by Ken Terry, iHealthBeat Contributing Reporter

April 29, 2013

Recent studies point to significant and growing problems with the usability of electronic health record systems and their effect on physician productivity. Some of these issues appear to be related to the addition of extra features to meet the meaningful use requirements, such as quality reporting and patient portals. Many physicians also have trouble documenting patient encounters in EHR drop-down boxes, which is an example of the poor usability of user interfaces. Moreover, current EHRs do not fit clinical workflow well, and practices have had to develop numerous workarounds to get their daily tasks accomplished.

Software design is not to blame for all of these problems. Inadequate training and poor preparation for switching from paper to electronic records are also factors, experts say. The rapid adoption of EHRs in response to the government’s EHR incentive program has exacerbated these pain points, as doctors scramble up the steep learning curve to EHR mastery. Nevertheless, even many physicians who are experienced EHR users are dissatisfied with their systems.

The clearest evidence of these perceptions of EHRs comes from an AmericanEHR survey of 4,279 physicians. Presented at the Healthcare Information and Management Systems Society conference in March by representatives of the American College of Physicians and AmericanEHR Partners, which was founded by the ACP and Cientis Technologies, the survey shows that EHR satisfaction and usability ratings dropped from 2010 to 2012 across a broad range of practice settings, specialties and products from multiple vendors.

Key findings of the survey include the following:

  • The percentage of clinicians who would not recommend their EHR to a colleague increased from 24% in 2010 to 39% in 2012.
  • Clinicians who were “very satisfied” with the ability of their EHR to improve care dropped by 6% compared with 2010, while the percentage of those who were “very dissatisfied” increased by 10%.
  • Thirty-four percent of users were “very dissatisfied” with the ability of their EHR to decrease workload — an increase from 19% in 2010.
  • In 2012, 32% of the responders had not returned to pre-EHR levels of productivity, compared with 20% in 2010.
  • Dissatisfaction with ease of use increased from 23% in 2010 to 37% in 2012, while satisfaction with ease of use dropped from 61% to 48%.

One other finding reveals a great deal about the state of the EHR market: Only three of the respondents’ 10 most highly rated EHRs — eMDs, Medent and Practice Fusion — were in the top 10 ambulatory-care products most often used to attest to meaningful use, based on October 2012 data from CMS. Together, those three EHRs were used in only 6.5% of the attestations.

In an interview with iHealthBeat, Alan Brookstone, chair of Cientis Technologies, said that the EHRs with the highest adoption rates among survey respondents were Epic (13%), eClinicalWorks (7%), NextGen (7%), Cerner (5%) and Allscripts Professional (5%).

Asked why so many doctors use these EHRs despite their low satisfaction ratings compared with other products, Brookstone offered two explanations. “In many instances, they chose products that were not necessarily appropriate for their style of practice. Specialists, for instance, may have selected products designed for primary care. But there was also an impact from the employer selecting a system or the individual being forced to use a system that was preselected for them.”

Rapid Rise in Adoption

From 2009, when the meaningful use incentive program began, through 2011, the percentage of office-based doctors who had any kind of EHR jumped from 48% to 57% and the percentage of those who used what the government terms “basic” EHRs climbed from 22% to 34%. With such rapid adoption, one might expect that many doctors would still be struggling to learn how to use EHRs, which could explain some of the increase in dissatisfaction with these systems.

However, the composition of the samples in the 2010 and 2012 AmericanEHR surveys was very similar. Half of the respondents in both polls had used their EHRs for at least three years, and many had used them for five years or more. According to Brookstone, this aspect of the survey design limited the impact of new users on the results. The only significant finding related to duration of use, he said, is that doctors who had EHRs for more than five years were more likely than newer adopters to say that the technology had improved the quality of their care.

What made a real difference in the two-year period, he said, was the increasing complexity of EHR use because of the new features in EHRs certified for meaningful use Stage 1. “The vendors are challenged by building in new functionality very quickly to conform to the meaningful use requirements. So the EHRs have actually become more difficult to use,” he said.

Before the meaningful use program, many doctors had been content to use just a portion of their EHR functionality, Brookstone noted. “But because of the reporting requirements, they have to use the EHR for most, if not all of what they do,” he said, adding, “So they were happy with the functionality they had before and didn’t do some things because they thought it was too tough to do in the EHR. Now they have to do it in the EHR, and that could be why they’re reporting lower satisfaction.”

Decreased Productivity

Two other factors may have contributed to doctors’ declining satisfaction: The sharp increase in the percentage of physicians who did not find that EHRs had reduced their workload, and the equally marked rise in those who had not seen their productivity return to the level they had achieved before adopting EHRs.

Cindy Dunn, a senior consultant with MGMA Consulting, is not surprised by these results. Many physicians feel they were sold a bill of goods, she said, because they were told that “the EHR was supposed to make it faster and easier for me and my patients, and it doesn’t.”

Computer-generated visit notes are often voluminous and difficult to read, and it’s much harder to enter data in EHR templates than to simply dictate the note, she pointed out. Moreover, if a doctor misses a step, somebody is looking over his shoulder and will tell him to correct it.

Physicians are waiting for a “Star Trek computer” that will be able to parse their dictation and enter discrete data into the system automatically, she said. That’s what natural language processing is supposed to do, but it’s still not there yet.

Both Dunn and Brookstone said physicians and practice staff need better training on how to use EHRs. Today, many physicians receive three days of training or less, or perhaps none at all.

“Practices need realistic training to make these systems work,” Dunn said. “They need somebody who understands the workflow and can work with the docs.”

Considering the growing frustration of physicians with EHRs, Brookstone said, it would behoove CMS to consider slowing the introduction of stages 2 and 3 of meaningful use.

“If physicians are struggling to cope with EHRs customized for meaningful use Stage 1, and stages 2 and 3 are going to be more stringent, it might be time to take a breather, do some more research and analysis, and determine whether there is some optimization that needs to be done on EHRs’ existing functionality,” he said.

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