The Growing Dissatisfaction with Office EHRs
How Meaningful Use May Have Contributed to the Decline
Over 60% of physicians are frustrated with their office Electronic Health Record (EHR). Surveys show the number is growing. It doesn’t have to be that way. We have a great opportunity to improve efficiency, effectiveness and patient safety. The growing dissatisfaction with office EHRs can be turned around if we understand the issues and the opportunities.
“Electronic Health Records (EHRs) now are a part of most medical practices, yet doctors remain unhappy with them.” – Medical Economics 2017 EHR Report
I typically hear these comments from physicians about their office EHRs:
- We need a new EHR!
- The notes I get from other doctors are bloated and worthless.
- I don’t own my EHR, so I can’t fix it.
- I am spending more time on the computer and less time with my patients.
- I’m spending every night and weekend finishing my work.
- I need more training.
While each statement contains an element of truth, they are also beliefs that hold many physicians back from overcoming their EHR challenges. It is hard to win a victory when the physician and staff are focused on what the EHR has DONE to them rather than what it could DO to improve productivity, profitability and patient care.
With over 990 million physician office visits annually, even a 5-10% improvement in productivity would yield great returns for patients, physicians and office staff.
Did Meaningful Use Create More Victims than Victors?
Part of the EHR problem has been the unintended consequence of the Meaningful Use (MU) incentives under the HITECH Act. While the Office of the National Coordinator (ONC) laid out a productive roadmap for digitalizing America’s health records, there was often an urgency to check off functionality deployment, rather than workflow enhancement.
As a result of the rush to collect incentives and avoid penalties, EHR deployments accelerated across the U.S. in the first five years of this decade. EHR physician satisfactionn data over the past eight years has demonstrated the results of this disruption. Innovators and early adopters prior to 2009 saw high levels of satisfaction (see table 1).
MU pushed the early and late majority to implement EMR’s at a more rapid pace than natural adoption, often with inexperienced implementation teams pushing out immature features to meet MU timelines.
It is little wonder why many physicians in these latter groups voice growing dissatisfaction with office EHRs. Table 1 below also shows the documented downtrend in physician attitudes toward their EHR during the MU rollout.
Table 1: Physicians Use of EHR Systems 2014 (940 respondents)
|Survey Responses of:||2014 Results||2010 Results|
|“Satisfied” or “Very Satisfied” with my EHR:||34% (down)||61%|
|“Difficult” or “Very Difficult” to use my EHR to improve efficiency.||55%|
|“Difficult” or “Very Difficult” to use my EHR to decrease workload.||72%|
|Believe that the EHR has increased my total operating cost.||54%|
|Have not yet overcome productivity challenges with implementation of my EHR.||43%|
The Surveys Behind the Growing Dissatisfaction with Office EHRs:
2017 Physician EHR Survey of 3,200 Physicians
The recent 2017 EHR Report Card published annually by Medical Economics, summarized current perspectives of physicians’ EHRs:
Q. "What effect has your EHR had on the quality of care your practice provides?" [Ref 5]
Q. "What is your staff’s opinion of your EHR system?" [Ref 5]
Q. "What effect has your EHR selection had on the finances of your practice?" [Ref 5]
Q. "What have been the disadvantages of your EHR system (if any) to your practice’s daily operations?" [Ref 5]
Q. "In what ways (if any) do you feel your EHR has improved the quality of care your practice provides?" [Ref 5]
Survey of Family Physicians
The Medical Economics findings are similar to the 2012 EHR User Satisfaction Survey: Responses from 3,088 Family Physicians published in the American Academy of Family Physicians' (AAFP's) Family Practice Management.
“The aspects of EHRs that users are most satisfied with are the way they facilitate:
- Intra-office messaging and tasking (60% positive),
- Finding information (58% positive),
- Documenting (57% positive), and
- E-prescribing (56% positive).
“The areas of lowest EHR satisfaction were:
- Effects on productivity (only 16% positive responses),
- Their effects on the physician's ability to focus on patient care, (only 24% positives), and
- Vendor support (36% percent positive responses).
"Finally, only 38 percent of users agree or strongly agree that they are highly satisfied with the systems they use. It appears that there is a lot of room for improvement in the EHR product world – this despite the fact that 37 percent of respondents (1,131) agree or strongly agree with the statement, “I enjoy using this EHR.” [Ref 6]
Deloitte's 2016 Survey of US Physicians on EHRs - Physicians Want Better Productivity
600 physicians responded to Deloitte’s annual 2016 survey of healthcare information technology and electronic health records. “78% of respondents in 2016 believe that EHRs are useful for analytics and reporting capabilities.” This was up from 68% in the 2014 survey. However,
- "70% think EHRs reduce their productivity.
- 75% believe that EHRs increase practice costs, outweighing any efficiency savings.
- 47% believe that EHRs improve clinical outcomes – down from 55% in 2014.
- 57% want improved workflow and increased productivity."[Ref 7]
The Three-Fold Solution
Physicians need a paradigm shift to focus on three areas of EHR Return on Investment (see Sidebar article):
- Money, and
- Peace of Mind.
EHRs are critical to meet the needs of 21st century care and reimbursement models. Physicians and their office staff need to leverage their EHRs:
- To improve personal and staff productivity,
- To create Practice Improvement Activities under Medicare’s merit-based incentive payment system (MIPS),
- To better align to patient-centered medical homes (PCMH) and other shared-services models,
- To adopt new alternative payment models (APMs),
- To increase patient and physician satisfaction,
- To improve chronic care management,
- To promote better health of specific populations, and
- To get the most out of their EHR investment.
This is not just about EMR training. It begins with "change leadership" principles. It moves to influencing beliefs, so that physicians and their staff can best understand how to reframe their EHR as a valuable asset in both word and action. The journey needs to lead them through the process of awareness, self-assessment, and action on specific ideas that they can apply to their own unique situations.
It is time to stop this growing dissatisfaction with office EHRs and help physicians to use EHRs to improve their productivity.
Any physician or office manager can begin the process of unlocking the power of their EHR. They can start with reviewing the 12 Principles of Office EHR Optimization. Or email questions to psmith@healthITaccelerator.com
Footnotes and References:
 2017 EHR Report. Survey of 3,200 physicians. Medical Economics. October 25, 2017.
 CDC. National Health Interview Survey, 2015. https://www.cdc.gov/nchs/fastats/physician-visits.htm
 Physicians Use of EHR Systems 2014. AmericanEHR.com and American Medical Association. August 2015.
 Blue curve shows bell-shaped distribution of adoption of products and technologies. Yellow curve shows cumulative market adoption over time. Typically, the time to go from 0-10% adoption equals the time it takes to go from 11-95% adoption. The MU program accelerated deployment, at the expense of adoption. Graph image from Wikipedia. Graph content revised from Diffusion of Innovations by Everett Rogers, 1962.
 2017 EHR Report. Survey of 3,200 physicians. Medical Economics. October 25, 2017. Respondents were 22% Family Physicians, 16% Pediatrics, 14% OB/GYN, and 13% Internal Medicine. 20% solo practice, 30% 2-5 physicians. 55% independent practices, 31% hospital/health system-owned, 5% academic, and 4% government.
 Edall RL, Adler KG. 2012 EHR User Satisfaction Survey: Responses from 3,088 Family Physicians. Fam Pract Manag. 2012 Nov-Dec;19(6):23-30.
 Deloitte has surveyed physicians on Health IT and EHRs annually since 2011. The 2016 report is summarized at: http://medicalsoftwaresolutions.net/deloitte-2016-survey-us-physicians-findings-health-information-technology-electronic-health-records/
The EHR Opportunities: An Early Adopter's Viewpoint
When I started looking at EMRs in 1992, I was in the “innovator” group of early adopters (see Figure 1 on this page). I knew that there were things in my office that automation would improve. I divided them into three objectives:
- Money, and
- Peace of Mind.
I knew if I stayed focused on these high-level value statements, I would be successful. I was also adding a new physician to my practice and wanted to keep overhead low. Less than a year later, I went live with an off-the-shelf EMR - developed by a family physician in Iowa. My new associate, straight out of residency, was not as excited to adopt the technology – my “late adopter” control. I had a great laboratory in which to understand how to use, or not use, the EMR.
Prior to the EMR, we took home charts almost every night, to catch up with the dictations of the day. We had to wait for those dictations to come back, review and sign off on them… and live with the consequences that the information was not available until two days post-visit. We both wanted our lives to get simpler. However, I was determined to adapt and improve workflow – my associate (like many in the late majority) wanted to do business as usual.
I think this represents the two camps of physicians today… those who embrace the technology and those who don’t. While the problems physicians face today are different than the early 1990’s, it is helpful to see how time, money and peace of mind can help frame the potential benefits of today's EHRs. During our first year with the EMR, the results exceeded my expectations:
- Notes were done during office hours without a decrease in number of patients seen. I spent 2-3 hours less per day doing after-hours charting. Saved 2.5 hours x 22 work- days or 55 hours/month.
- My associate, who chose to hold notes till the end of day (like we did with our dictations before the EMR), actually added 2-3 hours / day to his work load. Thus business as usual showed how NOT to use the EMR.
- I no longer took charts home to finish them on evenings and weekends.
- The net difference in our monthly workload was 100 hours, even though I saw more patients per week as the new physician.
- We (physicians and clinical staff) no longer had to look for paper charts. If a patient called, the nurse could immediately triage, since records were immediately available and up-to-date.
- Pharmacists never had to call us for clarity since our prescriptions were now printed.
- Based on data from our EMR, we moved to modified wave scheduling. This made our office more efficient and productive. We were able to see more scheduled and “work-in” patients. We typically were on schedule at the start of every hour of the day.
- Our patients spent less time in the waiting room. They quit calling after-hours because they knew that we could always fit them in, any weekday, for an urgent need.
- Based on EHR and phone log data, we devised daily proactive callbacks of selected patients seen the prior day with new illnesses or new medications.  This drastically reduced our interruptions, and improved patient satisfaction. Patients appreciated that our nurse called them to make sure they were doing well with the treatment or new prescription.
- We eliminated transcription costs as well as need for signing off and filing transcribed notes.
- Since notes were always done immediately, we had less non-productive time in the office… and fewer interruptions from the staff.
- We no longer printed records in office, but could print for the patient for less cost than photocopy.
- We got referrals from doctors up north of new Snowbirds who came in saying, “Our doctor in <their state> says you are the best doctor in Florida” (probably because he or she got complete legible records each spring, hand-carried by the patient.).
- We were able to see more patients and walk-ins each week. Added to bottom line and paid for EMR investment in 9 months, despite the fact that computer hardware was very expensive at that time.
Peace of mind:
- Notes were more complete and enhanced to include more specific details that helped patient satisfaction at follow up. (e.g. “How was your Alaskan cruise?”, or “How is your niece doing in college?”)
- Since our printed prescriptions also included common side effects as a tear-off, patients were better informed about new medications. This meant less chance of harm from illegibility issues and less callbacks after reviewing potential side-effects with the pharmacist. [On a recent survey above, physicians tout e-prescribing as the best benefit of EHRs.]
- We provided a Clinical Summary for travel and printed records for our Snowbirds (winter Florida residents who lived up north in summer).
- This minimized continuity of care issues for our traveling patients and Snowbirds. This built our reputation, and surprisingly, increased referrals from out-of-state doctors.
These represent only a sampling of the opportunities, benefits and lessons learned. I will add that we learned to make the patient the focus of the visit… leveraging the EMR in the exam room as an asset, not an intrusion. This is what I call EMR exam room etiquette – a skill often lacking when I observe many struggling EHR users for the first time.
While many EHR issues today are different, they can be successfully solved by addressing the common myths and helping physicians discover the value of their EHRs. Understanding successful offices will help us reverse the growing dissatisfaction with office EHRs.
 For perspective, I did not have email or an Internet account until 1995, nor wireless networks. The IBM-80286 was the state of the art desktop computer at this time.
 Prior to this proactive approach, we averaged 12 calls/day from such patients. They would first talk to the receptionist, then to the nurse; who would check with the doctor; then call the patient back. This reactive process typically occurred over 1-2 hours, with much inconvenience to the patient, who was waiting by the phone, in these “pre-cell phone” days. The new proactive approach took less than two minutes, and was greatly appreciated by the patient who rarely expected a call from the office to “check up on their progress.”