It’s easy to heap blame on electronic health record (EHR) vendors for the clerical burdens associated with their products. But that would take others off the hook for the EHR’s contributions to physician professional dissatisfaction and burnout.
Along with some vendors’ poor product design, payers, lawmakers and regulatory bodies all have had a hand in creating a situation that leaves too many physicians feeling like documentation drones instead of doctors. Health care organizations have also played a role through their decisions affecting governance, resource allocation, and EHR implementation and training.
These key influencers in physicians’ negative EHR-user experience are identified in a Journal of the American Medical Informatics Association perspective essay written by AMA researchers led by Michael A. Tutty, PhD, the Association’s group vice president of professional satisfaction and practice sustainability.
The AMA is committed to making technology an asset in the delivery of health care, not a burden.
So, in addition to noting how different parties contribute to the problem, the AMA authors also write how they each can be part of the solution.
In the JAMIA paper, Tutty and colleagues note that “the primary goal of the EHR should be to support patient care.” But a host of other parties have piled on with “non-value-added tasks” that take up almost six hours of a physician’s day, including one to two hours of “pajama time” in the evening completing EHR-related work.
“There are multiple opportunities for regulators, policymakers, EHR developers, payers, health system leadership and users each to make changes to collectively improve the use and efficacy of EHRs,” says the article, co-written by Lindsey E. Carlasare, Stacy Lloyd, MPH, and AMA Vice President of Professional Satisfaction Christine A. Sinsky, MD.
According to the AMA researchers, these are the seven influences imposed by the government, health care organizations and EHR vendors that have combined to create the challenges in EHR-use that all stakeholders must work on jointly to overcome.
Government regulations that increase data-entry requirements beyond what is needed for patient care. This started with the 2011 implementation of “meaningful use” standards by the Centers for Medicare & Medicaid Services (CMS) Office of the National Coordinator for Health IT.
Along with requiring physicians to do more typing, the meaningful use program mandated design standards despite a lack of evidence that they would result in better patient outcomes or user experiences.
Shifting targets for payment and quality measures that create barriers to the efficient use of EHRs. Physicians are required to use certified EHR systems if they participate in the Merit-based Incentive Payment System of the CMS Quality Payment Program (QPP), but “navigating the shifting targets has proven challenging.”
Private payers also add layers of complexity with their own data requirements for claim submission, prior authorization, prescription coverage, billing and quality reporting. Increasing demand to use the EHR for documenting payment data and quality reporting—and the possibility that practices’ EHR systems may lack the functionality to support these tasks—affects usability.
The sluggish pace of interoperability improvements. Despite government incentives to promote interoperability, disincentives such as high cost and conflicting business interests hamper data exchange. Frustration, delays in care and patient-safety risks are created when a physician cannot access a patient’s records that originated in another hospital or clinic.
Health care organization governance practices. Policies geared toward compliance and risk management can spur workarounds such as using copy-and-paste functions that guard against legal disputes but create “note bloat,” which in turn can perpetuate errors or make it hard to find relevant information amid the data overload.
Confusion on compliance issues adds unnecessary administrative burdens. The AMA’s “Debunking Regulatory Myths” resource provides authoritative guidance that reduces regulatory guesswork.
Decisions on implementation, training and customization can have long-term usability effects. The researchers listed the following as possible contributors to a negative EHR user experience:
- Overly cautious or misinformed compliance departments.
- Inadequate allocation of IT resources pre- and postimplementation.
- Poor system design and functionality decisions.
- Intensity and delivery of training.
- Inadequate staffing levels.
- Inattention to workflow redesign necessary to effectively integrate new technology.
They also noted that system customization may lead to long-term challenges for upgrades, design variability across locations and difficulty in training.
Practice design and resource allocation that don’t accommodate workflow and clinical space needs. Decisions to maintain outdated servers or software can lead to slow systems or dangerous workarounds, whereas using dictation and transcription devices can streamline documentation. The proper equipment and setup in the exam room can improve efficiency and enable better patient engagement and eye contact.
Vendors who don’t involve clinicians in usability testing. The authors cite a JAMA study finding that:
- 63% of vendors used less than the standard 15 people in usability tests.
- 51% did not include required demographic data.
- 17% did not have any physicians testing their products.
- 12% lacked enough detail to know if physicians participated in testing.