Schattauer 2011
Applied Clinical Informatics 460
L. Grabenbauer; A. Skinner; J. Windle: EHR adoption: Maybe Its not about
the money physician super-uers, Electronic Health Records and Patient Care
Research Article
Electronic Health Record Adoption
Maybe Its not about the Money
Physician Super-Users, Electronic Health Records and Patient Care
L. Grabenbauer
1
; A. Skinner1
; J. Windle1
1University of Nebraska Medical Center, USA
Keywords
Adoption; electronic health record
Summary
Objective: The slow adoption of electronic health record (EHR) systems has been linked to physician resistance to change and the expense of EHR adoption. This qualitative study was conducted
to evaluate benefits, and clarify limitations of two mature, robust, comprehensive EHR Systems by
tech-savvy physicians where resistance and expense are not at issue.
Methods: Two EHR systems were examined the paperless VistA / Computerized Patient Record
System used at the Veterans Administration, and the General Electric Centricity Enterprise system
used at an academic medical center. A series of interviews was conducted with 20 EHR-savvy multiinstitutional internal medicine (IM) faculty and house staff. Grounded theory was used to analyze
the transcribed data and build themes. The relevance and importance of themes were constructed
by examining their frequency, convergence, and intensity.
Results: Despite eliminating resistance to both adoption and technology as drivers of acceptance,
these two robust EHRs are still viewed as having an adverse impact on two aspects of patient care,
physician workflow and team communication. Both EHRs had perceived strengths but also significant limitations and neither were able to satisfactorily address all of the physicians needs.
Conclusion: Difficulties related to physician acceptance reflect real concerns about EHR impact on
patient care. Physicians are optimistic about the future benefits of EHR systems, but are frustrated
with the non-intuitive interfaces and cumbersome data searches of existing EHRs.
Correspondence to:
Lisa Grabenbauer, MS, MBA
982265 Nebraska Medical Center
Omaha, Nebraska 681982265, USA
E-mail: [email protected]
Appl Clin Inf 2011; 2: 460471
doi:10.4338/ACI-2011-05-RA-0033
received: May 27, 2011
accepted: October 10, 2011
published: November 9, 2011
Citation: L. Grabenbauer; A. Skinner; J. Windle. Electronic health record adoption maybe its not about
the money physician super-users, electronic health records and patient care. Appl Clin Inf 2011; 2: 460471
http://dx.doi.org/10.4338/ACI-2011-05-RA-0033
Schattauer 2011 L. Grabenbauer; A. Skinner; J. Windle: EHR adoption: Maybe Its not about
the money physician super-uers, Electronic Health Records and Patient Care
Research Article Applied Clinical Informatics 461
Introduction
President Obama and former President Bush have called for the complete implementation of electronic health record systems across the United States by 2020 [1, 2]. National organizations including the Joint Commission for Accreditation of Hospital Organizations and the Leapfrog Group,
alongwith federal agenciessuch astheCentersfor Medicare & Medicaid Services,have advocated for
the early adoption of health information technology as a way to improve patient care. The EHR is
viewed as the solution to many challenges that exist in our health care system. It is promoted for its
promise to improve health care quality, prevent unnecessary variations in care, and reduce medical
errors [37].
Despite this, adoption of health information technology has moved slowly since the introduction
of technology to the international healthcare industry in the 1980s. In the United States, adoption
rates range from 1224%, dependent on size of practice [8, 9]. Physician resistance to technology is
often cited as a cause [8, 1012]. Reasons for this resistance include lack of time for documentation,
lack of knowledge about the system, privacy concerns, lack of standardization between systems, and
the costs to deploy a technology solution [1315].
In our previous study of academic and private physicians, we learned that resistance from both
physician groups was related to the perceived impact of technology on communication, workflow,
and patient care [16]. The selection of a broad sample of physician leaders and decision makers included a segment of older and less technically savvy users, who may not represent the segment of
physicians most likely to adopt, use and improve EHR systems.
The objective of this research is to explore the perceptions of technically-savvy physicians of the
impact of an EHR on patient care, where knowledge and adoption were not barriers to EHR use.
More specifically, the aims are
1. to document EHR interactions that impact acceptance,
2. to describe functionality areas that affect patient care, and
3. to compare the characteristics of the two EHR systems studied.
The physicians in the study practice at two institutions with long-standing comprehensive EHRs,
theVeteransAdministration Nebraska-Western IowaHealthCare System (VAHC), andThe Nebraska Medical Center (TNMC).
In this qualitative study, we examine whether a gap exists between physician super-users who are
well versed in EHR use and health information technology, and our original study sample. Superusers are technically adept userswho are trained to provide support to other users and serve as product champions, leading the way in their organization for technology change [17]. Super-users may
play a significant role in successful technology adoption by providing insight into daily tasks and
workflow, and providing support to other users during system implementation [1820].We explore
the perceptions and insights from physician super-users who practice at TNMC as well as theVAHC
in Omaha. This research extends the previous study by seeking to eliminate a potential bias against
EHR use by practitioners who are technology neophytes and are resistant to change. Our sample includes recognized super-users of the EHR who have practiced only in facilities with an established
comprehensive EHR.
Methods
The research objective was to understand the use of health information technology by technically
adept physicians, and to compare their experiences with two well-known and comprehensive EHR
systems.A qualitative design was chosen to allow meaningful insight into the potential variables and
social interactionsthatimpactthe acceptance of EHRsystems.Grounded theory guides both the collection and analysis of data to identify underlying concepts which describe the experience of a social
group and the meanings associated with a phenomenon of study [2123]. The qualitative method
used in this study facilitates an understanding of physicians adoption of technology by exploring
their perceptions of EHR system interaction.This approach allowsfor collection of a rich contextual
Schattauer 2011 L. Grabenbauer; A. Skinner; J. Windle: EHR adoption: Maybe Its not about
the money physician super-uers, Electronic Health Records and Patient Care
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narrative to provide meaningful insight into the users experiences, beliefs and values, and howthese
factors influence adoption.
TheVeteransAdministration has been a leaderin the development and adoption of a robust EHR,
and hasreceived attention foritswell-developed and comprehensive EHRsystem beginningwith the
development of VistA in the mid 1980s [24, 25]. The system was later enhanced with the introduction of a userinterface,theComputerized Patient Records System (CPRS).This comprehensive EHR
contains componentsthatinclude inpatient and outpatient documentation,Computerized Provider
Order Entry (CPOE), alerts, medications, problem lists, image storage and retrieval, communications/routing, e-signature, progress note storage and templated notes.
TNMC is a not for profit hospital system that includes both academic and private physicians.
TNMC has used GE Centricity Enterprise and its predecessors (IDX and Phamis), a commercially
available comprehensive EHR, for inpatient and outpatient care for over 20 years [26]. As implemented, it has limited CPOE functionality and note templates, utilizes interfaces for external image
storage and retrieval, and contains progress notes in both electronic and PDF formats.
Participants
The Chair of the Department of Medicine and Chief of General Medicine,who has published extensively on the subject of the EHR, identified a convenience sample of super-users from a comprehensive list of faculty,residents and fellows who practice at both institutions. Small group sessions were
performed with a total of 20 participants, including 9 residents and 11 faculty members who accepted our invitation. The initial analysis of the first 18 participants did not yield saturation, and
sessions were conducted with two additional faculty members chosen from the convenience sample.
As a group the participantswere sophisticated users of the EHR.Theywere familiar and comfortable
with each medical record system, and in some cases,worked with information technology members
to develop templates and forms used by the systems, advised EHRvendors on functionality, and published articles on health information technology. Additionally, several of the faculty members were
experienced with other EHR systems, including Epic and Cerner.
Data Collection
Focus groups were conducted with physicians who practice at both institutions. Participants were
asked open-ended questions about their interaction with EHR systems and the systems perceived
benefits and limitations. The EHR systems selected for the study have been maintained and used
consistently, for over 20 years at their respective institutions. Focus group sessions and analysis took
place from November 2008 through December 2009.An average of 5 participants attended sessions
for approximately one hour. Proceedings were digitally recorded and then transcribed. Theoretical
samplingwas used to identify usersfor additional focus group sessions as part of the concurrent data
analysis until no newconceptswere discovered, and saturationwas achieved [21].The resulting transcripts were reviewed for completeness and clarity prior to data analysis.
Data Analysis
Using the data analysis method of constant comparison, the two investigators independently reviewed the transcripts [23]. Concepts were found using an iterative process of reviewing transcripts
following each session, identifying patterns within the participants responses, and annotating the
transcripts.NVivo v8.0 softwarewas used to formalize the concepts and facilitate the bottom-up formulation of themes. The relevance and importance of themes was assessed using a schema of frequency, convergence and intensity. Frequency represents the number of times that the topic appears
in the users discussion, and was documented using NVivos frequency reporting feature. Convergence,the relative occurrence of the topic across both EHR systems,was assessed by each reviewer as
high,medium,orlow.Intensitywas defined asthe emotion and importance of the topic to the speaker, using a scale of high, medium or low based on a subjective analysis of the digital recording for
vocal tone, pace and volume. An example of a high intensity statement by a participant is you actually have more interaction with the damn computer than the patient. The reviewers also noted
Schattauer 2011 L. Grabenbauer; A. Skinner; J. Windle: EHR adoption: Maybe Its not about
the money physician super-uers, Electronic Health Records and Patient Care
Research Article Applied Clinical Informatics 463
whether the participants perceptions were positive or negative toward the respective EHR system.
The emergent themes and the rating schema were examined in an open dialogue among investigators until consensus was achieved.
Trustworthiness and credibility of the study findings were demonstrated with the following
methods[27].The investigators(an informaticsresearcher/practicing physician at a teaching hospital, and a researcher experienced in information technology design) independently reviewed the
transcripts, and then met periodically to review their emerging themes.A third investigator (a public health researcher with qualitative study expertise) audited the identification of concepts and the
formulation of themes process to ensure consistency during the collection and analysis of the data.
Through an iterative process of comparative analysis [28],reviewers achieved consensus on important themes, and potential biases in interpretation were reconciled.
Results
Patient care was at the center of many of the discussions, and serves as a framework forthe successes
andweaknesses of the EHR.Table 1 describesthe resulting themes and theirrelative importance to
the participants, and summarizes the benefits and limitations of each EHR. Two themes emerged to
describe EHR interactionsthatrelate to patient-specific data at the point-of-care; the relationship of
the EHR to physician workflow and the EHRs association with communication issues. Two additional themes described EHR interactions that were associated with aggregated EHR patient dataeducation, and outcomes/research. These are described in more detail below.
Physician Workflow Direct Influence on Patient Care
Physician workflow, as defined by the participants, is the complex physical interaction of the physician with information and with patients,which includes the amount of time needed to capture,retrieve and process information using the EHR. This theme was frequently noted for both EHR systems.Physiciansspoke aboutthe benefits of workflow, and strongly valued the accessibility of patient
datawhen itwas needed at the point-of-care,whichwas present in both TNMCandVAHCEHR systems. Participants also spoke strongly about the negative impact of both EHRs on physician workflow, and reinforced their concerns about the expanded overhead for documentation. A common
perceptionwasthatthe high cost of input and retrieval of an individual patientsinformation significantly reduced time available for direct patient care.
Differences were noted between the two EHR systems on issues of usability. The TNMC system
was better organized but less comprehensive, with the need to access scanned documents. Participants using the TNMC EHR system spoke about the difficulties of completing documentation during a patient visit:
So, we dont type in our clinic notes at this point. But we spend a lot of time outside of clinic documenting.
I just finished clinic and I now have 12 charts to dictate sometime today.
VAHCusersfound the system was more comprehensive but very difficult to search.Use of templated
notes at the VAHC saved documentation time and improved documentation compliance but at the
expense of readability and comprehension. Participants echoed concern about documentation, and
spoke directly about an interface that supported both data entry and retrieval:
Follow up involving order entry takes at least 510 minutes per patient,so if you add that on to the end of your
day it is at least an extra hour, because nothing goes on paper, and its not convenient to enter info until youre
finished with seeing all patients.
I want it to be intuitive … I dont want to have to ask somebody to make it for me.
You have chaplain notes, you have PT notes, you have everything and literally youre looking at a list that for one
patients hospitalization may be a list of 300 notes.
Schattauer 2011 L. Grabenbauer; A. Skinner; J. Windle: EHR adoption: Maybe Its not about
the money physician super-uers, Electronic Health Records and Patient Care
Research Article Applied Clinical Informatics 464
Communication Direct Influence on Patient Care
Communication is the interaction between physician and patient, as well as communication within
the healthcare team. Likeworkflow,the theme of communicationwas common across EHR systems,
and evoked intense responses from participants. Physicians recognized benefits that included improved communication, the availability of patient data asynchronously, and the ability to share patient-centric information with other physicians, and with patients. However, direct communication
between health care providers was a frequent complaint, distancing consultants from primary care
providers and physiciansfrom nursesin the inpatient environment.Thiswas perceived as a substantially greater problem at theVAHCthan TNMC.In the outpatient environment the availability of reports from other providers was viewed as a positive, however,searching through the records was still
perceived as more difficult at the VA.
[at TNMC there is] lots of interaction with nurses, they get to know who you are and often provide additional information about your patient that happens just because of physical presence it provides another opportunity
to share relevant information that doesnt happen at the VA because there is less interaction. This collaboration
also provides more reliability that orders are followed.
I dont think that you can rely on the medical record system to provide you all the communication that you need
because any electronicsystem still needsto be overridden by human initiation in terms of a phone call or a page.
Outcomes/Research and Education Indirect Influence on Patient Care
Outcomes/research is a theme that describes the use of data in a structured and summarized way to
satisfy research, outcomes and billing, and includes the capture of data in the appropriate formats.
Education describes the use of technology to support the physicians medical education, as well as
any learning that is required to effectively use the EHR system.
Although less common, physicians perceived potential EHR benefits to improve patient outcomes and support research for populations. Yet, at the individual patient level, both systems were
viewed as cumbersome and not very helpful. In addition, the responses related to education were
also mixed,but tended to be more positive.Both faculty and residentswere positive about the impact
of web-based educational content such as UpToDate and Google scholar. Both groups also expressed concern about the difficulty in learning how to use EHR systems.
The longer you are at the VA, the more tricks you learn about using it and it becomes more and more powerful
but sometimes that learning curve is very steep.
Summary of Themes
The comprehensive EHR systems studied had perceived strengths but also important limitations.
Both TNMCs GE Centricity Enterprise System and theVAHCs CPRS system were praised for presenting patient datawhen itwas needed at the point-of-care, addressingworkflowissues of integrated
accessto patient data, clinical guidelines, and evidence-based domain knowledge within the space of
a patient visit. The systems also were acknowledged for the potential to improve communication
through the sharing of patient data among the diverse members of the healthcare team through direct access or a reporting interface. Physicians using both systems concurred on the unrealized potential for the EHR to positively impact on population health as well as to contribute to ongoing
physician education through the potential delivery of evidence-based knowledge at the bedside.
While participants would not return to paper-based systems, the positive benefits of the EHR
were offset by itslimitations.These concernsincluded disruptionsto patient management workflow
needed to complete required documentation, elimination of and feedback, as well as the potential for cumbersome data gathering for research and the potentially high
learning curves for increasingly sophisticated EHR systems. Individually, the TNMC system was
noted forits logical organization, but it was limited by difficult searches for patient information due
to the inclusion of structured and non-structured documents.TheVAHC system was applauded for
its comprehensive nature, but it was considered non-intuitive and labor intensive. Neither system
Schattauer 2011 L. Grabenbauer; A. Skinner; J. Windle: EHR adoption: Maybe Its not about
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adequately addressed physician needsrelated to workflow, communication, outcomes/research, and
education.
The adoption of EHR systems is influenced by how well system functionality supports the relationship between the physician and patient. The model described in Figure 1 is grounded in the
findings from the study, and depicts a patient-centric ratherthan top-down approach to EHR adoption and usage, and defines relationships that can serve as a framework for future study. The model
provides a structure to describe the relationship between desired EHR features and the satisfaction
of the physician with EHR system use, which is moderated by physician commitment to the stability and improvement of patient care. The resulting framework provides an opportunity to explore
each feature category. Forinstance, an improvedworkflowdesign, accomplished through addressing
the issues of ease of documentation and the ability to share real-time patient information may improve the physiciansperception of delivery of care.The resulting usersatisfaction can then be examined for its relationship to EHR adoption.
Discussion
Our study documents the gap that is present between leaders who call for the rapid implementation
of health information technology and physicians (even the tech savvy) who are practicing in the
trenches. Present solutions for EHR adoption emphasize financial incentives, rather than address
functionality areassuch as physician workflow and communication,which can improve patient care
[29]. The physicians interviewed were committed to the potential of the EHR and were positive
about its potential usefulness.However,their acceptancewastempered by theirfrustration with ease
of use particularly the impact of trade-offs between patient care and the significant time required
to search for information and input data.
Our previous study, as part of an Integrated Advanced Information Management Systems
(IAIMS) project, explored issuesrelated to the broad acceptance of EHRs by health care professionals
and administrators.Although the physiciansin the study believed thatthe EHRisinevitable,surprising to us was the strong concordance of concerns raised by both private and academic practitioners
about the perceived negative impact of the institutions EHR on patient care. In contrast, administrators believe that creation of administrative data is the primary job of the EHR, and eagerly anticipate the availability of the data for quality and outcome measurements. A concern of the study was
that it did not include a sufficient number of young physicians in the sample, and that it examined
a single EHR.
Both studies reflect similar perceptions from the participating physicians whether they were
general EHR users, or EHR super-users, particularly regarding workflow. Physicians felt that EHR
applications were not designed to support their workflow, and often interrupted their interaction
with patients.Although not part of our study, additional information surfaced to support the assertion that EHRuse impacts negatively on direct patient care.We learned thatVAHCinternal medicine
clinics have reduced the number of available time slotsfrom 8 patientsto 6 patientsin a 4 hour clinic
to compensate for the additional time spent at the computer.In addition, an internal study of workflow at TNMC indicated that house staff spent an average of 24 minutes for each inpatient. This included 20 minutes for preparation and follow-up, and only 4 minutes of direct patient care [30].
Overcoming adoption barriersrequiresstrategieswhich span organizational and domain boundaries and identify categories of issues which include design, management, organization, and assessment. Successful adoption requires an understanding of EHR users and their work setting [3134].
Clinical workflows are often complex, and effort is underway to better understand users and their
tasks within the context of the clinical setting [35]. Many clinical systems have been commercially
developed, yet research confirms issues with communication and workflow [3639].A critical piece
often missing from EHR implementations is the input of the doctors, nurses and pharmacists who
can identify what is needed to improve their jobs [40]. This lack of participation leads to challenges
that are often found in EHR implementations in the US, and reinforces the need to enlist physicians
in usability analysis and system design.
The experienced EHR users in this study call into question assumptions and strategies currently
touted by US government leaderswho call forthe rapid implementation of technology [41].The Of-
Schattauer 2011 L. Grabenbauer; A. Skinner; J. Windle: EHR adoption: Maybe Its not about
the money physician super-uers, Electronic Health Records and Patient Care
Research Article Applied Clinical Informatics 466
fice of the National Coordinator for Health Information Technology and the Presidents Council of
Advisors on Science and Technology propose that aggressive healthcare quality and efficiency improvements be driven top-down by national initiatives. Financial incentives to encourage EHR use
beginning in 2010 have been prescribed, while at the same time, policies and standards for EHR design are being formulated [42, 43].
Limitations
Our findings, define relationships between themes, but do not verify causality. The rich description
expands what is known about physician needs, and creates opportunity for ongoing research on
antecedents for EHR usage.
Both faculty and residentswere consistent in their perceptions of EHR impact onworkflow, communication, and outcomes/research, therefore we did not separate the participants into groups
based on years of experience. The groups differed slightly on the minor theme of education. Faculty
expressed some concern about dilution of the medical education experience, yet both groups agreed
on the potential benefits of the use of the EHR during medical training.
Recommendations
This study suggests EHR adoption will be stimulated by an approach which addresses user satisfaction by focusing on a patient-centric, rather than transactional, view of patient data. This includes
the involvement of users in the identification of requirements that improve the effectiveness of
workflow and communication, testing the usefulness and usability of interfaces, as well as the pursuit of collaborative design methodologies that combine the expertise of computer scientists, informaticists and clinicians. Current top-down efforts to spur EHR adoption, such as the Health Information Technology for Economic and Clinical Health Act (HITECH), focus on financial compensation for clinicians and hospitals.This approach overlooks both documented issueswith system
usability and the needs of its mostsophisticated users,which may limit itssuccessin improving EHR
adoption.
Conclusion
Contrary to many observers outside the practicing community, the issues related to physician acceptance of an EHR system are not due to reluctance to adopt new technology but on real concerns
about the adverse impact of EHRs on the delivery of patient care. Physicians are optimistic about
EHR potential for systematic collection of data to improve patient care, but are frustrated with the
cumbersome interfaces and processes of existing EHR systems.
A significantly greater effort in EHR development needs to be made to meet the needs of endusers.EHRvendors(including theVAHC) need toworkwith health care providersto facilitateworkflow and health care team communications, and to better understand the impact of technology on
patient care. The potential for EHRs to positively transform healthcare is real but not yet fully realized in currentsystems.Effective use of an EHRsystem willrequire more than top-down policies and
incentives. It will require the input of physicians who best understand the impact of technology on
patient care. Much work is yet to be done.
on the whole, both systems are better than the paper systems we had years ago.
Schattauer 2011 L. Grabenbauer; A. Skinner; J. Windle: EHR adoption: Maybe Its not about
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Research Article Applied Clinical Informatics 467
Clinical Relevance Statement
Our study suggests that low EHR acceptance by tech-savvy physicians is related to insufficient
functionality and its potential negative impact on patient care.
Conflicts of Interest
The authors declare that they have no conflicts of interest in the research.
Human Subjects Protections
The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, and was reviewed by
the University of Nebraska Medical Center Institutional Review Board. Informed consent was obtained in all cases.
Schattauer 2011 L. Grabenbauer; A. Skinner; J. Windle: EHR adoption: Maybe Its not about
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Research Article Applied Clinical Informatics 468
Fig. 1 Drivers for EHR system adoption and usage
EHR Functionality
Workflow Communication
Education/
Decision
Support
Outcomes /
Research
User Satisfaction
EHR Adoption
Delivery of Patient Care
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Table 1 Impact of TNMC and VAHC electronic health record systems
Theme TNMC VAHC
Workflow
(Frequency = 55%,
ConvergenceHigh,
Intensity High)
+ Patient data available at point-of-care
Time needed for documentation reduced time for patient care
+ Patient-centric structure, well organized
Some patient data was scanned and
not searchable
+ Patient data comprehensive and structured
Many clicks to get to desired patient data
Archaic commands
Watered down patient progress notes
Communication
(Frequency = 15%,
ConvergenceHigh,
Intensity High)
+ Patient data can be shared across healthcare team
+ Availability of reports based on patient data
Less direct communication across healthcare team
+ Supports interaction with nursing Difficult searches for specific patient data
Outcomes / Research
(Frequency = 11%,
ConvergenceLow,
Intensity Low)
+ Potential to improve population health
Cumbersome for individual patient management
Education
(Frequency = 4%,
ConvergenceLow
Intensity Low)
+ Potential for evidence-based knowledge at point-of-care
Difficult learning curve takes focus away from patient
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