While it’s no secret that physicians have complaints about electronic health records (EHRs), the co-author of a new medical study about hospital-based physicians’ perceptions of EHRs says the study findings illustrate that EHR usability should be addressed as a quality of care issue.
As reported by Healthcare Informatics, an analysis by researchers at Brown University and Healthcentric Advisors, and recently published in the Journal of Innovation in Health Informatics, found that hospital-based physicians and office-based physicians generally perceive EHRs, in their current design, negatively altering patient interactions, however, hospital-based physicians cited different reasons than their office-based counterparts. Hospital-based physicians commented most frequently that using EHRs takes time away from patient contact; office-based physicians commented on EHRs worsening the quality of their patient interactions and relationships.
The analysis is based on the open-ended answers that 744 doctors gave to this question on a Rhode Island Department of Health survey in 2014 on health information technology: “How does using an EHR affect your interaction with patients?”
According to the study, one hospital-based physician commented, “We spend less time at bedside and more time interacting with our computers.” The study found that the second most common theme among hospital-based physicians was the negative impact of EHRs on the quality of interactions with patients and therefore physicians’ relationships with patients. One hospital-based respondent commented, “My nose is now burrowed deep into my computer interface, leaving markedly reduced time to make eye contact and actually interact one on one with my patient.” The study also found that hospital-based physicians report benefits from using EHRs, ranging from better information access to improved patient education and communication.
The study authors contend that this particular analysis is novel for its relatively large sample size and its incorporation of both hospital and office-based physicians. And, the findings add to the prior literature, which focuses on outpatient physicians, and can be used to shape interventions to improve how EHRs are used in inpatient settings, the study authors stated.
The study was led by Rebekah Gardner, M.D., an associate professor of medicine at the Warren Alpert Medical School of Brown University and a senior medical scientist with Healthcentric Advisors; Kimberly Pelland of Healthcentric Advisors and Rosa Baier, associate director of the Center for Long-Term Care Quality and Innovation and an associate professor of the practice at the Brown University School of Public Health.
Healthcare Informatics Associate Editor Heather Landi recently spoke with Gardner about the implications of the study findings, the issue of EHR software usability and the potential impact on quality of care.
What motivated you and your fellow researchers to examine this issue of EHRs and the impact on physician-patient interaction in hospitals?
The Rhode Island Department of Health has been administrating this health IT survey since 2008, and every year there’s a box at the end that says, ‘If you have any additional comments, please leave them here.” It’s a standard survey box, and we were struck by the anguish that came through in the comments that people chose to leave and we really noticed quite a common theme where people said, ‘We get it, EHRs aren’t going away and they do add value, but here are the things that really make it so hard for us.’ After reading these comments year after year, we thought we needed to get at this in a more scientific way. So, we specifically included a question about the patient interactions and devoted time to doing an actual qualitative analysis, which is different than reading through comments and getting a general sense. In 2014, we invented that particular question [used in the study] and we wanted to take a more scientific approach to echo what we had been hearing for years, but hadn’t really fully captured by the usual use of multiple choice questions.
What is unique about this study compared to previous research about physicians’ use of EHRs?
Most of the research has been done in the office-setting, mostly around primary care physicians and family physicians. Those physicians are all unified in way because there is a commonality across the doctors who see the same patients time and time again; they have a longitudinal relationship with patients. They are usually using a computer in the exams room. That’s a particular type of doctor-patient relationship, and a particular use of the computer. We really noticed an absence in the literature of inpatient physicians. I practice medicine, personally, both in the office and in the hospital and reflecting on that, the way we use the computer in the hospital is quite different. Usually the computer is outside the exam room; we go in and have a conversation with the patient that we’re meeting for the first time that day and may never see again. Then, I go and document later in the chart without the patient being there. The way the computer is part of the physicians’ day is quite different and the relationship between the patient and the physician is quite different. We wanted to get a sense of whether the computer is even an issue, honestly, for inpatient doctors, and it turns out, it was.
Where you surprised with the study’s findings, or did the findings resonate with what you have experienced?
I would say the outpatient data was not at all surprising to us; it reinforces what’s been shown in other studies. This was a fairly large data sample compared to other qualitative studies, which have been more focus groups and the nature of that study design limits the number of study participants. It was gratifying to see that we certainly reinforced findings that have been found elsewhere, and we were able to show that across specialties as well, which is different, and that was not surprising but it was validating. For us, the inpatient findings were surprising in that computers really do bother inpatient physicians a lot, but for different reasons. Thinking about it, it makes sense. But we didn’t typically get ad hoc comments from inpatient physicians about their distress. Reading those comments and seeing their perspectives was interesting and, we feel, hadn’t been shared before.
What are the implications of these study findings, for physicians, for technology vendors and even for health IT policymakers?
Certainly, reading this makes you think about, ‘Okay, now what, what do we do with this?’ I would say there may be different answers in the different settings. There are folks, especially at the University of Chicago, who are doing great work on how outpatient physicians can better incorporate the EHRs into the patient visits. They have models where they instruct physicians; when you walk into the exam room, don’t turn on the computer, greet the patient, make eye contact, do what’s called ‘honoring the golden minute’ and have that face-to-face conversation before turning on the computer and also narrate whatever you’re doing on the computer as you do it and face the screen so that it’s also facing the patient. And these are all strategies to engage the patient, bring the patient into that computer experience, so the patient doesn’t feel so ignored. There is some merit to those strategies to really bring the patient in and try to improve the relationship, as it stands. It will be interesting when they take those studies to the next step and measure what patients think of that, that will be helpful to see.
In the inpatient setting, that’s not the issue we found, so we think the solutions there may be different. In the inpatient setting, we’ve heard loud and clear about the documentation burden and, certainly, outpatient physicians will be the second loudest voice on that. And what we’ve heard is that there is so much in the documentation requirements for quality measures, for billing, for public reporting; the EHR is there to serve so many different masters. It’s really not just a chart for clinical care. The way we use the EHR and the process of reporting information about a patient visit really reflects the fact that we’re trying to serve so many masters at one time.
So, most inpatient and outpatient doctors would say, ‘Look, we have to reduce the documentation burden,’ and then in a similar vein, most outpatient and inpatient physicians, particularly inpatient, would say that if the user interface is so clunky and the way we enter data is not in keeping with how we think through a patient case and how we do a patient history, that we suffer slowdowns just with the data entry piece, even if we’re good typists, just the data entry part of it is so non-intuitive and disjointed.
Many healthcare leaders advocate the use of medical scribes to ease the physician documentation burden. What are your thoughts on the use of scribe to address this issue?
The use of scribes is really interesting. There’s two models for scribe use—one, which is more common, is the fly on the wall model. The scribe is recording everything the physician is saying. I see the point of that, but it’s weird to have that other person in the exam room, but the doctors I know who use scribes have them find them to be a lifesaver. The other model is treating the scribe as a member of the healthcare team, so a nursing assistant, and they may participate in the visit too, so they are not just silently typing things. They might do the visit wrap-up or other things related to the visit, and that may feel a little more organic for the patient. Scribes are ultimately a symptom of a larger problem, which is that the EHRs are not useable in a way that is supportive of physicians. It’s a way of treating a symptom, but not curing the problem.
What do you think needs to be done to address the usability issue?
I think the problem is the documentation burden, the usability of the EHRs and making those more intuitive, and, this may be pie in the sky, trying to separate out the billing pieces. The way we do billing is very challenging and requires documentation in certain fields and certain phrases and all those these things are not harmonious with how doctors think and talk and would like to record information about patients. So, I think separating out the billing somehow, and figuring out ways to measure quality that doesn’t require documentation in certain fields, all those things are very challenging. I think the tech industry is up for it, but there hasn’t been much motivation for them to do anything differently, because people are getting paid, quality measures are being reported, and so not everyone is so interested in doctors’ complaining. We otherwise have it pretty good. I think there is not so much sympathy. I think the real issue is that there is growing data and evidence that stress around EHR usage leads to physician burnout, and that is a quality issue, that is a workforce issue and so that may be a place where physicians’ voices may be more compelling.