Familiarity breeds doctor contempt with EHRs

New Orleans The meaningful use incentive program has resulted in more physicians implementing electronic health record systems and using them in advanced ways. Yet doctors' dissatisfaction with the systems has increased.

Theories for what is driving the dissatisfaction include rushed implementations, too little training and physicians doing too much too soon as they struggle to meet meaningful use requirements, other federal mandates and changes to the health care landscape. EHR vendors also are thought to be taking on too much in too little time. As they rush to deliver products certified for meaningful use, usability may have suffered.

A survey by AmericanEHR Partners of 4,279 clinicians, including primary care physicians, specialists and diagnostic professionals, found that user satisfaction declined from 39% in 2010 to 27% in 2012. The rate of those “very dissatisfied” increased from 11% to 21% during the same period. The findings were presented in March at the Healthcare Information and Management Systems Society annual conference in New Orleans.

“These findings highlight the need for the meaningful use program and EHR manufacturers to focus on improving EHR features and usability to help reduce inefficient work flows, improve error rates and patient care, and for practices to recognize the importance of ongoing training at all stages of EHR adoption,” said Michael Barr, MD, who leads the American College of Physicians' Medical Practice, Professionalism and Quality Division.

AmericanEHR Partners, founded by the ACP, maintains a vendor-neutral database of EHR products and vendor ratings based on satisfaction reviews submitted by its member organizations, which represent more than 700,000 physicians. The American Medical Association signed on as a member in May 2012.

The long-held belief that satisfaction improves with time, as physicians become more comfortable with the technology and the resulting changes to work flow, was not backed up by the survey's findings. Alan Brookstone, MD, co-founder of AmericanEHR Partners, said three years was the average time respondents had been using their EHR systems before the survey.

A lack of usability

Before meaningful use, Dr. Brookstone said, respondents may have been using only a portion of the functions their systems were capable of. Those functions probably were ones that physicians and staff felt comfortable using. The government incentive program forced many to use EHRs in ways they weren't ready or optimized for, Dr. Brookstone said.

“Usability is a problem,” he said. The competitive environment in which the vendors are operating is not helping, because they aren't sharing best practices with one another. At the same time, the usability of what are considered basic functions, such as documentation, continues to be an issue for many physicians, Dr. Brookstone said.

However, there may be evidence that five years is the magic number for satisfaction to increase. The survey found that respondents on systems more than five years saw the most dramatic jump in satisfaction.

Taking five years — or even two years — for users to start feeling comfortable using a system “would be unacceptable,” said Kevin Donnelly, managing director and CEO of EMRapproved, an EHR consultancy aimed at implementation and training. He said taking that amount of time indicates that systemic issues need to be addressed. (See correction)

One of the issues respondents cited was the increased workload associated with EHR adoption.

For example, a research letter published online March 4 in JAMA Internal Medicine, formerly Archives of Internal Medicine, found that the 2,590 primary care practitioners in the Dept. of Veterans Affairs system surveyed received a median of 63 alerts per day through EHR systems. Eighty-six percent said the number was excessive, and nearly 70% said they received more alerts than they could effectively manage.

Donnelly said practices need to do a better job of analyzing and improving their work flow processes before adopting an EHR. When their work flow issues are addressed, they should find a system to match them.

Dr. Brookstone said primary care physicians are likely to have an easier time matching EHRs to work flow, because the majority of systems on the market were built for primary care users. The data showed that primary care physicians were the most satisfied, and surgeons were the least satisfied.

There's also a need for more careful and deliberate implementation procedures, experts say.

“I have seen numerous implementations where the results met or exceeded everyone's expectations, and I have seen numerous others where this was not the case,” said Bruce Eckert, principal with Beacon Partners, a health care consulting group that was not associated with the survey. “My observation is that the difference between these, the 'secret sauce' if you will, is the quality of the EHR implementation, not the software. All EHR vendors have very successful, very satisfied users, and others who are not.”

Dr. Brookstone argues that it often takes several cycles of users adopting systems, providing feedback to vendors and the vendors making changes based on the feedback to become more suited to users' needs. The process can take a long time, he added. Thus, practices that adopt after early adopters have helped the vendors improve might achieve satisfaction more quickly.

Eckert said the survey by AmericanEHR Partners showed some encouraging signs. More than half of respondents said they are satisfied with their EHR features and functionality, and about 40% are satisfied or very satisfied with their EHRs' ability to improve patient care.

“Overall, physicians are benefiting from their EHR investments, and that should provide encouragement to us all to diligently work to resolve those situations where this is not the case,” Eckert said.