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Electronic Health Records: How to Reduce Dissatisfaction with Them and Increase Their Usability

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Pat Stricker, RN, MEd
Senior Vice President
TCS Healthcare Technologies

It has been eight years since the Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted to stimulate the adoption of electronic health records (EHRs). When it was enacted in February 2009, healthcare providers were offered financial incentives for demonstrating "meaningful use" of EHRs. Meaningful use (MU) guidelines define minimum U.S. government standards for using EHRs and for exchanging patient data between healthcare providers, insurers, and patients.

The goals of meaningful use were to use EHR technology to improve quality, safety, and efficiency; reduce health disparities; engage patients and families; improve care coordination; improve population and public health; and maintain privacy and security of patient health information. As a result, it was hoped that clinical and population health outcomes would improve, transparency and efficiency would be increased, and more robust research data on health systems would be available.

The rollout was scheduled in three (two-year) stages, to be finished by 2015, but because of a slow start, the time frame was moved back from 2015 to 2017. After that time, providers may receive penalties if meaningful use is not demonstrated. The objectives of each stage were:

  • Stage 1 2011-2012 Data capture and sharing (focused on promoting adoption of EHRs)
  • Stage 2 2014-2016 Advance clinical processes (clinical decision support, care coordination requirements, and patient engagement rules)
  • Stage 3 2017 Improved outcomes (robust health information exchanges)

For providers to be compliant and receive the financial incentive, they had to use government-certified EHR technology (CEHRT). The program was voluntary, but the incentives provided a strong economic reason to participate.

The goal of meaningful use was to encourage the use of EHRs, and you can see from the following statistics that it has certainly accomplished that in a relatively short time.

Provider organizations using EHRs in 2015:

In 2009, $27.4 billion was set aside to jump-start the use of EHRs. By December 2012, the Centers for Medicare & Medicaid Services (CMS), which administers the program, paid $9 billion to more than 177,000 eligible professionals and hospitals. As of February 2017, a total of $23.9 billion has been paid to more than 517,000 healthcare providers participating in this program. Unfortunately, some original participants dropped out of the MU program at Stage 2 due to the difficulty in meeting the requirements to "view, download and transit" data. While they are not in the program, they are still using EHRs.

The program also created a lot of additional EHR vendors. In 2009, there were 96, and by 2012 there were 229. Today, there are over 1,100 vendors providing basic and certified program. The Certified Health IT Product List (CHPL), which is a comprehensive list of Health IT products that have been tested and certified by The Office of the National Coordinator of Health IT (ONC) for use in this program, lists 343 certified EHR products. The CHPL website provides details of each product and allows users to compare products. It is a very useful tool for organizations thinking about purchasing a new system or changing from their current one.

Speaking of changing from one system to another, it seems that a large number of organizations are already switching from their original EHR to new ones. Why would they be doing that so quickly, especially given the time, effort, loss of productivity, and cost of the change?

A survey of hospital executives found that 40 percent were dissatisfied with or indifferent about their current system, and a KLAS Research study of 400 practices of different sizes found that 30-40 percent of healthcare organizations and physician groups are changing or planning to change their EHRs. While some changes are being done to obtain a larger system for their growing needs or to consolidate disparate systems because of mergers or acquisitions, more than 50 percent of the changes are due to dissatisfaction with the usability (54 percent) or functionality (53 percent) of the original system. Specific examples of these and other dissatisfactions included:

  • User interfaces do not match clinical workflows and processes, and they cannot be changed
  • Difficult, complex, non-intuitive navigation
  • Time-consuming data entry (requires point/click and cannot use narrative, text entries)
  • Interference with face-to-face patient interactions
  • Decreased productivity
  • Too much functionality leads to confusing workflows, complexity, and increased time
  • Increases physician documentation time (requires physicians to perform tasks that could be done by transcribers or data entry assistants)
  • Degradation of quality documentation (requires template-based notes)
  • Voice-activated dictation is not accurate
  • Information overload (repetitive and non-essential automatic alerts, messages, and reminders)
  • Lack of interoperability that leads to incomplete medical record (doesn’t seamlessly transfer data from all systems)
  • Many of the efficiencies are designed for office operations, not the physician’s clinical processes
  • Systems don’t improve over time (vendors don’t make requested changes or improvements)
  • Cost of the system

The American Medical Association (AMA) sponsored a research study, conducted by RAND Health, to determine factors that influenced physician professional satisfaction. One of the topics studied was the use of 14 different EHR systems. They found that most physicians approved of the concept of using EHRs because they feel they provide remote access to patient data, improved tracking of guideline compliance and disease markers, better communication among healthcare team members, and improvements in the quality of care. Yet, 45 percent of the providers felt patient care was worse, and 69 percent said care coordination with hospitals had not improved since using the EHR. Only 18 percent of the providers preferred paper records to EHRs.

Why is there so much dissatisfaction?

One thing we need to keep in mind is that dissatisfaction (and satisfactions) are perceptions based solely on the experience of a user. The perceptions are not based on objective, measureable facts or statistics. They can be attributed to and influenced by the user’s computer competency, personal attitudes about technology, usability, design, functionality, practice size, organizational structure, clinical and business processes, hardware, or speed of the system. Over time, the satisfaction rates with EHRs have increased. Improvements in the systems may account for some of the increased satisfaction, but some may also be attributed to providers becoming more familiar and accustomed to working in EHRs and seeing the value they bring to the patient and the entire healthcare team.

What can be done to improve EHRs and increase provider satisfaction?

The KLAS study mentioned above identified usability and functionality as the two main reasons for changing EHR systems. These need to be addressed in order to increase provider satisfaction with EHR systems. The AMA, working with an external advisory committee of practicing physicians and health IT experts, researchers, and executives, developed a new framework for EHR usability to leverage the potential of EHRs to enhance patient care, improve productivity, and reduce administrative costs. The framework identified eight solutions requested by providers that should be included in the design of all EHRs:

  • Enhance Ability to Provide High-Quality Patient Care

Enable physician-patient engagement. The use of cumbersome, time-consuming documentation requirements and pop-up reminders should be streamlined. The system should fit seamlessly into practice workflows, so physicians have time to engage in face-to-face patient interactions.

  • Support Team-Based Care

Maximize productivity. Allow physicians to delegate tasks and parts of the documentation to others, as appropriate.

  • Promote Care Coordination

Provide seamless connection with other systems, so data can be transferred in real-time to create a complete patient record. Provide automatic tracking of referrals, consultations, orders, and labs.

  • Offer Modularity and Configurability

EHR workflows should be effective and efficient and fit seamlessly into the practice’s workflows and processes. They should be able to be configured easily by the provider to meet the changing needs of the practice and the patient population.

  • Reduce Cognitive Workload

Medical decision-making should be supported by including customized tools for reporting, analyzing data, and supporting decisions.

  • Promote Interoperability and Data Exchange

Data should be imported and exported to/from other systems to provide a coherent, real-time, longitudinal patient record.

  • Facilitate Digital Patient Engagement

Interoperability should be incorporated with mobile and telehealth technologies to provide a platform that can manage chronic conditions and promote health and wellness.

  • Use Provider Input and Feedback in Product Design

Provider feedback and suggestions, as well as context-sensitive automated feedback, should be used by the vendor to improve the EHR’s performance.

Incorporating these design suggestions into EHRs would make them fit more seamlessly into a provider’s practice and thereby increase the provider’s satisfaction level.

Things to Keep In Mind When Looking for a New EHR System

For those who may be looking for a new EHR system, there are a few suggestions that may help make the process easier. The first step is to research vendors and their products very carefully, so you are sure you are choosing the ones that best fit your organization. This will also make sure you don’t waste your time sitting in on demos for systems that really don’t even meet your needs. The Black Book Rankings of Top Ambulatory EHR Vendors is a good resource to use, along with the Certified Health IT Product List and its website. Make sure the vendor verifies that they can configure the system to add your workflows and that there should not be a separate customized charge for this. Give them a couple of your key workflows and ask them to configure an example in the system for your demo. This will let you know if they can really add it and show you their level of customer service and commitment.

Prepare an objective check sheet to be used during the demo by your selection team that lists all your key "must have" requirements and provides an area for comments about the product. The team should fill out the sheet for each product during the demo and return it at the end of the demo.

Once an EHR has been selected, spend time prior to the beginning of the implementation to work on reviewing and revising all your workflows to make sure they are up to date and meet your specific needs. They should be developed without thinking about how they will "fit into" the system. The vendor will be responsible for making sure your workflow fits in the system. Also, be sure to review each workflow with the vendor to see if there are ways to automate specific functions in order to streamline the process and provide even more efficiency. These things all take time, but it will be more than worth it when you have an easy-to-use, streamlined system.

Jacob Reider, family practice physician and director of the Office of the Chief Medical Officer of ONC, encourages physicians to take their time, act deliberately, learn from others, and leverage IT toward practice transformation when implementing IT systems. This means thinking very carefully about each workflow and how it can be optimized to leverage work processes. He cautions that if physicians think they can just plug in a computer and start using it, as is, they are going to have problems.

Pat Stricker, RN, MEd, is senior vice president of Clinical Services at TCS Healthcare Technologies. She can be reached at pstricker@tcshealthcare.com.

 

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