Objectives Electronic health records (EHR) are increasingly common. Understanding of their impact on clinical practice is incomplete. Thus, we intended to describe clinician computer skill and practice styles and their association with the length and content of primary care visits conducted using EHR for sick children.

Methods A prospective, observational study was performed in paediatric primary care. Clinician volunteers completed a survey of self-assessed computer skills. Observers then performed a qualitative analysis of clinician styles of EHR use and completed a quantitative instrument assessing the duration of seven non-overlapping patient care activities (ie, history taking or counselling). These activities were categorised as occurring solely with families, on the computer only, or both. Activities outside the exam room were similarly assessed (interrater reliability κ  =  0.75).

Results 27 paediatricians from 12 offices volunteered (59% women; 63% working full-time). A total of 553 visits were observed (duration 2–>60 minutes). Based on survey results, clinicians were divided into three skill levels. Qualitative analysis identified three styles: all documentation performed in exam room; use of the computer in exam room for history only and all computer use outside of the exam room. Among observed activities, history taking and diagnosis and treatment were most lengthy. Analyses revealed variation among those with different skill levels or documentation styles in visit length, total computer time and distribution of activities performed.

Conclusion Computer skill and styles of EHR use influence exam room activities and the delivery of paediatric primary care. These must be considered as EHR are increasingly implemented.