Q&A: Electronic health records bring 'extraordinary opportunities' for care

Satisfaction and support for electronic health records were significantly higher among physicians working in physician-owned practices than those in non-physician-owned practices, according to findings published in JAMA Network Open.

In a related commentary, Richard J. Baron, MD, the president and CEO of the ABIM, called the findings “both provocative and tantalizing.”

“It is provocative because it finds meaningful and important differences between EHR satisfaction reported by physicians working in physician-owned practices compared with those working in non–physician-owned practices,” he wrote. “It is tantalizing because, as robust and important as the finding is, the authors’ data don’t provide much insight into why this might be true.”

In the cross-sectional study, Lisa S. Rotenstein, MD, MBA, an assistant professor of medicine at Brigham and Women’s Hospital, and colleagues surveyed 1,368 non-federally employed physicians who provided office-based care in 2019 through the National Electronic Health Records Survey. In total, 59.5% of respondents worked in a practice owned by a physician or physician group.

The researchers reported that 68.1% of physicians in physician-owned practices were satisfied with their EHR compared with 58.5% of physicians in non-physician-owned practices. In addition, respondents in physician-owned practices were significantly more likely to report that time spent on EHR documentation was appropriate (44.8% vs. 32.4%) and that staff support for documentation was available (36% vs. 26.7%).

Healio spoke with Baron to learn more about why satisfaction with EHR documentation is so low among physicians, particularly those in non-physician-owned practices.

Healio: How valuable are EHRs to clinical practice?

Baron: EHRs bring enormous value to clinical practice. I think one of the tragedies of national EHR implementation is that it’s been done in a way that the pain and anguish of changing platforms on which you provide care has drowned out the extraordinary opportunities for better care that everybody experiences daily on an electronic platform.

My clinical practice career spans paper charts moving to electronic charts. With a paper chart, you often couldn't even find the chart when you were trying to talk to a patient. If you were using a dictation service, you might not have a transcript for a week after you did the appointment. If you were handwriting, you might not have produced anything legible. And when you weren't in the office, you didn't have access to information about patients. I spent 30 years taking phone calls from patients, the first 25 of them with literally no information about them other than what they could tell me or what I would know already.

I think the availability of information to a lot of people in a lot of places at the same time is a huge advantage for EHRs, and I think that's one advantage that most practicing doctors would agree with. A variety of daily activities in practice, such as prescription refills and processing lab test results, can be done much more efficiently in an EHR once you develop the systems you need to do it, communicating with other members of the team about things you want them to do, or things they want you to do. A lot of doctors today would say that's not a benefit; they would say that's the worst thing about an EHR because inbox overload is a huge problem. However, it's a solvable problem. We just have to change the way we staff practices and figure out better ways to distribute work. Today, EHRs are a huge improvement both for doctors and patients compared with a paper world.

Healio: How are EHRs associated with burnout?

Baron: The satisfaction issue goes way deeper than compensation. Compensation is part of it.

It's that a lot of tasks that used to be done by somebody else wind up being done by the doctor. They're done more efficiently than they were done before but if the doctor wasn't the one doing them, then that is a downgrade from the doctor's point of view.

When I was practicing, and we moved to an EHR, we realized that we needed to redefine pretty much everybody’s job description in the office and create different workflows so that we use the EHR to support the work we needed to be done. We had to reallocate that work. I think in lots of practices around the country, that hasn't happened, and doctors wind up with this major inbox overload where everything is flowing by them. We need to reimagine workflow in the office so that doesn't happen.

I hope over time it will happen, but in places where it isn't happening, doctors are struggling. That is one of the reasons for the findings in the study, that physician-owned practices are more likely to take seriously the workload burden and the shift of work to the doctors and more likely to control budgets and staffing and workflows in a way that protects doctors from the worst features of the EHR. Non-physician-owned practices are paying less attention to that.

Healio: In addition to updating the workflow, what actions can physicians take to optimize their satisfaction with EHRs?

Baron: They almost certainly need different kinds of staff trained differently. A lot of the inbox management stuff really could be handled by people, not doctors, who aren't reliably part of the staffing package in an office. Doctors need to look at the work they're doing on the EHR and ask themselves whether it would be possible for a non-physician to do this work. For a good portion of the work, it's absolutely possible for a doctor not to do it.

Doctors have to say pretty ruthlessly that if we don't have somebody to do that work, we need to create a new job description for somebody. For example, one thing that happened, particularly in emergency rooms and in some offices, doctors who were not good at typing created a new position of a medical scribe. The doctor would talk to the patient, and somebody would create the EHR while the doctor would talk. That is an extreme example these days, especially with young doctors who are keyboard natives. That isn't as big an issue for them, but it sure was a big issue for people who didn't grow up on computer keyboards as a part of their lives. That is just one example of work that doctors are doing an inbox management that somebody else could and should be doing. There wasn't a need for a medical scribe until doctors had to interact with the keyboard. There isn't a need for somebody to work an inbox until there's an inbox to be worked.

Healio: Do physicians receive training in medical school or through CME on EHR implementation and use?

Baron: Sadly, no. What is taught is the documentation requirements you have to meet to support billing codes and to withstand an audit from a third party. This is a missed opportunity to invite people to think about redesigned workflows so that doctors don’t do everything, and how to use the presence of information technology at the point of care to improve the quality of care that we give to patients, which I think is what most doctors care about.

It's a matter of teaching people what you can do with an EHR that you can't do without an EHR, how you can ask and answer questions that matter in your practice, and how you can use it as a tool for better patient care. I don’t think we spent a lot of time inviting people to think about that.

Healio: Do you have anything else to add?

Baron: One of the major points I express in the commentary is that, at the end of the day, it's about giving physicians agency over their use of EHRs. As a practice manager or owner, you tell a doctor what they have to do on the EHR. You never have a conversation with the doctor about how they would like to use the EHR to help them. That's the conversation people need to have.

The study reports as a possible explanation that if institutions are run by doctors who really care about how to make the work process better, and how to make patient care better, then they will take steps to make doctors happier with their EHRs. If institutions are run by people who are focused on how to keep the hamster wheel turning, and how to get a certain volume of encounters through the door, then the doctors are going to suffer and they're going to be unhappy and burned out. It is not impossible for practices that are owned and controlled by non-physicians to engage their doctors in conversations about how to use the EHR better. That is a critical step and a message from the study, that people who run practices should be talking to their doctors about their user experience, about how to make it better, and how to use it as a tool to improve the care of the patients they take care of.

References:

Baron RJ. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.8309.

Rotenstein LS, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.8301.