EHR Adoption Report: The Latest Trends

By Debra Wood, RN, contributor

March 15, 2013 - Hospitals are making progress toward implementation and meaningful use of electronic health records (EHRs), according to American Hospital Association data, but challenges remain. One is that clinician dissatisfaction seems to be growing along with the rate of EHR implementations, according to a new survey of physicians.

William Fera: Despite meaningful use, physicians don't find EHRs user-friendly
Bill Fera, MD, said many physicians feel they are being forced to use systems that do not live up to the electronics in their daily lives.

“Neither are a surprise,” said Bill Fera, MD, a principal in Ernst & Young Health Care Advisory Services, which is based in New York. “The federal incentives have caused hospitals to be more assertive in deploying technologies.”

The Office of the National Coordinator (ONC) for Health Information Technology’s most recent data briefs, reporting hospital adoption of EHR technology based on American Hospital Association (AHA) data, indicated the number of nonfederal acute-care hospitals with EHR systems--also known as electronic medical record (EMR) systems--has more than tripled since 2009, increasing from 12.2 percent to 44.4 percent.

Andrew Agwunobi: Every hospital undergoing EMR implementations and upgrades
Andrew Agwunobi, MD, MBA, said every hospital is either implementing or upgrading an EHR.

“What we are seeing is the result of the financial carrot and the financial stick,” said Andrew Agwunobi, MD, MBA, director of hospital performance improvement for Berkeley Research Group in Washington, D.C. He added that many hospitals had dragged their feet as other industries moved to electronic recordkeeping. The federal meaningful-use incentives got them moving, yet few are fully electronic.

“There are substantial incentives for hospitals to comply with the criteria established for them,” added Jim D’Itri, a partner at CSC, headquartered in Falls Church, Va. “The typical hospital is eligible for millions of dollars.”

D’Itri estimates hospitals can expect to receive $5 million to $7 million in meaningful-use incentives. Delaying the process and missing the deadline of September 30, 2013, could cost a hospital $1 million, he added.

In a second report, also using AHA data, ONC said hospitals are increasingly using advanced functionality, compared with 2008. Use of electronic active medication lists and clinical decision support rules increased to 87 percent, from 62 percent and 66 percent, respectively. The percentage of hospitals using computerized provider order entry (CPOE) jumped 167 percent, from 27 percent in 2008 to 72 percent in 2012.

South Nassau Communities Hospital in Oceanside, N.Y., implemented CPOE as well as laboratory and radiology reporting last year and successfully attested for meaningful use.

“We’ve been moving on a deliberate path, and our pace has been steady,” said Richard Rosenhagen, MBA, RHIA, assistant vice president of electronic medical record, health information management and clinical documentation improvement at South Nassau.

South Nassau built its 150 CPOE order sets to populate core measure metrics. It developed the system mindful of physician workflow and trained providers in its use and monitors usage.

Not all hospitals have taken the time to actively involve physicians or allowed them to lead the EHR adoption process, Agwunobi said, which may result in a system the clinicians do not like or feel wastes their time or reduces productivity.

Anthony Slonim: Electronic medical records change workflow, affecting user satisfaction.
Anthony Slonim, MD, explained that electronic records change workflow for clinicians, affecting their satisfaction.

“You change the clinical workflow of everybody involved,” said Anthony Slonim, MD, DrPH, chief medical officer and executive vice president for Barnabas Health, a seven-hospital system based in West Orange, N.J., which has achieved meaningful use. “Everything you have done for decades has changed.”

That change in workflow could be responsible, Slonim said, at least in part, for the dissatisfaction with EHRs found in a survey conducted in conjunction with 10 different professional societies by the American College of Physicians (ACP) in Philadelphia and its affiliated AmericanEHR Partners.

The ACP/AmericanEHR study showed user satisfaction fell 12 percent from 2010 to 2012, with the percentage of very dissatisfied clinicians increasing by 10 percent. Thirty-nine percent of physicians would not recommend their EHR to a colleague. The numbers were similar for physicians in a variety of practice settings.

“Overall, satisfaction levels are dropping across the board,” said Alan Brookstone, MD, co-founder of AmericanEHR Partners and chairman of Cientis Technologies. 

“Physicians do not like the EHRs they are being forced to use,” said D’Itri, who was not surprised by the study findings. “They are being forced to change their behavior.”

Brookstone offered several hypotheses, including the difficulties and speed with which physicians are having to become meaningful users of EHRs and meeting the requirements. Additional training may help, from the vendor or becoming involved in a user group. 

“Training we feel is a critical factor and not just around the initial implementation of the EHR, but ongoing training so they could get more effective at using the more advanced functionalities linked to the requirements of the meaningful-use program,” Brookstone said.

Fera suggested that additional training should take place three- to six-months after implementation, showing new shortcuts when physicians are used to the system and not so overwhelmed.

“Once you get the system in, you have started the journey,” Slonim said. “There are lots of additional work that has to go on to optimize and refine the system to serve the patients and clinicians caring for them.”

Jim D’Itri said federal incentives are promoting hospital EHR adoptions
Jim D’Itri indicated federal incentives are promoting the increased use of hospital EHRs, but they are not enough to motivate some physician practices.

Training could be part of the solution D’Itri said, but not if physicians are dissatisfied with the system. Additionally, when it comes to office practices, incentives for physicians are not as high as for hospitals, D’Itri said: either $44,000 over a five-year period for Medicare or $67,500 for Medicaid, which requires more than 30 percent of the provider’s patient population being on Medicaid. D’Itri added that physicians do not consider $8,000 a year enough of an incentive.

Deterioration in satisfaction also can occur if physicians do not feel their concerns are heard, D’Itri said.

South Nassau takes all suggestions for improvement seriously. A committee considers all ideas and a formal process assesses downstream implications. 

Involving physicians is critical to an EHR’s success, said Slonim, who brought together physicians from the Barnabas system to create order sets and ensure the system was useable.

Fera suggested that physicians do not like being forced to use electronic technologies and that EHRs do not measure up to what they are used to in their day-to-day lives, which include iPad apps and smartphones, saying that record systems are fairly rigid with a flat interface.

Agwunobi agreed that the current EHR systems lack features that physicians desire. 

Additionally, Slonim raised the issue that now the physician population using EHRs includes more of the naysayers, not just the early adopters.

“As you get more of them involved, it’s not surprising the survey results would deteriorate,” Slonim said. “Now we are doing it with people that don’t want to be on the cutting edge.”


Resources for EMR implementation projects:

EMR/EHR Computer Conversion Staffing Solutions - AMN

© 2013. AMN Healthcare, Inc. All Rights Reserved.