November/December 2018

EHRs Still Burden Physicians
By Elizabeth S. Goar
For The Record
Vol. 30 No. 10 P. 18

A recent study adds more fuel to the fire, detailing how physicians and patients at OB/GYN practices were dissatisfied with their experiences.

Despite countless advances in functionality, capabilities, and usability since the HITECH Act of 2009 converted EHR systems from a luxury to a necessity, they are still under fire from dissatisfied physicians. This was made clear most recently in a study from Lehigh University, which found that both physicians and patients were largely unhappy with the role of EHRs in the care process.

"EHRs do several things very well. For example, they increase information transmission between providers and across care settings. But they also change the work processes and workflows in outpatient offices," says Chad Meyerhoefer, PhD, a professor of economics at Lehigh University and coinvestigator for the study, which appeared in the August 2018 issue of the Journal of the American Medical Informatics Association. "In the EHR system we studied, one issue from the physician standpoint was that they were required to do more documentation because of the way the EHR was structured. It was more time-consuming and took time away from face-to-face visits with the patient. Or they had to document during the visit. Physicians reacted negatively to those changes."

Documented Dissatisfaction
The study, "Provider and Patient Satisfaction With the Integration of Ambulatory and Hospital EHR Systems," was conducted by researchers at Lehigh University and the Lehigh Valley Health Network. It examined how implementation of an ambulatory EHR at OB/GYN practices and its subsequent interface with an inpatient perinatal EHR impacted providers' satisfaction with the transmission of clinical information. It also looked at how patients rated their care experience.

Data on provider satisfaction were collected through four survey rounds during the phased implementation of the EHR, while patient satisfaction data were pulled from Press Ganey surveys. Researchers tracked two OB/GYN practices and a regional hospital from 2009 to 2013, a timeframe that spanned implementation through integration with the hospital system beyond the point when full two-way exchange of clinical information was achieved.

While the researchers did find positive effects, including better information flow, a reduction in adverse birth outcomes, and increased quality of care, Meyerhoefer says, "If you look at physician productivity in RVUs [relative value units], there is a substantial reduction after implementation of the system. It took several years for productivity to approach preimplementation levels."

Furthermore, the quality increase "is correlated with more time and effort needed to report on these patients through the system, so in some ways you could say it's what you might expect," he adds.

Specifically, the study found that outpatient OB/GYN providers became more satisfied with their access to information from the inpatient perinatal triage unit once system capabilities included automatic data flow from triage back to the OB/GYN offices. However, physicians were generally less satisfied with how the EHR affected their work processes than other clinical and nonclinical staff. Patient satisfaction also dropped after initial EHR installation.

These findings led researchers to conclude that "dissatisfaction of providers with an EHR system and difficulties incorporating EHR technology into patient care may negatively impact patient satisfaction. Care must be taken during EHR implementations to maintain good communication with patients while satisfying documentation requirements."

Root Causes
The Lehigh study findings came as no surprise to Steven Waldren, MD, director of the American Academy of Family Physicians' Alliance for eHealth Innovation. Noting studies that have shown a steady decline in EHR satisfaction among physicians—who are less satisfied today than they were five years ago—he points to pressure on vendors and physicians by government initiatives designed to accelerate adoption and "the fundamental issue that the EHR was originally designed for documentation and billing and not for care delivery."

Waldren says federal programs such as meaningful use were intended to improve EHR technology. However, they forced vendors to focus research and development on satisfying certification requirements over the needs and concerns of the physician users. These programs also put pressure on all providers—not just those who saw their value—to adopt EHRs to avoid financial penalties and/or to earn incentive dollars.

"Those were the biggest contributors to dissatisfaction," he says. "Add to that the increased requirements for prior authorizations and quality measurements that require physicians to recapture information that already exists in the EHR, as it is not automatically populated."

Other issues negatively impacting long-term EHR satisfaction Waldren cites include the lack of interoperability, challenges finding needed information within the software, and the complexities of incorporating EHRs into the clinical workflows.

"Unfortunately, in many cases, [the EHR] is still just an electronic filing cabinet," he says. "It automates the business of health care, not the delivery of health care. Right now, EHRs are all about making sure documentation is complete and billing is done, but not how to do" health care better.

According to Doug Brown, managing partner of Black Book Research, the problem lies in the disconnect between what the staff expects of an EHR and what the technology delivers. While pre-EHR workflows may have been inefficient, they worked. Adding an EHR to the mix to complete those same tasks made things less efficient as staff struggled to become proficient.

This is particularly true when EHRs are selected on cost and implementation considerations rather than what the staff could work well with. The result is frustration that extends to patients, who experience increased wait times, less time with physicians, missed test results, and staff who can't help them technically navigate patient portals.

"Over time, staff realize the technology they were told would make things better actually makes things more complicated," he says, pointing to Black Book research that shows that 83% of independent physicians don't know how to effectively use their EHRs. "With too many workflow options and insufficient training, physicians know only a fraction of the EHR's functionality, so they struggle to use the tool effectively."

With EHRs still failing to meet their needs, many physicians are left feeling as though their voices are not being heard by vendors when it comes to EHR design. That's not necessarily the case, Waldren says. Rather, vendors are still focused primarily on meeting certification standards and the requirements hospitals and physicians have through meaningful use and now the Merit-Based Incentive Payment System.

"There's really a great opportunity over the next couple of years with artificial intelligences and machine learning to make these systems smarter," Waldren says.

Identifying a Solution
Meyerhoefer notes that while the physicians he surveyed didn't provide specific recommendations on how to improve EHRs, they did point out that while more information is good, "it needs to be transformed into an interface that didn't require so much of their time to go through.

"They didn't have an answer for how to do that, but they immediately saw the need for information filters," he adds. "You see a lot of this with networks that implement customized EHRs. They'll come up with metrics that aggregate clinical data and put it in some sort of risk scale or process metric. This type of aggregation is very useful, but it's not easy to do."

Brown notes that until recently little has been done to resolve physician dissatisfaction with EHR technology. However, most of the challenges that providers have identified can be solved through more advanced and better streamlined innovations.

"The answer lies in finding the link between the chosen EHR system and staff sentiments," he says.

Brown sees more provider organizations taking the lead on working with physicians and medical office staff at resolving usability issues rather than forcing them to switch EHRs. For example, health care systems are working to identify those physicians who don't know how to efficiently use the EHR, then paring the data from those efficiency reports with targeted physician education to reduce burnout and send a strong message about the organization's commitment to support its medical community.

"A light in the tunnel includes physicians in the future making use of virtual assistant technology in their patient visits that will eliminate the need for the burdensome levels of documentation currently required," Brown says.

Waldren recommends taking the lead from companies such as Uber, which leverages application programming interfaces from multiple places, stitching them together to deliver value without having to bear the cost of building such interfaces from the ground up. It's a service-oriented approach that gives users more options to create the system they need.

"Right now, physicians are solely dependent on their EHR vendor. If the [vendor] isn't focused on what they need, physicians must forgo them today or spend a lot of money and time to do the data sharing themselves," Waldren says. "[Adopting] more of a service-oriented approach to IT would give physicians better options to stitch together" EHR functionality to create exactly what they need without the cost and complexity of a fully customized solution.

"We need to talk about substitutability. Right now, if a physician or hospital has purchased an EHR product, it's very difficult to substitute one out for another," he continues, noting that to switch EHRs is a costly prospect, particularly when it comes to moving data and workflows. "It's very expensive after putting all the capital toward purchasing the original system. So even if EHRs improve, it's not feasible for physicians to act en masse and vote with their feet and buy a new product. That's why the [American Academy of Family Physicians] has been very adamant about promoting the need for interoperability to lower that bar for substitutability. Without that, it will be difficult to see accelerated progress on usability and physician satisfaction."

— Elizabeth S. Goar is a freelance writer based in Tampa, Florida.