An Ethnographic Study of Electronic Health Record (EHR) Use in Solo/Small Group Primary Care Practices in the United States

Electronic health records (EHRs) are described as one strategy to: 1) improve health care quality; 2) prevent medical errors; 3) reduce health care costs; 4) increase administrative efficiencies; 5) decrease paperwork; 6) expand access to affordable care; and 7) bring public health benefits through tracking and early detection of disease (Health and Human Services, n.d.). This dissertation uses sociological inquiry to address most of these perceived benefits. Objective: To better understand the impact EHRs have on the structures, institutions, and practice of primary care as it relates to cost, quality of care, workflow, time, and provider-patient interactions using a grounded approach from both theoretical and practical standpoints. The human factor of this nonhuman technology is explored as is relates to the practice of health care, specifically as it relates to cost and quality and efficiency.Research Methods: Ethnographic analysis of 11 Case studies of early-adopter solo and small group primary care practices using an EHR (including ethnographic observations, semi-structured interviews, surveys, and review of practice financial and productivity records) funded by the Commonwealth Foundation and unfunded 5 supplemental in-depth interviews of primary care providers using an EHR in various practice settings. Findings: The macro-level findings are, when using an EHR: 1) the biomedical paradigm is reproduced and formalized; 2) provider power and autonomy are reproduced and formalized; and 3) the reimbursement structure is exploited. The mezzo-level findings are, when using an EHR: 1) health care providers' work remains relatively unchanged in type and content; 2) how the EHR is used is more important than that it is used; 3) all members of a practice are critical in the use of the EHR; 4) the EHR is used primarily for profit; 5) the EHR is secondarily used for efficiency; 5) quality-oriented features are often unused. The micro-level findings are, when using an EHR: 1) using the computer during an encounter strains interaction with patients; 2) management of information is the basic use of the EHR; 3) workflow patterns change; and 4) there are increased stages of the medical encounter. Policy implications are discussed