Although EHRs were designed to streamline patient documentation and provide increased access to patient information, EHR usage can lead to decreased physician satisfaction and quality of care.
Given that almost two hours of EHR and other desk tasks are needed for every hour of direct patient care time, as studied via time-motion research across multiple specialties,1 getting a handle on how EHR usage is affecting physician job satisfaction and quality of care is crucial.
A separate study from late 2018 found that EHR-related stress — especially for primary care doctors — is associated with physician burnout: Doctors who spend “moderately high/excessive time on EHRs” outside the office experienced burnout 1.9 times more often than doctors with little to no EHR use at home.2
Despite the challenges associated with EHRs, there are benefits to patient care when it fits into a physician’s workflow well. Physicians who report that EHR use enhances their overall patient care found the technology to be beneficial, and the longer a physician uses an EHR, the more likely he or she is to report satisfaction with the EHR — suggesting that EHR experience can also be a positive influence on physician job satisfaction.3
EHR use takes time away from face-to-face patient care and interaction and can lead to professional time spent typing and clicking a mouse, which may lead to physician frustration, burnout and even patient dissatisfaction.4
Despite intent to streamline documentation and increase access to patient records,5 EHR technologies create bottlenecks resulting in a higher percentage of physicians dissatisfied with the use of EHRs.6
Higher-functioning EHRs with sophisticated systems also can result in increased physician stress and reduced job satisfaction as compared to lower-operational EHRs. One study noted that physicians’ workloads and cognitive capabilities should be considered as EHRs can lead to decreased productivity and inadvertent consequences for physicians if not properly implemented.7
This issue is particularly acute for small medical practices. Smaller offices struggle with EHR performance, as studies show growing job dissatisfaction among smaller-practice physicians regarding EHR use and the perception that EHRs fail to bring value to medical practices and patient care.8
These findings are supported in part by a group of physicians from Southwest Florida who reported their experiences with and perceptions of EHRs regarding their job satisfaction and quality of care.
EHRs, physicians and “snowbirds”
More than a dozen physicians in an urban, mixed-specialty outpatient medical practice in Southwest Florida were interviewed, all board-certified and none in primary care. In addition to daily functions as diagnosticians and personal physicians, this group were also consultants and educators in resident physician programs.
Focusing on this group of physicians was important because seasonal tourists, often referred to as “snowbirds,” create a significant increase in the general population during a six-month period between fall and spring. With a high populace influx throughout a six-county area and need for specialized physicians to care for these patients, physician experience with EHRs can affect overall physician job satisfaction and patient quality of care.
These physicians were asked a series of questions on their EHR usage, perceptions of the EHR and its relationship to their job satisfaction. In analyzing their responses, eight themes emerged.
Although the physicians were generally happy with their career choice in the medical profession, they reported EHRs had both a negative and positive influence on their job satisfaction. On one hand, the requirement to use EHRs has caused angst in their job satisfaction because of the reduced face-to-face interactions with patients and increase in data entry tasks that some feel are below their skillset. Conversely, other physicians felt EHRs enhance their job satisfaction with its portability, prescription or treatment prompts to improve patient quality of care, and ease of access to transmit patient information among medical treatment facilities.
Digging deeper
Physicians’ experiences with EHRs can influence physician job satisfaction, which, in turn, can influence patient quality of care.9 This study was designed to explore physicians’ attitudes and feelings about EHR usage in this area because of the high influx of seasonal tourists and the need for specialized physicians to care for these patients.
Availability of information
Participants generally felt EHRs afforded them and their patients increased access to and availability of information, as well as enhanced ease of access to information. One participant also believed increased access to patient information led to improved patient care, explaining how readily available information facilitates communication with patients, which can lead to improved patient interaction. These findings support an earlier study that found that EHRs positively influenced patient care and physicians’ work environments by reducing information duplication and spending less time searching for test results or operative reports.10 They also echo a study that reported that EHR benefits included better access to patient records, which led to improved clinical outcomes.11
Several physicians reported EHR software is often developed for primary care use and is not specific to subspecialties, therefore limiting rather than enhancing availability of information for these physicians. This is similar to earlier studies that suggest EHRs may depersonalize the patient care experience and cause confusion due to incomplete information in the EHR.12
Impact on medical practice and decision-making
Many participants, when asked about the role of medical decision-making in their use of EHRs, identified positive effects from EHRs. This is in line with a past study that noted EHRs often improve medical decision-making.13
Documentation and note-taking
Physicians offered mixed views on information documentation in EHRs and its effect on their job satisfaction. Some participants reported documentation was more detailed and legible in the EHR, leading to enhanced intelligibility and fewer mistakes. Many participants, however, reported dissatisfaction filling in checkboxes and templates as a means of documentation, with the consensus being that this method of documentation often failed to capture important details of patient visits.
Interactions with patients
Most physicians in the study reported that EHRs had a negative influence on their interactions with patients, reducing satisfaction and quality of care. Participants believed specifically that they paid too much attention to their computers during patient visits instead of meaningfully interacting with patients. This is largely in line with previous studies on EHRs’ influence on patient interaction, including:
- Reports that EHRs interfere with the collection of psychosocial and emotional information from patients14
- Reports of diverting physicians’ sight, affecting eye contact with patients and physical examinations15
- Reports of less time overall for patient interaction due to EHR use16
At least one study noted that the integration of patient demographics and information on patients’ lifestyles and behavior can enhance physician-patient communication and overall interactions with patients.17
Time management
Time management findings from the study were somewhat mixed. Many physicians reported EHR-related tasks negatively affected their time management regarding patient care and face-to-face communication. Some participants also reported EHR-related tasks were time-consuming and negatively affected their productivity. One participant described EHR-related tasks as “laborious.” Past research has shown that EHR documentation tasks can lead to physician frustration, which may influence productivity.18 Some participants, however, reported positive effects of EHR documentation on time management and productivity. One participant said that EHRs enhanced productivity and increased the number of patients who were able to be seen by making documentation easier. Ease of documentation, however, was dependent on familiarity of the EHR system.
Use of assistants
Many participants mentioned the use of scribes or assistants in the completion of EHR tasks as a resource to improve physician job satisfaction and order entry of patient information for quality measures. When physicians were supported by a medical assistant or scribe, they reported increased job satisfaction because the use of assistants helped to address issues related to decreased patient interaction, data collection support during patient encounters, chart preparation before seeing patients and time management. When nonlicensed team members are trained to become efficient scribes, it allows the physician more time for patient examinations and discussion of diagnosis or treatment plans, as well as easing the burden of EHR tasks.19
Learning process
A major challenge to EHR use that negatively affected job satisfaction, as noted by many participants, was the learning process associated with EHR system usage. This finding supports past research that learning EHR systems can be a major challenge for physicians and a salient factor to their job satisfaction.20
The learning process regarding EHRs has also been shown to be related to age. Younger physicians are more likely to perceive the advantages of EHRs than older physicians, thus leading to more positive expectations and experiences for younger physicians than for older physicians.21
Specificity and compatibility
One common aspect of an EHR’s negative influence on physician job satisfaction was the lack of specificity of EHR systems to their specialty or discipline. EHRs seemed to be geared toward general practice use through a one-size-fits-all approach, and these systems made it difficult for participants to enter and find information relevant to their specialties. One participant reported wasting time having to sort through too much unnecessary information.
Although it may be necessary to better tailor EHR systems to physician specialties, compatibility and interoperability also remain concerns for EHR use. Many participants reported the need for compatibility between EHR systems so that information can be communicated and shared more effectively. This finding supports research that confirms a need for the standardization of EHR systems for ease of use and quick retrieval of patient data, and that interoperability remains a major challenge to EHRs and physician satisfaction.22,23
Implications for practice
As EHR technology progresses to support physician job satisfaction and patient quality of care, it is important for practice leaders to choose an EHR that supports a physician’s workflow. Increased free-text documentation, along with the ability to chart directly on the computer screen, may help to encourage EHR practice so physicians can enhance their patient care. The ability to take notes in a more user-friendly mode embraces the EHR change and may allow physicians to enjoy more face-to-face personal communication with patients.
Teaching medical assistants to better understand the functionality EHRs offer will also free up physicians’ time to help them concentrate on medical treatments and actions required to improve quality of patient care and increase productivity through better time management. Improved documentation can create direct successful paths for physicians to meet necessary regulatory Merit-based Incentive Payment System (MIPS) criteria, which reflect a high standard of care and, ultimately, physician reimbursements from government and commercial payers.
As the programming functions of EHRs are enhanced to meet the needs of specialty care physicians, it is expected the more intuitive an EHR system becomes, the higher its demand for interoperability and use across integrated delivery systems, thus potentially leading to increased physician job satisfaction.
Continuing physician education can help improve physicians’ opinions of EHRs. By embracing information technology, physician job satisfaction and patient quality of care can be improved throughout healthcare.
Notes
1. Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L, et al. “Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties.” Annals Intern Med.; 165:753–760. doi: 10.7326/M16-0961.
2. Gardner RL, Cooper E, Haskell J, Harris DA, Poplau S, Kroth PJ, Linzer M. “Physician stress and burnout: the impact of health information technology,” Journal of the American Medical Informatics Association. 26(2), February 2019, 106–114. doi.org\\10.1093\\jamia\\ocy145.
3. King J, Patel V, Jamoom E, Furukawa M. “Clinical benefits of electronic health record use: national findings.” Health Services Research. 49(1pt2), 392–404. doi:10.1111/1475-6773.12135.
4. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, … Oreskovich MR. “Burnout and satisfaction with work-life balance among U.S. physicians relative to the general U.S. population.” Archives of Internal Medicine. 172(18), 1377-1385. doi.org/10.1001.archinternmed.2012.3199.
5. Westgate A. “Ten ways to use your EHR more efficiently.” Physicians Practice. Jan. 9, 2015. Available from: bit.ly/2TBL383.
6. Butler R, Johnson W. “Rating the digital help: Electronic medical records, software providers, and physicians.” International Journal of Health Economics and Management. 16(3), 269–283. doi.org/10.1007/s10754-016-9190-8.
7. Babbott S, Baier Manwell L, Brown R, Montague E, Williams E, Schwartz M, ... Linzer M. “Electronic medical records and physician stress in primary care: results from the MEMO Study.” Journal of the American Medical Informatics Association. 21(1), 100–106. doi.org/10.1136/amiajnl-2013-001875.
8. Meigs S, Solomon M. “Electronic health record use a bitter pill for many physicians.” Perspectives in Health Information Management. 13 (Winter 2016), 1–17. Available from: bit.ly/2lRfRoi.
9. Butler, Johnson.
10. Manca D. “Do electronic medical records improve quality of care? Yes.” Canadian Family Physician. 61(10), 846–847. Available from: bit.ly/2jRduBq.
11. Raglan G, Margolis B, Paulus R, Schulkin J. “Electronic health record adoption among obstetrician/gynecologists in the united states: Physician practices and satisfaction.” Journal for Healthcare Quality. 2017, 39(3), 144–152. doi:10.1111/jhq.12072.
12. Krenn L, Schlossman D. “Have electronic health records improved the quality of patient care?” Physical Medicine and Rehabilitation. 9(5), S41–S50. doi.org/10.1016/j.pmrj.2017.04.001.
13. Ibid.
14. Rathert C, Mittler J, Banerjee S, McDaniel J. “Patient-centered communication in the era of electronic health records: What does the evidence say?” Science Direct. 2017, 100(1), 50–64. doi:10.1016/j.pec.2016.07.031.
15. Ibid.
16. Raglan, et al.
17. Heart T, Ben-Assuli O, Shabtai I. “A review of PHR, EMR and EHR integration: A more personalized healthcare and public health policy.” Health Policy and Technology. 6(1), 20–25. doi.org/10.1016/j.hlpt.2016.08.002.
18. Shanafelt, et al.
19. Contratto E, Romp K, Estrada C, Agne A, Willett L. “Physician order entry clerical support improves physician satisfaction and productivity.” Southern Medical Journal. 2017, 110(5), 363–368. doi:10.14423/SMJ.0000000000000645.
20. Butler, Johnson.
21. Duarte J, Azevedo R. “Electronic health record in the internal medicine clinic of a Brazilian university hospital: Expectations and satisfaction of physicians and patients.” International Journal of Medical Informatics. 2017, 102, 80–86. doi:10.1016/j.ijmedinf.2017.03.007.
22. Greiver M. “Do electronic medical records improve quality of care? No.” Canadian Family Physician. 61(10), 847–853. Available from: bit.ly/2MSBS0g.
23. Manca.
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