Practices’ Experience with EHR Features

Interviewed staff members at treatment and control practices with EHRs were generally interested in using their EHRs to improve patient care and make the practice more efficient. However, they also expressed some level of dissatisfaction with the EHR features.

1. Treatment Practices

a. Features that Support Clinical Care

Treatment practice staff reported that multiple EHR features were helping improve the care offered, including electronic patient visit notes, electronic viewing of test results, e-prescribing, alerts and reminders, electronically downloadable educational materials, and clinical messaging (Table III.3). One treatment practice reported that the ability to electronically order laboratory tests and view results had enabled MAs at the practice to be actively involved in care: for the

past three years, they have reviewed test results and followed up with patients with outstanding test results (for mammograms, for example). At this practice, MAs can also print out educational materials (for example, about how to follow a low cholesterol diet) and review them with patients at the time of a visit. Seven of the visited treatment practices noted that, due to the ability to electronically enter and view patient visit notes, as well as problem and medication lists, more complete and useful information was available to practice staff at the time of patient visits. Several physicians at 2 separate treatment practices noted it was much easier to access and track patient information (such as medication use and abuse or test results), thereby ensuring faster followup with patients if there is an alert for a specific problem or test result.

Table III.3. Selected EHR Features Cited as Supporting Clinical Care

Feature

Number of Treatment Practices Electronic patient visit notes (including accompanying templates, problem and

medication lists)

7

Online results viewing for laboratory tests and imaging (including ability to produce a graph of test results over time)

5

E-prescribing (including referencing drug formularies at time of prescription, screening for drug interactions, online prescription transmission to pharmacy)

5

Automated patient-specific alerts and reminders 3

Patient-specific educational materials 1

Clinical messaging with other physicians and practice staff 1

Source: Mathematica interviews with practice physicians and administrative staff at 12 treatment practices using EHRs, spring/summer 2010.

b. Problematic EHR Features

Staff at the visited treatment practices expressed frustration with many of the same EHR features they believed have had a positive impact on clinical care, including templates to organize entry of electronic patient visit notes, alerts and reminders, electronic viewing and ordering of laboratory tests, educational materials, and e-prescribing (Table III.4). These features were viewed as problematic due to (1) their bulk, including the number of templates and copious information contained within each template; and (2) the time they add to patient visits, including time spent entering data, which reportedly resulted in a less efficient workflow.

Too much data entry. Although interviewed staff said that the practices benefited from the improved documentation available through the EHR, staff at 6 treatment practices also emphasized that EHRs contained too many templates, with voluminous information displayed in a manner that is not user-friendly. Physicians at 4 treatment practices also reported that the EHRs had impacted their ability to maintain visual contact with patients during the visit; they were too busy flipping between the templates and entering relevant data. Physicians at one treatment practice chose to ignore the templates altogether and dictated their notes into the EHR. Only one practice reported an attempt at a solution: an office manager at a large treatment practice said that to deal with the “overwhelming” nature of the EHRs and improve the ability of physicians to use the EHR system effectively, the practice now requires physicians to complete eight hours of continuing education on using the EHR.

Table III.4. Problematic EHR Features

Feature Reason Feature Is Problematic

Number of Treatment Practices Electronic patient visit notes (including

accompanying templates)

Templates not physician-friendly; too many templates

6

Automated patient-specific alerts (for drug interactions) and reminders (for preventive care)

Too many alerts/reminders; not all preventive tests are warranted

6

Online ordering and results viewing for laboratory tests and imaging

Lack of interoperability with laboratory or imaging facilities; too expensive to connect to vendors; results are not complete; physicians do not know how to order tests; too time- consuming to use online ordering

3

Patient-specific educational materials Not specific to geriatric population 1

E-prescribing Lack of interoperability with local pharmacies 1

Source: Mathematica interviews with practice physicians and administrative staff at 12 treatment practices using EHRs, spring/summer 2010.

Too many alerts and reminders. While interviewed practice staff were appreciative of the EHR system’s alerts (for allergies and drug interactions) and reminders (for preventive services), they were dissatisfied with the sheer volume and inability to customize them. The office manager at a large treatment practice reported that the practice’s IT department was able to adjust the number of alerts and reminders; however, practice staff still found alerts for drug interactions were too frequent and were often not helpful to the physicians. A physician at one treatment practice reported he was not heeding the clinical reminders for preventive services because of debate in the literature about when to stop performing such tests as mammograms, colonoscopies, and prostate exams.

Issues with interoperability. Interviewed staff members were interested in achieving better interoperability with hospitals and laboratory and imaging vendors so they could order tests, view results, and seamlessly exchange information as patients moved to and from the hospital. However, 2 treatment practices reported they were impeded by the costs of the interfaces with other health care organizations. One treatment practice reported it cost approximately $1,300 to connect with each organization; only one associated organization, a large laboratory, was covering these costs. Two treatment practices found online ordering of laboratory tests too time- consuming and difficult to use, although, at the time of the site visits, it was not clear whether ordering was taking place through an internet or EHR interface with the laboratory vendor.

2. Control Practices

When talking about the impact of the EHR on quality of care, the five visited control practices using an EHR remarked on many of the same EHR features as their treatment counterparts. The features improved the ability to have complete information in hand at the start of a patient visit, and included: (1) electronic patient visit notes (4 practices), (2) online diagnostic test viewing (2 practices), (3) alerts and reminders (2 practices), and (4) e-prescribing (1 practice). Of these, several functions were also seen as problematic. As was reported by treatment practices, control practices found there to be too many templates (3 practices), and

alerts and reminders (1 practice), and experienced issues with interoperability with vendors (1 practice).