Table 5.

Factors Contributing to the Value-Added of GEM

Theme	Practice A	Practice B	Practice C
Level of integration	"The whole thing when we bought this particular program [EHR name], they told us well the next version [program name] will be fully integrated. That's I don't know how many versions ago, and it's not, and it never will be as far as I can tell... I told the [researchers from another study] if you just get [the vendor] to write a little subroutine to pull this stuff out so it was actually in the system, I think we would use it every time we did a lipid panel on somebody. But trying to get the stuff you guys do into these commercial vendors software is difficult." (Provider 1)	"Well, we've used the [EHR modules] with the patient-entered questionnaire since 2003. And so the GEM was more like a modification of the same program... Technically, the only challenges that we had was in 2005 the computer vendor could not integrate all the questions that came out of [the EHR modules] into the computer vendor's software as part of the HPI, so what we had to do was literally cut and paste in blocks those responses out of [the EHR modules] into the HPI section coming in as one data point... It is still not integrated" (Provider).
Nursing workflow	"It was similar to what we do already for the questions we ask... I didn't find it hard to use" (Staff 2).	"Say if I have a diabetic patient and I have to do a lot with a diabetic patient that hasn't been in the office in a while and if I'm doing a lot, like, they might need an EKG for the exam here and blood sugar you know, just a lot, then they bring like a bunch of medicine and you have to key in all their medicine. It's just time-consuming... you know, you're trying to work as fast as you can because you've got other patients in the lobby ready to come back" (Staff 4).	"If I had to ask the [GEM] questions I would not be happy about that" (Provider 2). "I can see if a nurse, or a care provider, or somebody ahead of time was... asking [the GEM] questions, that that could be an issue... They just don't want to have to sit in there for 30 minutes, you know, because they're trying to get people checked in and out" (Provider 2).
Patient Reluctance	"I think we probably lost some patients when we first implemented [our EHR]... Oh yeah, absolutely... No, they're all gone. Those people that (pause) I had a friend of mine that said if he had a doctor that typed while he was being seen that he would just go to another doctor. He just thought it was totally inappropriate. I can't argue with that. But this particular practice after five years of this stuff is gonna object to what, 8 questions, or whatever it is? No" (Provider 1).	"We also ran into issues, which was surprising, of patients saying, 'Well I don't want to put my information in the computer.' Well you put them in IMH last week! But this week you don't want to do the GEM module because somebody came in and said, 'I'll give you a ten-dollar Wal-Mart card if you're part of the study.' Whereas last week it was IMH that was part of the routine of the practice. And so, it was something about being a research person or whatever that (pause). Again, these were all study issues that came up, but not, not the module" (Provider).