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Doctors' love-hate relationship with EHRs

By knowing what users say is good and bad about electronic health records, physicians in the market will have a better sense of what to look for.

By Pamela Lewis Dolan — Posted May 7, 2012

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As with anything new, most physicians go into implementation of an electronic health record system with certain expectations. Sometimes those expectations are exceeded, sometimes they are not met — for better or worse.

Many likes and dislikes about EHRs are consistent in the physician community. Implementation will, no doubt, change a practice. But knowing what to expect will help determine how physicians handle the changes.

There are some changes with EHR implementation that physicians dislike but learn to live with. There are others that force the physicians to switch vendors altogether. Knowing the pain points, as well as the things physicians really like about EHRs, doctors still in the market may have a better idea of what to look for — or at least a better idea of what to expect.

“The computer is always a good and a bad story if you ask me,” said Dean F. Sittig, PhD, professor of biomedic informatics at the University of Texas Health Science Center at Houston School of Biomedical Informatics. “It’s a hugely important new tool for your clinic, and you have got to learn to use it. It’s not a simple thing. It’s not like a new kind of stethoscope. It’s a whole new way of doing something.”

Loves

1. Documentation is more thorough. Peter Weigel, MD, an internist and co-founder of the Medical Associates of Westfield (N.J.), said he doesn’t believe that the implementation of his EHR helped make him a better doctor in terms of doing more thorough exams. But it has helped him document the thoroughness of his exams.

“In the past, I would ask all the questions and only sort of document half of them because of having to write it all out,” Dr. Weigel said. “The [EHR] allows me to document more thoroughly, which is good for a number of reasons.” Among them, he said, is the ability to provide a complete record of the exam in the event he has to share those records with another doctor or caregiver.

2. Charge captures improve, which means more money. More thorough documentation also can lead to more charge captures, experts say. With a more thorough record of what happened in the exam room, the more accurate charges can become.

Dean Gushee, MD, medical director at the Mason General Hospital & Family of Clinics in Shelton, Wash., said he has received a lot of feedback about the increased revenue as a result of the EHR system implemented the emergency department there. (See clarification)

“I know that we were missing a boatload of charges on the nursing side on things like start and stop times for IVs, which we could never keep track of,” he said. The system also provides feedback and prompts for physicians to add more information for more accurate recordkeeping.

3. Data retrieval is easier and more customizable. Sittig said physicians appreciate the fact that with an EHR, they can access information with a simple query as opposed to searching through stacks of paper.

When emergency physicians are at the patient’s bedside in the hospital, Dr. Gushee said, they no longer have to wait for charts or yell at nurses to retrieve test results. They also can see in real time if a nurse or another doctor has updated the chart in any way.

“It’s enhanced efficiencies, and it’s really quieted the department,” he said. “And I think from a patient safety standpoint, it’s huge — the ability to see what other providers or other people are writing on that same patient and what’s being documented and what’s not being documented is an enormous patient safety hit.”

4. Responsibilities can be shared by many people, including patients. Many physicians whose EHRs have patient portals have found an increase in productivity, because the patients are now taking responsibility for doing some of the administrative work that front desk staff used to do.

Also, practice management systems and EHRs have blended into one product, said Eric Mueller, president of WPC Services, the health care technology consulting arm of Washington Publishing Group. With a combined system, responsibilities can be spread across many staff members. Staff in Dr. Weigel’s practice, for example, help answer messages sent through the patient portal. They are able to filter the messages so that they get to the proper person. The administrative staff handles other messages.

5. Physicians no longer are tied to a desk. Jody Spaulding, client services executive of provider delivery for CTG, an information technology and business consulting firm based in Buffalo, N.Y., said several physician clients have told her that they appreciate the ability to have access to patient data from anywhere. “I can get in from my home office, from my PDA, from iPhone or my iPad, and it becomes a truly networked scenario that we have not really had to any great extent in health care in the past,” Spaulding said.

Dr. Weigel said he no longer is forced to stay at the office late to finish patient charts. He can do that work home, which is great for work-life balance.

Hates

1. There is no guaranteed gain in productivity. Although many heath IT proponents are known to make claims of increased efficiencies with an EHR, many physicians have been disappointed to learn that improved efficiencies don’t equate to increased productivity. In fact, after weeks or months of decreased productivity postimplementation, many are happy to match pre-EHR productivity levels eventually.

The reason for the productivity issues is that physicians are doing more with an EHR. Mueller said EHRs are configured to collect more data than physicians are used to collecting when using paper charts, and that takes time. They must ask more questions than they are used to asking, and documenting data elements they are not used to documenting.

2. Data are sometimes hard to find. Though data are stored in a way that makes it easier for physicians to query information or do population health reports, finding a particular piece of patient data in an EHR sometimes isn’t as easy as flipping through a paper chart.

“When they are trying to find pieces of data or pieces of an encounter, it’s hard for them to find it, because it’s not in a form they are accustomed to,” Mueller said.

3. There are too many steps to complete a task. One of the things that many satisfaction surveys have found is that love and hate toward an EHR almost always can be determined by the number of clicks it takes to complete a task. Writing a prescription on paper, for example, is as easy as pulling out pen and paper. A system that requires the toggling of five screens is not going to make for a pleasurable physician experience.

Dr. Gushee said one of the first things Mason General tried to implement was a computerized physician order entry system. The system required so many steps and was so painful to use that the hospital eventually had to put the brakes on the entire system.

4. The dynamic in the exam room is altered. Marcel Devetten, MD, an oncologist and chief quality officer at the Nebraska Medical Center in Omaha, said he hears from physicians that by introducing a computer into the exam room, the physician-patient relationship will change fundamentally — and not necessarily for the better.

“Physicians are concerned that if they are continuously facing their computer screen and typing as the patient is speaking, it changes the interaction they are having with the patient,” he said. Doctors have to relearn how to establish a solid relationship with patients while using the EHR, he said. For many, that change is not welcomed.

5. Practices become too reliant on the systems. One thing physicians don’t anticipate is a complete loss of their ability to practice when there is a power outage or system failure. They have no backup files from which they can pull patient histories or medications. They are just stuck until the power comes back or the system is restored.

The bottom line for many organizations is that implementing an EHR system will mean big changes to the practices — and not everyone will embrace the change. However, technology advocates say the positives will outweigh the negatives.

“That idea of change is a big one,” Sittig said. “And it can be a really, really good one for everyone.”

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ADDITIONAL INFORMATION

Which doctors are most satisfied EHR users?

Satisfaction surveys of electronic health record users have found that primary care physicians are more likely than specialists to be happy with their chosen systems.

A February report by the Orem, Utah-based health technology market research firm KLAS found that internal medicine doctors reported a satisfaction score of 7.6, and family physicians reported a score of 7.5 on a scale of 9. They were the two specialties with the highest EHR satisfaction scores. The lowest score, 5.8, was reported by oncologists and ophthalmologists.

Chase Titensor, research director of the clinical team at KLAS, said internists and family physicians routinely report that vendors deliver “out-of-the-box” EHR products that don’t require a lot of customization.

“Physicians are a hard bunch to please, especially when it comes to their patients’ records. As they should be,” Titensor said. “The patient records are their business. It’s the way that they document and manage patient care, but it’s also a way to have a cohesive record and really be able to not just document for documentation’s sake, but … do something with that information.”

The report found that many vendors try to create solutions that can be used by a broad number of specialties with the fewest gaps in needed functionality and usability. As data entry gets more complex, vendors struggle with how to develop systems that meet the needs of each specialist. Specialists often are forced to customize EHR systems, because the appropriate content is not preconfigured, which makes them less satisfied with their products.

Titensor said vendors realize this is an area in need of attention and that many vendors are working on it. “There will be vendors that differentiate themselves with usability,” he said.

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EHR satisfaction related to practice size

A satisfaction survey published in 2010 by Family Practice Management, the monthly publication of the American Academy of Family Physicians, found that practice characteristics could help predict electronic health record satisfaction among family physicians.

Kenneth Adler, MD, a family physician and medical director of information technology for Arizona Community Physicians in Tucson, and Robert Edsall, editor-in-chief of Family Practice Management, analyzed EHR user-satisfaction survey results from 2,012 physicians collected online and by mail in 2009. They found that solo physicians were the most satisfied and that satisfaction decreased as the practice size grew to 50 physicians.

The survey results also found that physicians in practices with only family physicians reported higher satisfaction than physicians in multispecialty practices. Physicians in 100% productivity-based practices were more satisfied than salaried physicians. Doctors involved in selecting their EHRs reported greater satisfaction than those who had not.

However, there was little correlation between the length of time physicians use EHRs, and their happiness with them.

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External links

“Ambulatory EMR Specialty 2012: Finding the Fit,” KLAS (link)

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Clarification

This article originally gave an incorrect impression about the electronic health record system of Mason General Hospital & Family of Clinics in Shelton, Wash. Dean Gushee, MD, medical director at the Mason General Hospital & Family of Clinics, was referring to the EHR system implemented in the emergency department when he said he had received a lot of feedback about the increased revenue.

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