On or Off the Record: The Physician Experience of the Transition to Electronic Health Record

I conducted longitudinal, ethnographic research into the clinician experience during the transition from a paper record system to an electronic health record (EHR) system. My study provides an empirical examination of the contexts, routines, local processes, and conflicts during significant organizational change. I examine these phenomena through the theoretical lenses of negotiated order, conflict, and culture. This is a multi-method case study of a networked ambulatory care group located in a primarily urban region in Northern California. The group is composed of two organizations working in partnership: a not-for-profit foundation providing management services and a for-profit medical group. The study situates the organization within the context and against the backdrop of both the healthcare and health information technology (HIT) industries. I conducted: (a) participant observation of doctors, nurse practitioners, support staff, IT personnel, and corporate management; (b) in-depth interviews with doctors regarding perceptions of EHR, (c) organizational surveys of doctors and staff; and (d) organizational data. I found that the cultures of the individual clinics within the networked group shape the ways in which clinicians experience and respond to implementation. This setting provides a cultural "tool kit" on which clinicians rely when identifying problems or managing conflict. This is true both in longstanding clinics with cultures that pre-date the formation of the larger network as well as in recently formed clinics with recently developed organizational cultures. I recommend administrators and clinicians understand and work with existing cultures when implementing EHR systems in order to better anticipate not only trouble and conflict but the consequences of how different cultures will manage and resolve them.