Electronic health records (EHRs) were pioneered in medicine nearly 30 years ago, but only in the past decade have large numbers of physicians adopted their use. The conversion from paper records to EHRs requires extensive time, money, and energy, and users' opinions as to whether it is worth it are mixed.
POOR GRADES FOR EHRs
In 2014, Kane and Chesanow surveyed 18,575 physicians about their use of EHR systems and asked participants to rate them on a scale of 1 (poor) to 5 (excellent).1 The 18 top-rated EHR systems received average grades from 3.9 to 2.6, suggesting that physicians generally remain unimpressed with the performance and use of EHRs, even with the best systems.
In terms of the drivers of physicians' dissatisfaction, 70% cited decreased face time with patients, and 57% noted a reduced ability to see more patients. Thirty-eight percent of respondents specifically associated EHRs with worsened service. On the other hand, some respondents noted an improvement in responding to patients' issues (35%), documentation (63%), and collections (39%).
Physicians' opinions were split regarding clinical operations, patient services, and staff management. About 35% claimed EHRs improved these critical aspects, and 35% stated the opposite.
Clearly, there is a dichotomy between physicians who have perceived benefits from EHR adoption and those who have found the technology to be an impediment. Experience may be one key factor in this division. In the survey, 81% agreed that, with time, using an EHR system became more comfortable.
WHAT ARE THE BENEFITS?
Two benefits that satisfied EHR users commonly mention are improvements in documentation and billing.2 With this technology, charts are not lost, and partners' notes are legible. Physicians have access to patients' records when they are on call, which may reduce inappropriate or erroneous medication refills, especially for glaucoma patients who have not been seen for many years. Physicians have also realized significant cost savings in transcription or dictation services. Although staffing reductions are uncommon as a result of adopting an EHR system, many physicians report that, with staff freed of tasks like filing, they can assume more productive roles such as in patient services.
Expert EHR users have exploited EHR data summary functions and tracking to facilitate better care. Summary screens with the dates, results of tests and procedures, and trends over time save time spent on chart searching and eliminate duplicated efforts. EHRs have also aided in recruitment efforts for studies.3 On the balance, e-prescribing can save time, may reduce errors, and in some systems, allow providers to see refill information. Physicians can more easily track their own outcomes, although many are concerned about third parties' accessing this information.
Even EHR enthusiasts admit that physicians now have the continued challenge of talking to monitors rather than patients. Interestingly, some users of EHR systems have found ergonomic interventions to minimize this issue. Documentation time remains a key issue.4-6 EHR system selection, customization, and physicians' expertise are critical factors. The proper use of the copy and paste functions (or copy forward function) and automated letters are tools that can save time and reduce drudgery when used intelligently but, like a sharp scalpel, can be wielded with dangerous results.
PATIENTS' AND PHYSICIANS' PERCEPTIONS
Computer technology is ubiquitous, and patients expect medicine to be high tech. Paper charts are not consistent with the image that most physicians wish to convey to their patients. Health care providers' use of technology has an impact on patients' perceptions of a practice.
Physicians have perceived EHRs as the source of woes, but in many ways, the technology has been the messenger or vehicle by which third-party regulations and requirements have been imposed. Some of the inefficiencies in EHR systems are driven by documentation requirements related to coding, legal concerns, and meaningful use initiatives that may not be directly related to providing excellent care. The realization that many of the constraints inherent in the transition to EHRs are related to outside regulations may reduce misplaced anger. Thus, EHRs can be viewed as a solution to these impositions rather than the source.
Considering the challenges, the complexities, and the broad and diverse reactions to EHRs, these are clearly interesting times to be a physician. Some physicians have been more successful in this transition, and the rest need to seek those individuals out and emulate their efforts. Not only will this prevent the proverbial reinvention of the wheel, but it will also help drive the EHR industry to copy best practices. Physicians' flexibility, leadership, and active involvement in this process are critical to their welfare and that of their staffs and patients. n
1. Kane L, Chesanow N. Medscape EHR Report 2014. Medscape News and Perspective. Published July 15, 2014. http://www.medscape.com/features/slideshow/public/ehr2014. Accessed January 15, 2015.
2. Sanders DS, Lattin DJ, Read-Brown S, et al. Electronic health record systems in ophthalmology: impact on clinical documentation. Ophthalmology. 2013;120(9):1745-1755.
3. Embi PJ, Jain A, Clark J, et al. Effect of a clinical trial alert system on physician participation in trial recruitment. Arch Intern Med. 2005;165(19):2272-2277.
4. Chan P, Thyparampil PJ, Chiang MF. Accuracy and speed of electronic health record versus paper-based ophthalmic documentation strategies. Am J Ophthalmol. 2013;156(1):165-172.
5. Chiang MF, Read-Brown S, Tu DC, et al. Evaluation of electronic health record implementation in ophthalmology at an academic medical center (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2013;111:70-92.
6. Wakamiya S, Yamauchi K. Evaluation of electronic medical records for ophthalmology based on changes in staff work through introduction of electronization. Stud Health Technol Inform. 2013;192:968.
Jonathan S. Myers, MD
• associate attending surgeon on the Glaucoma Service at Wills Eye Hospital and director of the Glaucoma Fellowship
• (215) 928-3197; firstname.lastname@example.org
• financial disclosure: has paid fees to NextGen Healthcare for 10 years for EHR products and services