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Journal of Health & Medical Informatics
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Physician Opinions about EHR Use by EHR Experience and by Whether the Practice had optimized its EHR Use

Jamoom EW1*, Heisey-Grove D2, Yang N1 and Scanlon P1

1Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, USA

2Department of Health and Human Services, Office of the National Coordinator for Health Information Technology, USA

*Corresponding Author:
Jamoom EW
Department of Health and Human Services,
Centers for Disease Control and Prevention,
National Center for Health Statistics, USA.
E-mail: [email protected]

Received Date: June 24, 2016; Accepted Date: July 23, 2016; Published Date: July 30, 2016

Citation: Jamoom EW, Heisey-Grove D, Yang N, Scanlon P (2016) Assessing the Financial Impact of Reusing Electronic Health Records Data for Clinical Research: Results from the EHR4CR European Project. J Health Med Inform 7:247. doi:10.4172/2157-7420.1000247

Copyright: © 2016 Jamoom EW, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Optimization and experience with using EHRs may improve physician experiences. Physician opinions about EHR-related impacts, and the extent to which these impacts differ by self-reported optimized EHR use and length of experience are examined through nationally representative physician data of EHR users from the National Electronic Health Records Survey extended survey (n=1,471). Logistic regression models first estimated how physicians’ length of times using an EHR were associated with each EHR-related impact. Additionally, a similar set of models estimated the association of self-reported optimized EHR use with each EHR impact. At least 70% of physicians using EHRs continue to attribute their administrative burdens to their EHR use. Physicians with 4 or more years of EHR experience accounted for 58% of those using EHRs. About 71% of EHR users self-reported using an optimized EHR. Physicians with more EHR experience and those in practices that optimized EHR use had positive opinions about the impacts of using EHRs, compared to their counterparts. These findings suggest that longer experience with EHRs improves perceptions about EHR use; and that perceived EHR use optimization is crucial to identifying EHR-related benefits. Finding ways to reduce EHR-related administrative burden has yet to be addressed.

Keywords

Health information technology; Electronic health records; EHR optimization; Physicians; National Electronic Health Records Survey (NEHRS)

Introduction

The benefits promised by health information technology (IT) are numerous: safer and better coordinated care, and improved quality, population health, and administrative efficiencies [1]. Despite nearly all physicians using electronic health records (EHRs), not all user experiences are positive: increased administrative burdens, “click fatigue,” and interference with patient interactions have been described [2-6].

Practices may benefit from optimization: Clinical, financial, and operational assessments provide process refinements, workflow redesign, or practice-specific modifications for practices to effectively use their EHR [4,7,8]. Smaller qualitative studies have found that optimizing EHR use may improve physician experiences [7-9]. Installation and placement of workstations, coordination of work across a team, trainings, and identifying appropriate clinical decision support needs are considerations for any health IT implementation and optimization [3]. Providers may also identify new, previously difficult processes, such as running reports for managing patient populations by either demographics or chronic conditions. Use of health IT evolves as healthcare providers become more comfortable with the technology.

This study examines positive and negative opinions about EHRrelated impacts on administrative burden, financial benefits, patient care, and data security. Opinions about the effects of EHR use were also examined by the length of time the physician used an

Materials and Methods

The National Center for Health Statistics’ National Electronic Health Records Survey (NEHRS) measures physician and office characteristics, including EHR use. In 2014, nationally representative samples of physicians were randomly selected to receive special expanded content about the physician perceived-impacts of EHR use; questionnaires are available from the NCHS website [10]. Among eligible physicians, 1,763 completed the questionnaire with an un weighted response rate of 61%. More detail on the survey is publically available [11].

Methods

Only physicians with an EHR system (n=1,471, 82% weighted) were analyzed. The length of time a physician used an EHR system was based on the question, “estimate the approximate number of years you have used any EHR system,” and was defined as either at least 4 years EHR use or under 4 years EHR use to coincide with the start of the Medicare and Medicaid EHR Incentive Programs in 2011 for eligible professionals (Table 1).

Characteristics of EHR users in 2014 All physicians (n=1,763) Any EHR user (n=1,471)
Percent Percent
Physicians that use an EHR 81.7 100.0
Physicians with certified health IT 72.8 89.1
Any delivery service reform participation 33.6 38.3
Accountable Care Organizations (ACOs)
Participation 17.4 20.5
Not participating 52.4 46.4
Missing 30.2 33.0
Patient Centered Medical Homes (PCMH)    
Participating 8.1 9.7
Not participating 63.7 58.2
Uncertain/missing 28.2 32.1
Pay for Performance (P4P)
Participating 22.2 24.7
Not participating 53.7 48.0
Uncertain/missing 24.2 27.3
Practice location size
Solo 24.3 18.7
2 physician 13.4 13.2
3 to 5 physician groups 28.1 29.2
6-10 physician group sizes 17.9 19.4
11 or more physicians 16.4 19.5
'Physician Age
Under 50 years 40.8 43.9
50 years and over 59.2 56.1
Medical Specialty
Primary care specialty 45.0 47.6
Other specialties 55.0 52.4
Physician Ownership  
Physician owned practice 59.5 56.1
Other 31.5 35.7
Missing 9.0 8.2
Region
Northeast 21.7 20.8
Midwest 21.7 23.3
South 36.4 35.1
West 20.1 20.8
In Metropolitan Statistical Area?
Yes 91.7 91.7
No 8.3 8.3
No EHR experience 12.8 --
EHR experience - -
Under 4 years 31.3 35.4
4 years or more 48.2 57.7
Uncertain/missing 7.8 6.9
Practice has optimized EHR -- 72.8

Table 1: Descriptive characteristics of EHR users.

Physicians were asked the degree to which they agreed or disagreed with statements about EHR-related impacts. All questions about EHRrelated impacts were recorded into agree or disagree [12] Optimization was similarly defined by agreeing with the statement “overall, my practice has optimized the use of its EHR system.”

A set of logistic models estimated how physicians’ lengths of time using an EHR were associated with each EHR-related impact. A similar set of models estimated the association of self-reported optimized EHR use with each EHR impact. Marginal effects for each EHR-related impact were calculated after controlling for certified EHR, delivery system reform participation, physician age, specialty, practice size, ownership, and geographic characteristics include technical information about variables and analyses. Analyses were conducted using Stata 12.1 (College Station, TX) (Tables 2-4).

MODEL 1: Predicting attitudes for length of EHR use MODEL 2: Optimization of EHR use
  Data element Categories   Data element Categories
Dependent
variables
Attitudes of EHR use
listed below
Strongly agree or somewhat agree
Strongly disagree or somewhat disagree^
Dependent
variables
Attitudes of EHR uselisted below Strongly agree or somewhat agree
Strongly disagree or somewhat disagree^
Key independent variable Length of use of EHR 4 or more years Key independent variable Optimization Yes
Less than 4 years^ No^
Control variables Certified EHR Yes Control variables Certified EHR Yes
No^ No^
Participation in delivery system reform program Yes Participation in delivery system reform program Yes
(Defined as participation in at least one of the following programs:
* accountable care organization
* patient-centered medical home
* pay-for-performance)
No^ (Defined as participation in at leastone of the following programs:
* accountable care organization
* patient-centered medical home
* pay-for-performance)
No^
Physician Age Less than 50 years^ Physician Age Less than 50 years^
50 years or older 50 years or older
Physician specialty Primary care Physician specialty Primary care
Other medical/surgical specialty^ Other medical/surgical specialty^
Practice size 1-2 physicians Practice size 1-2 physicians
3-4 physicians 3-4 physicians
6-10 physicians 6-10 physicians
11+ physicians^ 11+ physicians^
Practice ownership Private ownership^ Practice ownership Private ownership^
Other Other
In a metropolitan statistical area? Yes^ In a metropolitan statistical area? Yes^
No No
Region practice is located Northeast Region practice is located Northeast
Midwest Midwest
South^ South^
West West

Length of use of EHR 4 or more years
Less than 4 years^

Table 2: Description of data elements used for multivariate regression.

Dependent variables
My EHR system(s) meet(s) my practice's clinical needs
The time spent ordering medical services has increased.
My practice receives lab results faster.
The time spent reviewing patient information has increased.
My EHR produces clinical benefits for my practice.
Overall, my EHR saves me time.
The time spent documenting patient care has increased.
Overall, my practice functions more efficiently with an EHR system.
My EHR disrupts the way I interact with my patients.
My EHR allows me to deliver better patient care.
Health Information is less secure in my EHR system than a paper-based system.
My EHR enhances patient data confidentialty.
My EHR produces financial benefits for my practice.
Use of my EHR results in incomplete billing for services.
Overall, the benefits of having an EHR outweigh its cost.

  Sample size (n) Among physicians with under 4 years EHR experience Among physicians with 4 years or more EHR experience Diff. p-value
Attitudes about EHR use Percent Standard Error Confidence Interval 95% Percent Standard Error Confidence Interval 95%
My EHR system(s) meet(s) my practice's clinical needs 1345 62.8% 0.031 56.7% 68.9% 81.1% 0.018 77.5% 84.7% 18.3% 0.0001
Overall my practice has optimized the use of its EHR. 1342 65.0% 0.033 58.5% 71.5% 77.1% 0.021 73.0% 81.2% 12.1% 0.002
The time spent ordering medical services has increased 1274 73.6% 0.034 66.9% 80.4% 71.2% 0.025 66.2% 76.1% -2.5% 0.5712
My practice receives lab results faster 1295 60.8% 0.030 54.9% 66.6% 72.9% 0.022 68.5% 77.2% 12.1% 0.0011
The time spent reviewing patient information has increased 1308 73.8% 0.032 67.5% 80.1% 69.3% 0.026 64.3% 74.3% -4.6% 0.2741
My EHR produces clinical benefits for my practice 1306 62.0% 0.035 55.2% 68.9% 79.1% 0.020 75.2% 83.1% 17.1% 0.0001
Overall, my EHR saves me time 1336 33.9% 0.032 27.6% 40.1% 49.3% 0.026 44.2% 54.4% 15.5% 0.0003
The time spent documenting patient care has increased 1336 84.5% 0.023 80.0% 88.9% 84.6% 0.019 80.9% 88.3% 0.2% 0.9495
Overall, my practice functions more efficiently with an EHR system 1338 49.2% 0.035 42.4% 56.0% 68.4% 0.024 63.6% 73.1% 19.2% 0.0001
My EHR disrupts the way I interact with my patients 1332 72.5% 0.032 66.2% 78.8% 60.6% 0.026 55.5% 65.6% -12.0% 0.0052
My EHR allows me to deliver better patient care 1324 43.4% 0.035 36.6% 50.2% 64.8% 0.024 60.0% 69.6% 21.4% 0.0001
Health Information is less secure in my EHR system than a paper-based system 1300 33.3% 0.031 27.3% 39.3% 27.1% 0.023 22.7% 31.6% -6.2% 0.1043
My EHR enhances patient data confidentialty 1297 53.5% 0.036 46.5% 60.5% 69.8% 0.024 65.2% 74.5% 16.3% 0.0002
My EHR produces financial benefits for my practice 1225 33.8% 0.032 27.6% 40.1% 53.9% 0.026 48.8% 59.0% 20.0% 0.0001
Use of my EHR results in incomplete billing for services 1225 28.6% 0.036 21.6% 35.6% 20.3% 0.020 16.5% 24.2% -8.3% 0.0389
Overall, the benefits of having an EHR outweigh its cost 1273 47.1% 0.037 39.8% 54.5% 65.6% 0.025 60.6% 70.6% 18.5% 0.0001

Table 3: Marginal effects of electronic health record user experience on probability that physician agreed with the following attitude.

  Sample size (n) Practice has optimized the EHR Practice has not optimized EHR use  
Attitudes about EHR use Percent Standard Error Confidence Interval 95% Percent Standard Error Confidence Interval 95% Diff. p-value
My EHR system(s) meet(s) my practice's clinical needs 1324 84.0% 0.018 80.5% 87.5% 49.6% 0.035 42.8% 56.5% 34.4% 0.0001
The time spent ordering medical services has increased 1265 67.8% 0.025 62.9% 72.7% 82.9% 0.034 76.3% 89.6% -15.1% 0.002
My practice receives lab results faster 1285 74.2% 0.020 70.2% 78.1% 52.8% 0.037 45.7% 60.0% 21.4% 0.0001
The time spent reviewing patient information has increased 1299 66.6% 0.025 61.7% 71.4% 82.4% 0.029 76.7% 88.1% -15.8% 0.0002
My EHR produces clinical benefits for my practice 1295 81.6% 0.019 77.9% 85.2% 50.8% 0.038 43.4% 58.2% 30.8% 0.0001
Overall, my EHR saves me time 1322 54.1% 0.024 49.4% 58.9% 13.6% 0.024 13.6% 2.4% 40.5% 0.0001
The time spent documenting patient care has increased 1323 82.0% 0.020 78.0% 85.9% 90.6% 0.019 86.9% 94.4% -8.7% 0.0042
Overall, my practice functions more efficiently with an EHR system 1323 73.6% 0.020 69.6% 77.6% 27.7% 0.034 21.1% 34.2% 46.0% 0.0001
My EHR disrupts the way I interact with my patients 1320 57.8% 0.025 52.9% 62.8% 85.1% 0.024 80.4% 89.7% -27.2% 0.0001
My EHR allows me to deliver better patient care 1308 69.1% 0.022 64.9% 73.3% 22.7% 0.027 17.4% 28.0% 46.4% 0.0001
Health Information is less secure in my EHR system than a paper-based system 1288 27.3% 0.020 23.4% 31.3% 36.2% 0.038 28.7% 43.7% -8.9% 0.0354
My EHR enhances patient data confidentialty 1285 70.0% 0.023 65.5% 74.5% 46.1% 0.040 38.4% 53.9% 23.9% 0.0001
My EHR produces financial benefits for my practice 1215 53.8% 0.025 48.9% 58.8% 24.9% 0.033 18.3% 31.4% 29.0% 0.0001
Use of my EHR results in incomplete billing for services 1216 21.0% 0.019 17.2% 24.8% 29.5% 0.035 22.5% 36.4% -8.4% 0.0259
Overall, the benefits of having an EHR outweigh its cost 1266 69.1% 0.023 64.6% 73.6% 31.1% 0.035 24.3% 38.0% 38.0% 0.0001

Table 4: Marginal effects of electronic health record system optimization on probability that physician agreed with the following attitude.

Results

Overall impacts of EHR use

Among physicians with EHRs, responses to positive EHR-related administrative impacts ranged from 44% of physicians reporting that their EHR saved time overall to 69% of physicians reporting that they received laboratory results faster due to EHRs (Figure 1). Responses to negative EHR-related administrative impacts were higher, ranging from 70% of physicians agreeing that the time spent reviewing patient information had increased to 84% agreement with increased time spent documenting care. 24% of physicians indicated EHR use produced clinical benefits (Figure 2). A majority of physicians (58%) indicated that their EHR allowed them to deliver better care however, more than 60% of physicians reported that their EHR disrupted their interactions with patients.

Medical-Informatics-Proportion-physicians-reporting-impacts

Figure 1: Proportion of physicians reporting impacts on administrative burdens associated with EHR use, USA, 2014.

Medical-Informatics-impacts-clinical-care-associated-with-EHR

Figure 2: Proportion of physicians reporting impacts on clinical care associated with EHR use, USA, 2014.

A majority of physicians (60%) indicated that the benefits of the EHR outweighed the cost, while just 48% indicated that their EHR produced financial benefits for the practice (Figure 3). Less than onequarter of physicians reported incomplete billing from their EHR use.

Medical-Informatics-reporting-financial-data-security-impacts

Figure 3: Proportion of physicians reporting financial and data security impacts associated with EHR use, USA, 2014.

Length of EHR experience

Physicians with 4 or more years of EHR experience accounted for 58% of the physician population using EHRs (Table 1). Physicians with 4 years or more experience were more likely to agree with positive impacts related to EHR use, across all 4 categories, than physicians with less experience (Figure 4, Table 3). The largest percentage difference in opinions associated with length of EHR experience was observed with patient care. Of the physicians with at least 4 years of EHR experience, 64.8% reported that their EHRs allowed them to provide better patient care; of those with less than 4 years of experience, 43.4% reported this– the difference being 21.4 percentage points. The smallest percentage difference among positive impacts was observed in the faster receipt of laboratory results (12 percentage point difference).

Medical-Informatics-Percentage-difference-EHR-related-impacts-between-physicians

Figure 4: Percentage difference in EHR-related impacts between physicians who had at least 4 years of EHR experience and physicians who had less than 4 years of EHR experience, USA, 2014.

Differences in the negative impacts of EHR use were small and generally not of statistically significant with 2 exceptions. Physicians with more EHR experience had lower agreement about the disruption of patient interactions (12 fewer percentage points) and incomplete billing resulting from EHR use (8 fewer percentage points) compared to physicians with less experience.

Optimization of EHR use

About three-quarters of physicians with EHRs agreed with the statement that their practice had optimized its use of EHRs (Table 1) [10]. Physicians who self-reported optimized EHR use by their practice were more likely to report overall practice efficiency (74 vs. 28%) and that their EHR saved time (54 vs. 13%), compared to those who did not report optimized use. Relative to those physicians who did not report optimized use, physicians self-reported optimized EHR use were more likely to report that benefits of an EHR outweighed its cost (69 vs. 31%), EHRs allowed them to deliver better patient care (69 vs. 23%), and to identify clinical and financial benefits (82 vs. 51% and 54 vs. 25%, respectively).

Smaller differences in negative EHR-related impacts were observed between physicians who believed their practices had optimized EHR use and those that did not (Figure 5). About 80% of physicians who selfreported optimized EHR use reported that the time spent documenting care had increased, compared to 91% of their counterparts (Figure 6). Between 67 and 83% of physicians across both groups reported that the time spent ordering medical services and reviewing patient information had increased as a result of their EHR system. Fewer physicians who self-reported optimized EHR use by their practice believed that their EHR disrupted physician interactions with patients compared to those who did not report optimization (58 vs. 85%).

Medical-Informatics-Proportion-physicians-reporting-positive-impacts

Figure 5: Proportion of physicians reporting positive impacts associated with EHR use based on physicians’ belief about their practice’s optimization of EHR use, USA, 2014.

Medical-Informatics-impacts-associated-with-EHR

Figure 6: Proportion of physicians reporting negative impacts associated with EHR use based on physicians’ belief about their practice’s optimization of EHR use, USA, 2014.

Discussion

As seen in earlier attitudinal studies, opinions about EHR-related impacts were mixed [13,14]. Across nearly all domains, a majority of physicians reported positive EHR-related benefits, which includes better patient care, enhanced data confidentiality, and that the benefits of EHR use outweigh its costs. Physicians with longer EHR experience or with self-reported optimized EHR were more likely to report positive impacts than their counterparts. Also, a high percentage linked their EHR use with increased administrative burden and patient disruption. Although physicians with self-reported optimized EHR use had lower perceived administrative burden than their counterparts, overall, a majority still agreed with those negative EHR impacts related to time spent using their EHR to review information, order services, and document care.

Optimization requires significant financial and staffing resources to implement, is an ongoing process, and is hard to standardize. [7,8,15,16]. Although EHR optimization presents a unique challenge for every practice, it is often tailored to meet a specific practice’s need. These analyses show that self-reported optimized EHR use was associated with physician agreement for the majority of positive EHRrelated impacts, suggesting optimization may have implications for safety and quality.

While about three-quarters of physicians self-reported their agreement that their practice “optimized its EHR use”, the definition of optimization was left to the respondent's discretion and how physicians interpreted this may be hard to elucidate. In earlier cognitive work, evaluation of other questions indicated that physicians did not typically think about official definitions when responding; rather it is likely that respondents were thinking about altering their system to suit their needs when answering the optimization question [12]. There is a need to further study the impacts on EHR use by optimization type yet there were differences in the perception of self-reported optimization on opinions of EHR use.

At least 70% of all physicians attributed EHR use with spending more time on administrative tasks. This percentage remained high even after accounting for optimized use. As physicians become more familiar with their systems or modify them to meet their specific needs, the amount of time spent on administrative tasks may diminish.

Conclusion

These findings suggest that longer experience with EHRs improves perceptions about EHR use; and that perceived EHR use optimization may identify benefits associated with health IT. Finding ways to reduce EHR-related administrative burden has yet to be addressed.

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