The EMR was not intuitive to clinical work flow

On-site support was lacking

The practice EMR environment was only available at work and there was no time to use it

“[T]he training was too long, very unhelpful, we couldn’t follow along with the scenarios”

“[The training should be] more applied by focusing on a patient scenario, to facilitate learning how to use the system safely and efficiently during a patient visit”

“[P]eople were not doing the same things and got off track ... the trainer didn’t know how to find things either”

“[It would help] having one IT support person to talk to, getting trainers who know the system, specifically medical providers who use the system”

System performance was poor; prone to freezing, crashing, and locking, and was generally slow

There were perceived effects on safety (no access to the chart); contributed to workarounds (eg, reverting to paper processes)

“I’m with a patient and trying to either do a lab or something and it just freezes. And then you’re sitting there, you’re done your encounter, you just need to give them their labs and it freezes .... That’s been happening a lot”

Flow of the EMR was awkward, time consuming, and not intuitive

Needed to look in several places for information, in addition to paper chart

Laboratory results scanned in; needed to open several documents to find a single result

Looking for information diverted attention from the patient

The EMR was not user-friendly: unintuitive drop-down menus and ICD-9 terminology

There was no clear plan for transition from paper to EMR; no time to enter data to facilitate chart close out

The EMR has potential for managing information and encouraging best practices

There was a lack of access of certain features (eg, creating flow sheets) owing to centrally managed database was frustrating

“It just looks bad when you’re clicking, ‘Oh not this one, oh not this one, not this one,’ when the patient’s sitting right there”

“It is so frustrating that you ... need to go in about 5 different fields and it still doesn’t accept it [appendectomy in 2007]. And then you have to put whatever and type a note under it to say, this is what I mean. And as a result of that, we all just don’t do it”

“Yesterday … I literally sat there with the patient playing thesaurus; how many words can there be for kidney, kidney disease, or whatever it was?”

Multiple communication channels were affected: provider to patient, provider to provider, and preceptor to resident

The EMR was implicated as a distraction from the patient, particularly for learners; faculty thought learners sometimes used the EMR as a crutch

The EMR was recognized as a tool and there was a need to mitigate its potential intrusion into the encounter

There was decreased face-to-face communication with the residents, and between faculty, owing to tools such as tasks and messages

There was recognition that the skill set to teach learners communication skills with the EMR is evolving from the past when paper charts were the norm

“I think the most positive part of it was the patient support. They were quite understanding that it’s a new system and it’ll take us a while to learn how to use it properly”

“I don’t think it will ever be acceptable to people to not be listened to no matter how old you are. It’ll be more acceptable to have electronics in the room and to be using them”

“And so that’s one of the things we have to teach them is, it’s a tool and it shouldn’t be replacing you as a person interacting with this patient”

Real-time continuity of information was possible (eg, shared documentation of previous treatment), which facilitated continuity of care through follow-up reminders for tests or consultations; this was identified as an important benefit of the EMR

The ability to future-date tasks and assign tasks to others or groups (eg, primary care assistants) was noted as a strong asset for continuity and quality of care

Legibility of notes was identified as a benefit (continuity of information)

There was reassurance from knowing information was up to date and accurate; this was recognized as an opportunity for increased efficiency

“You’re working on a patient and another patient calls you up and wants to know something. You know what, I’ll [take the] call, well, immediately .... [W]hat’s really nice is you don’t have to run around for the charts”

“I have one patient who’s set up until 2014; she’s diagnosed with something at CancerCare [Manitoba] and needs a series of stuff .... So I had tasked [the physician] to remember to fill out these particular requisitions”

“I’m calling the pharmacy a lot less to find out what people’s prescriptions are”