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How a doctor perceives uncertainty guides attitude to EHR

Understanding a doctor's decision-making process can help devise strategies to get the most benefit out of an electronic health record system.

By Pamela Lewis Dolan covered health information technology issues and social media topics affecting physicians. Connect with the columnist: @Plewisdolan  —  Posted June 17, 2013.

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Whether they realize it or not, all physicians perceive and react to uncertainty in their own way — and that can affect how they use their newly installed electronic health record system.

By recognizing what kind of perception they have, they might be onto the secret of why they like or dislike their EHRs, or why they use them a certain way. This recognition also can help physicians find the right EHR.

Holly Jordan Lanham, PhD, an assistant professor of medicine at the University of Texas Health Science Center, did a study that narrowed physician reaction to uncertainty to two categories, with a third category being a hybrid of both.

One category is physicians who engage in “uncertainty reduction.” These are doctors who rely heavily on documentation, both updating it and referring to it, to gain more control over what they see an uncertain situation. Another category is physicians who are “uncertainty absorbers.” They are more likely to seek more control through having deeper discussions with a patient, and are likely to see data entry as a barrier. Just by knowing how the types differ, physicians can easily identify which camp they fall into and how that affects their EHR use, Lanham said.

There are also doctors who are hybrids of both styles, and what they do bends to the situation and is harder to predict.

Physicians face uncertainty in nearly everything they do, from making a diagnosis to deciding on a treatment option, according to Lanham, who was the lead author of a study in the May 22 Journal of the American Medical Informatics Assn. that looked at how physicians' perception of uncertainty affects EHR use.

Those most likely to enjoy using an EHR are those with an uncertainty reduction perspective, because they feel that information found within a patient's record is of paramount importance. But that's not to say this group is preferred over others, or provides a higher quality of care, said Lanham, who also is an investigator for the South Texas Veterans Health Care System.

“Physicians should not be afraid of these differences,” she said.

“If we can acknowledge that there are differences in how physicians view uncertainty, and if those are related to how they use electronic health record systems, and possibly other health IT, and if physicians can have conversations about those differences, that may, in and of itself, be enough to help them work through these differences versus thinking, 'Well, they are not technologically savvy, so they don't understand why I like this system' or vice versa,” Lanham said.

“We have very pejorative terms to describe physicians who don't use EHRs and who aren't the EHR lovers, like us,” said Dean Sittig, PhD, professor in the School of Biomedical Informatics at the University of Texas Health Sciences Center and a co-author of the study. “We call them Luddites, backwards, and old, and technologically incompetent. And what I have learned is that some of these physicians who aren't using the computer system are some of the best physicians there are. The fact that they think differently from me doesn't make them a bad physician.”

Paper record use reveals a pattern

For uncertainty reducers, Sittig said, the EHRs likely don't make enough information available. For the absorbers, the information isn't valuable the way it is presented.

Lanham said that although the research looked only at physicians' relationship to electronic records, she recognizes patterns of use that also apply to paper records. When patient records were considered the property of the physician, kept within a specific practice and used mostly as textual reminders of what happened during an exam, the differences in how physicians kept those records had less of an impact on patient care. Now, Sittig said, patient records are viewed as being owned by the patient, and they follow that patient wherever that person goes. How a physician interacts with that record could affect the decisions made by other physicians who use the patient's record to inform their decision-making.

Lanham doesn't think it's impossible to get physicians to use an EHR in a different way from the way they are predisposed to using it. It just will take some work and discussions between physicians, she said. But the design of an EHR system also can affect how a physician uses it.

Physicians who are uncertainty reducers probably could benefit from add-ons to an EHR system that will deliver the best information in a short amount of time, Sittig said. Systems that provide links to studies, reference material from a diagnostic code or a medication name would be helpful.

Sittig gave an example of a pulmonologist he knew who used a prescription drug reference add-on to his EHR. Sittig questioned the need for such a tool, because the physician obviously knew a lot about the medications he routinely prescribes. The doctor's response was that, yes, he knew a lot about medications prescribed for pulmonary conditions, but very little about medications that may be prescribed by other specialists. He wanted the most information he could get before writing a prescription.

Uncertainty absorbers would do well with systems that have free-text capabilities, Sittig said. While a pull-down menu may not allow the physician to tell the story he needs the record to tell, a brief synopsis of the patient visit written in free text might do the trick.

Sittig said physicians need to embrace the fact that medicine is no longer an individual sport but a team sport. They have to recognize that to play a team sport, you have to communicate a little differently to help your team, he said. In the EHR world, communicating differently means adjusting the way you use the patient record.

Pamela Lewis Dolan covered health information technology issues and social media topics affecting physicians. Connect with the columnist: @Plewisdolan  — 

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ADDITIONAL INFORMATION

How physicians handle uncertainty

Researchers identified three categories for physician perceptions of uncertainty that will affect how they interact with their electronic health records. They said knowing what category a physician is in can help to identify how the doctor will use an EHR, and what changes might be necessary to get the most out of the system.

Uncertainty reduction

  • Views patient information contained in the medical record as paramount to the practice of medicine.
  • Seeks certainty and/or perpetually searches for ways to use information to reduce uncertainty.
  • Gives priority to codified patient information over other types of patient information (patient body language, tone of patient-physician interaction, tacit and/or difficult-to-capture aspects of patient encounter, etc.)
  • Believes that more information, particularly the kinds of data that can be captured in an EHR, always equals better patient care.

Uncertainty absorption

  • Views the co-creation and continual exchange of information between patients and physicians during patient encounters as paramount to the practice of medicine.
  • Manages uncertainty by engineering rich interactions with others.
  • Gives priority to information that was co-created, discovered, emphasized, and/or nearly missed during patient-physician encounters.
  • Believes that more information, particularly the kinds of data that can be captured in an EHR, does not always equate to better patient care.

Uncertainty hybrid

  • Views patient information contained in the medical record as paramount to the practice of medicine.
  • Views the creation and exchange of information between patient and physicians during patient encounters as paramount to the practice of medicine.
  • Manages uncertainty through information contained in the medical record and through interactions with others.
  • Believes that more information is necessary but not sufficient for better patient care.

Source: “Understanding differences in electronic health record (EHR) use: linking individual physicians' perceptions of uncertainty and EHR use patterns in ambulatory care,” Journal of the American Medical Informatics Assn., published online May 22 (link)

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External links

“Understanding differences in electronic health record (EHR) use: linking individual physicians' perceptions of uncertainty and EHR use patterns in ambulatory care,” Journal of the American Medical Informatics Assn., published online May 22 (link)

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