. Results: A diverse set of “champions,” largely practicing physicians, took substantial responsibility for developing the EHR with a focus on improving quality and patient-centeredness, and provided support to colleagues during EHR adoption. EHR implementation resulted in some challenges. Physicians noted a need for administrative time for completing patient records and responding to electronic communication. They expressed differing opinions regarding increased patient access to medical information, which was made available in an after-visit summary and online patient portal, noting the need to balance confidentiality with enhanced patient access. Despite these concerns, EHR implementation facilitated improvements in the quality and efficiency of care, particularly for highest risk patients with target conditions. Physician decision supports helped providers to structure the content of office visits, and the ease of provider-provider communication improved coordination of care for patients with complex conditions. Some patient inquiries were resolved through communication using the online patient portal, reducing the need for in-person visits. Discussion/conclusions: Full EHR adoption focusing on patient centeredness required strong leadership and multiple champions. EHR implementation created organizational challenges and changes, including the reallocation of staff time and responsibilities, yet resulted in opportunities for improved patient care and efficiencies.