Prescription writing work flow was very cumbersome

Drug interaction checking was too sensitive and sometimes not clinically relevant, and it could not be adjusted or turned off; considerable frustration was expressed

Clinical decision support systems were lacking; the EMR’s potential to support practice was recognized

“[I]f the person comes in, and they’re on a dozen meds and they say, ‘I need them all refilled today’ ... I warn them ahead of time now and say, ‘This is going to take 15 minutes’”

“I’ll ask them specifically about their parking: ‘Where are you parked and how much time [do] you have?’”

Workarounds were frequently mentioned as a source of frustration, associated with the cumbersome nature of EMR functionality

“The prescription piece [is] not user friendly .... I still write [paper] prescriptions out of sheer frustration sometimes. Sorry, I do”

“I would just find some kind of a workaround that I could get that patient out the door without pulling my hair out”

The EMR typically increased time required for certain processes associated with system performance and clinical work flow

The EMR saved time—less frequently noted

“[T]he process to input someone’s family history literally now can take 20 to 25 minutes because each family member with each of their medical problems has to be entered individually”

Blurring of clinical and administrative processes changed the scope of the work (eg, providers doing work previously done by administrative staff, such as preparing requisitions, generating letters)

The volume of information available enabled providers to address more issues at a visit; participants were challenged to focus the scope of a visit, learners more so

Filtering information became crucial and was more challenging for learners

“I just think it’s a question of learning how to make sure that you don’t [do] ... work that could be done by someone else .... I think it does slow you down ... how much work I do that someone else could be doing is within my control. So it’s a question of learning it and, you know, teamwork”

The ability to simultaneously view the chart and listen to and view the resident-patient encounter improved efficiency and effectiveness of postencounter debriefs and review of work

There was a need to augment teaching about communication and rapport building; the EMR was identified as a new third party to the patient-provider relationship

Some faculty preceptors were so busy learning the EMR they did not think they had maintained usual levels of clinical teaching

Faculty at the site with more EMR experience struggled with how best to use and share certain tools with learners, (eg, checklists and macros); concern was expressed that these could impede learning and assessment

“The notes are done quickly. You review them quickly, get them more quickly back [to the residents], and move on and it’s more efficient that way”

“I think having an EMR in the teaching clinic is crucial because I think that a huge learning objective is how to use an EMR .... And even there’s some teaching opportunities, huge teaching opportunities, about how to maintain the doctor-patient relationship when the EMR is there and how to not let the EMR detract from that because it can”