Recent RAND study provides the key drivers of physician dissatisfaction with EHRs and its affect on physician professional satisfaction.
A recent RAND research report reveals that the current state of EHR technology significantly worsened professional satisfaction in multiple ways. The project sponsored by the American Medical Association (AMA) gathered data from 108 in-person interviews and received 447 written responses across 30 physician practices in six states: Colorado, Massachusetts, North Carolina, Texas, Washington, and Wisconsin.
Key findings from the report cited the following nine key drivers of physician dissatisfaction with EHRs:
1. Time-Consuming Data Entry
The majority of physicians who interacted with EHRs directly (i.e., without using a scribe or other assistant) described cumbersome, time-consuming data entry. Physicians who used template-based notes or scribes were less likely to express these concerns.
A primary care physician express their frustration saying,
“All of the [EHRs] that I’ve seen have actually been very time-consuming for physicians. Physicians have to order everything themselves, which is time-consuming, and do all the data entry themselves, which is time consuming. [EHRs] at this point in the development are not time savers for physicians. They’re big time sinks. Everyone agrees, everyone I talk to in every practice.”
2. User Interfaces That Do Not Match Clinical Workflow
Beyond data entry, physicians and their colleagues described EHR user interfaces that, in important ways, hampered rather than facilitated their clinical workflow. Lack of intuitive order entry was noted as extremely problematic for physicians.
“For me, the most frustrating part is the extra time it takes. So if you have ten patients to round on, rounding on them isn’t hard; it’s all the order entry….Like the other day, I discharged a patient, and I went through every step, at least I thought I did. I did everything I thought I was supposed to do, and about an hour later, I got a call from the nurse saying, “I can’t discharge the patient. It won’t let me finish my part.” It turns out there was one button that I missed clicking, so she and I were on the phone, both on the computer looking at this patient’s chart, trying to figure out why it wouldn’t work. And it’s just so time-consuming,” said a pediatrician.
3. Interference with Face to Face Patient Care
Performing EHR data entry via keyboard described was cited as interfering with face to face patient care. Physicians have been forced to divide their attention between the patient and the computer or defer data entry until after leaving the patient leading to longer work hours.
4. Insufficient Health Information Exchange
Physicians in multiple specialties and a range of practice settings described frustration when health information was not exchanged between EHRs cited faxes as a common mode of exchanging patient information between care settings. The study found even when practices invested in EHRs, faxes were a common mode of communicating patient information between care settings. A primary care physician stated:
“We still get things faxed, and so we get the paper. Then the paper we have to … scan it into the system. So it hasn’t really saved us completely from paper. I’ve been in the system now two years, about, and still we have papers. We still have to scan, every day we have to do this. And plus the systems that you work with, not all of them talk to each other, as you know. … So also when the labs come, you know we have only one lab now that talks to us. So if people do labs different places then it comes in the form of [a] fax. … And also, we don’t have, yet, radiologist systems that talk to us. So it’s always again, it’s a fax, same thing scanned in.”
5. Information Overload
Physicians cited suffering from alert fatigue creating a unceasing volume of messages beyond the number they can managed diligently.
6. Mismatch between Meaningful Use Criteria and Clinical Practice
Primary care and subspecialist physicians cited a misa mismatch between meaningful-use criteria and what they considered to be the most important elements of patient care. Primary care physicians reported the documentation burden of meeting the meaningful use criteria detracted them from patient care.
7. EHRs Threaten Practice Finances
Purchasing an EHR solution exposed a physician practice to significant financial risks, in particular, the cost of switching EHRs. Other physicians in practice management positions expressed concern about the ongoing costs of maintaining their EHRs.
8. EHRs Require Physicians to Perform Lower-Skilled Work
Physicians who did not use scribes reported that their EHRs required them to perform tasks below their level of training, decreasing their efficiency.
9. Template-Based Notes Degrade the Quality of Clinical Documentation
While some physicians described using templates (or “macros”) to ease the writing of clinical notes (i.e., to overcome data entry problems), many described misuse of template-based notes as a significant threat to both clinical quality and professional satisfaction. Such notes were described as complicating the task of retrieving useful clinical information.
It is important to note that some of the causes cited were more prominent for senior physicians including those that lacked transcriptionists, scribes and staff to support data entry.
Despite the concerns highlighted in the study, physicians in multiple specialties and practice models still overwhelming felt EHRs improved their abilities to access patient data, patient engagement and quality of care.
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