Clinician Satisfaction Before and After Transition from a Basic to a Comprehensive Electronic Health Record
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Healthcare organizations are transitioning from basic to comprehensive electronic health records (EHRs) to meet Meaningful Use requirements and improve patient safety. Yet, full adoption of EHRs is lagging and may be linked to clinician dissatisfaction. In depth assessment of satisfaction before, during, and after EHR transition is rarely done. Using an adapted published tool to assess adoption and satisfaction with EHRs, we surveyed clinicians at a large, non-profit academic medical center before (baseline) and 6-12 months (short-term follow-up) and 12-24 months (long-term follow-up) after transition from a basic, locally-developed to a comprehensive, commercial EHR. Satisfaction with the EHR (overall and by component) was captured at each interval. Overall satisfaction was highest at baseline (85%), lowest at short-term follow-up (66%), and increasing at long-term follow-up (79%). This trend was similar for satisfaction with EHR components designed to improve patient safety including clinical decision support, patient communication, health information exchange, and system reliability. Conversely, at baseline, short-term and long-term follow-up, perceptions of productivity, ability to provide better care with the EHR, and satisfaction with available resources, were lower at both short- and long-term follow-up compared to baseline. Persistent dissatisfaction with productivity and resources was identified. Addressing determinants of dissatisfaction may increase full adoption of EHRs. Further investigation in larger populations is warranted.
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Clinician Satisfaction Before and After Transition from a Basic to a Comprehensive Electronic Health Record
- 1. Clinician Satisfaction Before and After Transition from a Basic to a Comprehensive Electronic Health Record Allison B. McCoy, PhD Richard V. Milani, MD Elizabeth Holt, PhD Marie Krousel-Wood, MD, MSPH
- 2. Disclosure Statement Southern Regional Meeting February 26-28, 2015 Speaker: Allison B. McCoy, PhD Dr. McCoy has documented that she has nothing to disclose.
- 3. Introduction • Electronic health records (EHRs) – Patient safety – Provider efficiency • Meaningful use incentive program • Barriers to EHR adoption – Costs, return on investment – Loss of productivity, clinician dissatisfaction 1http://healthit.gov
- 4. Introduction • EHR adoption vs. possession – Adoption – a specified set of EHR functions are implemented in at least one clinical unit – Possession – the hospital has a legal agreement with the EHR vendor, but is not equivalent to adoption – 59% vs. 93% (hospitals)1 – 48% vs. 78% (office-based physicians)2 1Charles D, Gabriel M, Furukawa MF. ONC Data Brief, no. 16. 2014. 2Hsiao C-J, Hing E. NCHS data brief, no 143. 2014.
- 5. Objective • Assess clinician satisfaction before, during, and after transition from a basic, locally- developed EHR to a comprehensive, vendor EHR
- 6. Study Setting • Not-for-profit academic medical center consisting of 8 hospitals and over 38 clinics in urban and rural settings – Preliminary evaluation included one site • EHR use for more than a decade
- 7. Survey Methods • Established survey methods1 based on published tool2 – Online via e-mail – Hard copy via standard mail • Incentives provided – iPad raffle – Flash drive or pen with hard copy 1 Dillman, DA, et al. Mail and Internet Surveys: The Tailored Design Method. 2000. 2 DesRoches CM, et al. N Engl J Med 2008.
- 8. Survey Components EHR System Use • The EHR decreases time in scheduling of consults. • …decreases the time in getting results of consults. • …allows me to access, store and retrieve patient information without difficulties. • …provides easy access to relevant clinical information when patients are transitioning between hospital to clinic or clinic to hospital. • …provides timely and accurate information to me. • …is a valuable aid to me in tracking and/or monitoring patients.
- 9. Survey Components EHR System Use • The EHR allows me to spend more time on other aspects of patient care. • …increases coordination between departments. • …facilitates the process of scheduling patients. • …improves the safety of patients. • …improves my productivity on the job. • …allows me to provide better care for my patients. • I have sufficient access to computers with the EHR. • There are adequate resources (staff, training, help lines) available to turn to for help in solving problems with the EHR.
- 10. Survey Components Assessment of the EHR • The EHR positively affects the quality of clinical decisions. • …facilitates communication with other providers. • …facilitates communication with my patients. • …assists with prescription refills. • …provides me with timely access to medical records. • …helps providers to avoid medication errors. • …facilitates the delivery of preventive care that meets guidelines.
- 11. Survey Components Patient Care • In providing patient care, have you avoided a drug allergy because of the EHR? • …avoided a potentially dangerous medication interaction because of the EHR? • …been alerted to a critical lab value because of the EHR? • …provided preventive care (e.g. vaccine, colonoscopy, mammogram) because you were prompted by the EHR? • …ordered an indicated lab test (such as A1c or LDL) as a result of an electronic prompt from the EHR?
- 12. Survey Components Satisfaction • Overall, how satisfied are you with the EHR system? • How satisfied are you with the ease of use when providing direct care to a patient. • …the reliability of the system (i.e. frequency of system failures, system speed). • …the sharing of medical information with system hospitals and health-care providers. • …obtaining medical information from outside hospitals and providers
- 13. Timeline Baseline Survey EHR Transition First Followup Survey Second Followup Survey 6 months 6 months
- 14. Analysis • Unadjusted – McNemar’s chi-squared test • Adjusted – random effect logistic regression – Age – Gender – Setting (outpatient vs. inpatient vs. both) – Practice (primary care vs. specialty care) – Time worked at study setting
- 15. Study Eligibility and Response Contact information for active providers obtained Ineligible CRNAs, Residents, Fellows, PRN, Worked < 6 months, Resign/Retire over study period, etc. Eligible Active MDs, DOs, NP, PA, Optometry, Mental Health Professionals Baseline Respondents (N=83) First Follow-up Respondents (N=51) Second Follow-up Respondents (N=47) * Recapture Rate: 47/83 (57%)
- 16. Respondents Gender Male Female 29 (62%) 18 (38%) Age 26-35 years old 36-45 years old 46-55 years old 56-65 years old > 65 years old 4 (9%) 16 (34%) 13 (28%) 12 (26%) 2 (4%) Training Staff Physician - MD Staff Physician - DO Mid Level Provider Optometrist Mental Health Professional 35 (76%) 1 (2%) 7 (15%) 2 (4%) 1 (2%)
- 17. Respondents Worked at Study Setting < 1 year 1 to < 5 years 5 to < 10 years 10 to < 20 years 20 years or more 3 (6%) 13 (28%) 18 (38%) 9 (19%) 4 (9%) Setting Outpatient only Inpatient only Outpatient and inpatient 24 (51%) 5 (11%) 18 (38%) Practice Primary Care Medical Specialty Surgical Specialty Hospital Medicine Anesthesia Laboratory/Radiology Services 19 (42%) 6 (13%) 12 (27%) 4 (9%) 2 (4%) 2 (4%)
- 18. Overall Provider Satisfaction 85.0% 66.0% 79.0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Baseline 6 Months 1 Year Note: Satisfaction = very satisfied/somewhat satisfied Unadjusted p=0.02, Adjusted p=0.11 Unadjusted p=0.03 Adjusted p=0.25 Unadjusted p=0.41, Adjusted p=0.53
- 19. Patient Safety 19% 83% 36% 72% 60% 9% 68% 13% 51% 57% 11% 66% 13% 40% 47% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Ordered an indicated lab test (such as A1c or LDL) as a result of an electronic prompt from the EHR. Been alerted to a critical lab value because of the EHR. Provided preventive care because you were prompted by the EHR? I feel the EHR improves the safety of patients. Using the EHR facilitates the delivery of preventive care that meets guidelines. Baseline 6 Months 1 Year Note: Satisfaction = very satisfied/somewhat satisfied, strongly agree/agree, in the last 6 months/ever *Unadjusted p < 0.05, †Adjusted p < 0.05 * * * * *
- 20. Health Information Exchange 38% 91% 85% 68% 64% 32% 96% 79% 64% 53% 26% 74% 87% 57% 38% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Obtaining medical information from outside hospitals and providers. Sharing of medical information with system hospitals and health-care providers. The EHR facilitates communication with other providers. The EHR facilitates communication with my patients. When patients are transitioning between hospital to clinic or clinic to hospital, the EHR provides easy access to relevant clinical information. Baseline 6 Months 1 Year Note: Satisfaction = very satisfied/somewhat satisfied, strongly agree/agree, in the last 6 months/ever *Unadjusted p < 0.05, †Adjusted p < 0.05 * * *
- 21. Productivity and Patient Care 40% 15% 68% 49% 28% 34% 17% 68% 43% 26% 62% 21% 83% 81% 45% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% There are adequate resources available to turn to for help in solving problems with the EHR. The EHR allows me to spend more time on other aspects of patient care. Ease of use when providing direct care to a patient. Using the EHR allows me to provide better care for my patients. Using the EHR improves my productivity on the job. Baseline 6 Months 1 Year Note: Satisfaction = very satisfied/somewhat satisfied, strongly agree/agree, in the last 6 months/ever *Unadjusted p < 0.05, †Adjusted p < 0.05 * * * * * * * †
- 22. Strengths and Limitations • Longitudinal data over three time periods • Majority adopters in real world setting vs. innovators and early adopters • Single study site • Modest response rate
- 23. Conclusions • Overall and after adjustment for age, gender, time in practice, and specialty, non-significant trends of initial lower satisfaction and subsequent improvement in satisfaction over time were identified. • Increasing trends were identified in several items related to patient safety and health information exchange.
- 24. Conclusions • Assessment of these trends in a larger sample is underway. • Longer follow up is necessary to determine if EHRs demonstrate improvements over time in patient care and safety in real-world settings. • Further research includes opportunities to identify components predictive of safety, quality, and EHR use.
- 25. Implications • Overcome barriers to EHR adoption • Improve EHR training and rollout • Improve patient safety and quality
- 26. Questions?
Notas del editor
- Thank you for the introduction. I’m excited to present this work that my colleagues and I have been working on to study the satisfaction and adoption of electronic health records.
- Before I get started, I have no disclosures to report.
- Implementations of electronic health records, or EHRs, have been increasing in recent years for many reasons. Most importantly, research has indicated that they have the potential to improve patient safety through clinical decision support and other features. They can also improve provider efficiency, for example by making patient information more readily available and improving communication. Meaningful Use has been another reason for increased adoption, and this is an incentive program from CMS. Its goal is to promote so-called meaningful use of EHRs, to increase data capturing, advance clinical processes, and improved outcomes. There are some known barriers to EHR adoption, and these primarily include concerns about cost and return on investment, along with the potential for loss of productivity and resulting clinician dissatisfaction.
- Some recent reports have been released describing EHR adoption across the country. One thing to note is that there is a distinction between having actually adopted an EHR compared to being in possession of an EHR. For these reports, they defined adoption as having implemented a specified set of EHR functions in at least one unit, such as having electronic patient data and computerized provider order entry. Hospitals and physicians can be in possession of an EHR or have implemented some of the software functionalities without having actually adopted the EHR. What these reports found is that despite all of the incentives for having EHRs, actual adoption is low. For hospitals, 59% met the criteria for having fully adopted an EHR, compared to 93% of hospitals who have are in possession. Similarly, only 48% of office-based physicians have fully adopted an EHR, compared to 78% who are in possession of one. While these numbers are significantly increased from previous reports over the last decade, there is still a lot of room for improvement.
- Given the potential for dissatisfaction to affect EHR adoption, our objective in this study was to assess clinician satisfaction before, during, and after transition from a basic, locally-developed EHR to a comprehensive, vendor EHR – in our case, Epic.
- We performed our study in a not-for-profit academic medical center that consists of 8 hospitals and over 38 clinics in urban and rural settings. What I’m presenting today is just a preliminary evaluation of the data, which includes satisfaction at one of these sites. One of the great things about this medical center is that they have been using an EHR for more than a decade, although the switch to the vendor system is more recent.
- We used established survey methods and repurposed an existing survey, published in the New England Journal, to assess EHR satisfaction and adoption. We first sent out e-mails to the clinicians with a link to the survey, and after about 10 e-mails, if they hadn’t yet responded, we sent out hard copies about 3 different times via standard mail with an enclosed self-addressed stamped envelope. We did provide incentives for completing the survey, so all respondents were entered into a raffle to win an iPad, and hard copy surveys that were mailed out included either a flash drive or a pen.
- There were 4 main components to the survey, each with a set of corresponding questions that we asked. The first component addressed EHR system use, so we asked questions about whether the EHR helped with consults and accessing patient information.
- Other questions about EHR system use asked about patient care, processes, safety, productivity, and access to resources.
- We asked them about their assessment of the EHR, including how it affects the quality of clinical decisions, communication, access to records, avoiding medication errors, and delivery of preventive care.
- Questions about patient care asked whether the EHR resulted in the avoiding interactions, whether they had been alerted to critical labs, provided preventive care, and ordered an indicated tests.
- Finally, we asked about their satisfaction, including how satisfied they were overall, and with different specific components.
- We went out 3 surveys to the clinicians. The baseline survey was sent out while the clinicians were using the older, locally-developed, basic EHR. We sent out the first followup survey approximately 6 months after we implemented and made the transition to the new, comprehensive EHR, and we sent the second followup survey out about 6 months after that.
- We first compared the responses for the three surveys using McNemar’s chi-squared tests, and then we used a random effect logistic regression model to adjust for age, gender, setting, practice, and time worked at the study setting.
- Eligible providers included full time active physicians, nurse practitioners, physician assistants, and optometrists. We excluded CRNAs, trainees, those who had worked at the study setting for less than 6 months, and those who resigned or retired during the study period. As I mentioned, these results are preliminary and do not include all sites at the institution, so I only have the numbers starting from those who completed the baseline survey. I do know that in the whole population, we had about 1300 active providers, 1130 eligible (86%), and 580 baseline respondents (52%), so I suspect that the response rates for this setting similar. We had 83 clinicians respond to the baseline survey, 51 respond to the first follow up, and 47 respond to the second follow up, which is a 57% recapture rate from baseline.
- Among those who responded, 62% were male, the majority were between 26 and 65 years old, and most were staff physicians.
- The respondents had mostly worked at the institution for 1 to 20 years, half were in an outpatient only practice, and a little bit less than half were in a primary care practice.
- Overall satisfaction was highest at baseline (85% satisfied), lowest at 6 months (66% satisfied), and increasing at 1 year (79% satisfied). Unadjusted differences in satisfaction between baseline and 6 months and between 6 months and 1 year were statistically significant, but the difference between baseline and 1 year was not. However, in the adjusted model, none of the differences were significant, likely due to the smaller sample size. This trend was similar across most of the questions we asked, where satisfaction dropped at 6 months and came back up close to baseline at a year, but there were some responses with a different trend, so I’ll go through those selected responses in more detail.
- Some of the questions about patient safety actually had an increasing trend at both 6 months and 1 year. Some of these were significant increases initially, but none of them were significant after adjustments.
- The increasing trends continued for some questions about information exchange with the EHR. Again, some of these were significant increases before adjustments, but none of them were significant afterward.
- Some responses actually went in the opposite direction, for example some of the questions about perceived productivity and ability to provide patient care. Only one of these was statistically significant in our adjusted analysis, and this was the difference between baseline and 6 months for whether clinicians felt like they could provide better care while using the EHR. This is one area where we can really spend some time on future research identifying problems and making improvements to satisfaction and adoption.
- Our study has some important strengths and limitations. One of the strengths is that we have longitudinal data over three time periods about clinician satisfaction instead of data at just a single point in time. Our study is also really unique in that we did our survey in a real world, typical setting, compared to innovators and early adopters that were assessed in previous studies. The limitations, however, are that in this analysis we were only looking at a single study site, although some early analyses of the larger population confirm that the trends we saw here persist across all study sites, so I expect we’ll have some more significant findings when we finish that evaluation. We also had a modest response rate for the surveys at about 50%, but with a large population of busy clinicians with 3 surveys, I think this is pretty acceptable.
- The primary conclusions from this study are that while overall satisfaction trended downward initially, we did see an increasing trend over time, so it’s important to continually assess satisfaction and make improvements wherever possible when implementing new technology. There are a lot of opportunities for further research, including opportunities to identify components predictive of safety, quality, and EHR use. In particular, we should explore in detail some of the responses, especially the perceptions on the ability to provide better care, to see if we can make improvements.
- The primary conclusions from this study are that while overall satisfaction trended downward initially, we did see an increasing trend over time, so it’s important to continually assess satisfaction and make improvements wherever possible when implementing new technology. There are a lot of opportunities for further research, including opportunities to identify components predictive of safety, quality, and EHR use. In particular, we should explore in detail some of the responses, especially the perceptions on the ability to provide better care, to see if we can make improvements.
- The implications of this research are huge, so hopefully with these results we can work in overcoming barriers that are preventing clinicains from fully adopting EHRs, we can improve the training and rollout of these EHRs, and ultimately we can improve patient safety and quality.