Frustrations with EHRs rampant as development slows

Physicians who have mixed feelings about their electronic health record (EHR) systems are far from alone. As practices adopt EHRs in response to federal incentive payments (and impending Medicare penalties for not using EHRs), frustrations have skyrocketed, leading 2 major physician organizations to demand changes that make the systems easier to use.

EHRs “have been a mixed blessing, incredibly helpful in many ways and surprisingly challenging in others” said Christine Sinsky, MD, FACP, an internist in private practice in Dubuque, Iowa, who also serves as the AMA's vice president of professional satisfaction. She contributed to an EHR “usability framework” that the association released last September (see sidebar).

“The most important thing we can give patients is our undivided attention,” she said. “We have lost some of our ability to give undivided attention to our patients with the way EHRs are designed, implemented, and regulated.”

Dr. Sinsky said requirement for direct data entry by the physician is a burden on the doctor-patient relationship. She added that the design of many current EHRs is so cluttered with clicks and so constrained by templates that they're inefficient, both for entering data and for getting them out again in a format that's useful to the physician.

“The human story is systematically reduced when it's recorded through dropdown boxes,” she said.

Nine in 10 hospitals now have EHRs, according to the latest figures from the Office of the National Coordinator for Health Information Technology (ONC), the federal agency charged with administering billions in EHR incentive payments included in the Obama administration's 2009 stimulus program. A little more than half of primary care physicians now have at least a basic EHR in place, and 78% have at least used one, reported the Centers for Disease Control and Prevention in a Data Brief published in January 2014. The program has paid out almost $30 billion.

But many physicians are feeling less efficient, not more. An ACP survey of EHR-using internists, published in JAMA Internal Medicine last September, found that they were losing an average of 48 minutes of free time per clinic day, or about 4 hours a week, compared with their pre-EHR workdays. Almost 90% said at least 1 data management function was slower with the EHR than it had been on paper, and a third reported that it took longer to find and review medical record data.

ACP issued its own position paper on EHR documentation in January, published online in Annals of Internal Medicine. It made many of the same points as the AMA's framework but included several specific recommendations, for example, not requiring the same piece of data to be entered multiple times and making sure that patient-supplied data (such as uploads from home monitoring equipment) are integrated into the record in such a way that the physician can tell they came from the patient.

EHRs can be a boon or a bane depending on which side of the data stream you're on, experts said.

“Satisfaction is in the eye of the beholder,” said Thomas Yackel, MD, FACP, associate dean of clinical practice at Oregon Health & Science University in Portland and chief clinical integration officer for OHSU Healthcare, who serves on ACP's medical informatics committee and coauthored its position paper. “Data consumers are happy, because they have more data. But if you're a data producer, it seems like more work to use the EHR to create your documentation.”

In addition, the ease of creating that documentation has added to the demand for it, he said, just as the introduction of the washing machine led people to expect cleaner clothes on a routine basis.

The EHR has to fulfill multiple data demands: for payers, for public health, and for documenting “meaningful use” of the EHR in order to receive incentive payments and avoid penalties, said Thomson Kuhn, senior systems architect at ACP and a coauthor of its position paper. “A lot of this is not documentation that physicians would do if they were just taking care of patients,” he noted.

The federal incentive program itself bears some of the blame for clunky systems, said Peter Basch, MD, MACP, another ACP coauthor and medical director for ambulatory EHR and health information technology policy at MedStar Health in Columbia, Md.

“Meaningful use certification has in many circumstances created workflows that are completely nonintuitive,” he said. “Vendors have to build toward regulatory requirements first. If you took those away, they could move to more elegant solutions.”

However, Mr. Kuhn said the usability situation is worse than it needs to be and that poor implementation is a big part of the problem. The federal incentive program included implementation help from regional extension centers (RECs). “We've heard from practices that the RECs' help absolutely worked, but the information is anecdotal,” he said. “The ONC needs to find a way to release the lessons learned from the program, so that we can apply them going forward.”

Each physician tends to have his or her own idiosyncratic way of charting, Dr. Yackel said, and that lack of standardization makes it difficult to agree on exactly what constitutes “usability.” Some users may attach the greatest importance to doing the most common tasks very quickly, while others may be more irritated by how hard it is to remember, or figure out, tasks they don't do very often.

“We need to define together what our standards are and how we want things to work,” he said.

Michael Zaroukian, MD, PhD, MACP, chief medical information officer at Sparrow Health in Lansing, Mich., professor of medicine at Michigan State University in East Lansing, Mich., and a contributor to the AMA's usability framework, has spent the past several years implementing and optimizing an EHR system at the 4-hospital system and its associated ambulatory practices.

He believes that while there are significant usability issues in many EHRs, physicians are sometimes much more sensitive to and intolerant of EHR usability problems they encounter in their busy practices than analogous problems they tolerate in the smartphones or other gadgets they adopt voluntarily and use in less hectic settings, for example, teeny keyboards, limited screen real estate, or rogue autocorrect functions.

However, he believes that one important and frequently overlooked aspect of EHR usability is user proficiency, which requires training and practice using agreed upon workflows that too many physicians choose to forgo or foreshorten.

“Even in a small practice, there's usually someone using the same system who is getting their work done well,” he said. “You should look for those superusers and harvest their best practices, as long as they're not taking dangerous shortcuts.”

As for vendors, Dr. Zaroukian said they could do more to allow users to personalize the way they see information and the options they have for clinical documentation. For example, voice recognition and documentation templates can be helpful to some users but of no interest to others.

Physicians who feel the meaningful use program rushed them into installing EHRs may be comforted that EHR vendors feel the same way, said Sarah T. Corley, MD, FACP, chief medical officer of EHR vendor Quality Systems, Inc. | NextGen Healthcare and vice chair of the Electronic Health Records Association, a vendor consortium.

“We like for people to want our products and have enough time to examine their workflows and plan for change,” she said. “It's about transforming your practice to take advantage of the system.”

The first stage of the meaningful use program wasn't too bad from the vendors' point of view, Dr. Corley said, since the required capabilities were straightforward and were often included in existing products already, or easy to add with a few tweaks. Stage 2 has been another story. With its focus on reporting quality measures, it required new system “functionality” that to physicians seems more like clutter.

“We had to add clicks so that meaningful use numerators could be captured, which doesn't necessarily provide benefit for the end user,” Dr. Corley said. “With a lot of time and thought, we could have mitigated it behind the scenes, but we didn't have a lot of time.”

Moreover, Dr. Corley said, physicians who adopted EHRs only because of the federal program are likely to have less friendly feelings toward technology than those who invested in EHRs without government prompting. “I'm tolerant of crawling around on the floor hooking up my own Internet,” she said. “Late adopters aren't going to do that.”

Dr. Corley said she doesn't anticipate a quick fix for physicians' frustrations. While usability research is progressing rapidly, it takes a while for vendors to incorporate the latest findings into their product designs and even longer to get them into hospitals and clinics, especially when many users are slow to upgrade to the most recent versions of their systems.

“We're making things better, and you won't have to wait years for improvements,” she said. “But right now physicians are deep in the valley of despair.”