Implementing an electronic medical record in a family medicine practice: communication, decision making, and conflict.

PURPOSE: Electronic medical record (EMR) systems offer substantial opportunities to organize and manage clinical data in ways that can potentially improve preventive health care, the management of chronic illness, and the financial health of primary care practices. The functionality of EMRs as implemented, however, can vary substantially from that envisaged by their designers and even from those who purchase the programs. The purpose of this study was to explore how unique aspects of a family medicine office culture affect the initial implementation of an EMR. METHODS: As part of a larger study, we conducted a qualitative case study of a private family medicine practice that had recently purchased and implemented an EMR. We collected data using participant observation, in-depth interviews, and key informant interviews. After the initial data collection, we shared our observations with practice members and returned 1 year later to collect additional data. RESULTS: Dysfunctional communication patterns, the distribution of formal and informal decision-making power, and internal conflicts limited the effective implementation and use of the EMR. The implementation and use of the EMR made tracking and monitoring of preventive health and chronic illness unwieldy and offered little or no improvement when compared with paper charts. CONCLUSIONS: Implementing an EMR without an understanding of the systemic effects and communication and the decision-making processes within an office practice and without methods for bringing to the surface and addressing conflicts limits the opportunities for improved care offered by EMRs. Understanding how these common issues manifest within unique practice settings can enhance the effective implementation and use of EMRs

How Complexity Science Can Inform a Reflective Process for Improvement in Primary Care Practices.

BACKGROUND: Quality improvement processes have sometimes met with limited success in small, independent primary care settings. The theoretical framework for these processes uses an implied understanding of organizations as predictable with potentially controllable components. However, most organizations are not accurately described using this framework. Complexity science provides a better fit for understanding small primary care practices. METHODS: The Multimethod Assessment Process (MAP)/Reflective Adaptive Process (RAP) is informed by complexity science. This process was developed in a series of studies designed to understand and improve primary care practice. A case example illustrates the application and impact of the MAP/RAP process. RESULTS: Guiding principles for a reflective change process include the following: an understanding of practices\u27 vision and mission is useful in guiding change, learning and reflection helps organizations adapt to and plan change, tension and discomfort are essential and normal during change, and diverse perspectives foster adaptability and new insights for positive change. DISCUSSION: A reflective change process that treats organizations as complex adaptive systems may help practices make sustainable improvements