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Obstetrician/Gynecologists' Experiences with Electronic Health Record
Systems: A Narrative Study
Article in The Journal of reproductive medicine · March 2015
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Obstetrician/Gynecologists’ Experiences with
Electronic Health Record Systems
A Narrative Study
Greta B. Raglan, M.A., Benyamin Margolis, Ph.D., M.P.H.,
Ronald A. Paulus, M.D., and Jay Schulkin, Ph.D.
OBJECTIVE: To explore the experiences of obstetrician/
commonly cited positives were electronic medication pregynecologists (ob/gyns) with regard to the use of elecscription (e-scribing) capabilities, efficiency, and ease of
tronic health record (EHR) systems in practice.
access to notes, including legibility.
STUDY DESIGN: Surveys
CONCLUSION: In spite of
were mailed to 1,200 ob/
increased adoption of EHR
While physicians reported many systems, more work is needed
gyns, with an overall reto improve ob/gyn satisfac­
sponse rate of 57.2%, 402 of
benefits to implementing
tion with EHR systems. (J
whom currently use an EHR
EHR systems, many still noted
Reprod Med 2015;60:95–
system. The survey included
102)
questions about the physisignificant obstacles …
cians’ use of EHR systems
Keywords: electronic
as well as what features they
health records, electronic medical records, obstetrifound most or least helpful. In addition, a focus group of
cian/gynecologists, physician satisfaction, narra6 practicing ob/gyns at a university-based hospital was
tive, task performance and analysis, technology.
conducted in which they were encouraged to give free responses about their experiences working with EHR systems. Responses from surveys and the focus group were
With the rise of government incentives, improved
analyzed for frequency by the investigators.
technology, and an increasingly wired world, use
RESULTS: The majority of ob/gyns who used an EHR
of electronic health record (EHR) systems has risreported being satisfied with that system (61.4%). The
en greatly in recent years among physicians in the
most commonly reported impediments to EHR use were
United States.1,2 In spite of this rise, physicians in
time needed, ineffective templates, note quality, interferthe U.S. lag behind other industrialized countries
ence with patient interactions, and expense. The most
in terms of EHR utilization, with certain specialties,
From the Research Department, American College of Obstetricians and Gynecologists, Washington, DC.
Supported by grant no. R60MC 05674 from the Maternal and Child Health Bureau (Title V, Social Security Act, Health Resources and
Services Administration, and Department of Health and Human Services (DHHS). The findings and conclusions are those of the authors
and do not necessarily represent the views of the Health Resources and Services Administration or the Department of Health and Human
Services.
Address correspondence to: Greta B. Raglan, Research Department, American College of Obstetricians and Gynecologists, 409 12th
Street SW, Washington, DC 20024 (graglan@acog.org).
Financial Disclosure: The authors have no connection to any companies or products mentioned in this article.
0024-7758/15/6003-04–0095/$18.00/0 © Journal of Reproductive Medicine®, Inc.
The Journal of Reproductive Medicine®
95
ORIGINAL ARTICLES
The Journal of Reproductive Medicine®
96
such as obstetrics and gynecology, being even less
likely to use EHRs.3 EHR systems have been found
to increase the efficiency of medical practice and to
reduce the number of medical errors.3 Additionally,
EHR systems allow practices to track patient information and health patterns in order to better care
for patients and to improve services.4 Despite these
advantages, physicians often cite drawbacks to the
use of EHR.
Some studies have noted that EHR systems may
add to the time that physicians spend on paperwork and record keeping, particularly when they
first implement a system.5,6 Concerns about patient
privacy and data accuracy have also been raised.7,8
Some studies have shown that EHR systems do not
necessarily lead to improved medical practices,9
and many systems are not fully utilized.10,11 In addition to these wide-reaching concerns, differences
in physicians’ needs mean that EHR systems are
less functional for certain medical specialties and
may be more difficult to adopt for older physicians.12
Approximately 15–20% of ob/gyn practices in
the U.S. currently use an EHR system, significantly
fewer than in other medical specialties like internal
medicine, orthopedic surgery,1 and primary care
(family physicians, general internists, and general practitioners).13 Among those ob/gyns who do
use an EHR system, few use an advanced system
or the full functions of their system.11 Ob/gyns face
unique challenges when selecting and using an EHR
system because their practices are often both office
and hospital based, medical and surgical, and are
focused on treating both a woman and her child.14-17
Some studies have found that most EHR systems do
not adequately address these unique aspects of ob/
gyn practice and that EHR systems are therefore of
limited usefulness to ob/gyns,18 but there is a great
deal of room for growth.19
Despite these challenges, EHR systems have the
potential to improve outcomes and documentation
in ob/gyn practices. Bernstein et al20 found that paper prenatal records completed prior to the implementation of an EHR system were more likely to
have missing information and were less likely to be
up to date than were electronic records. Eden and
colleagues21 found similar results after looking at
labor and delivery records before and after the implementation of EHR. In particular, they found that
paper records were more likely to lack information
about chief complaints, prenatal laboratory results,
and prenatal history21—information that could be
The Journal of Reproductive Medicine®
very important to physicians attending to patient
care. Electronic reminders, such as those regarding
regular Pap smears and mammograms, have been
found to increase the likelihood that patients receive
regular testing22 and that obstetrics practitioners adequately document these services.23
Another study found that electronic checklists led
to better documentation of care in cases of shoulder dystocia.24 Given the prevalence of legal cases
regarding inadequate documentation of shoulder
dystocia cases, this could have important implications for malpractice in ob/gyn. When using more
advanced systems, positive effects on patient care
are strengthened.11 Some research has suggested
that ob/gyn-specific EHR systems may improve accuracy and completeness of charts.18 When properly
utilized and functional, EHR systems have the potential to improve patient safety and medical practice in ob/gyn.25
Based on the potential for improved medical care
through EHR and the unique challenges of EHR
in an ob/gyn setting, the purpose of this study was
to gain a better understanding of the obstacles that
ob/gyns perceive to using EHR systems as well as
the benefits that they experience from having EHR
in place. We predicted that ob/gyns would have
mixed experiences operating EHR systems and that
some obstacles faced would be unique to ob/gyn
practitioners.
Materials and Methods
Measures
A survey regarding practices, opinions, and patient
characteristics was developed by the research department at the American College of Obstetricians
and Gynecologists (ACOG). Questions were developed in consultation with practicing ob/gyns and
were pilot-tested on a sample of practicing ob/gyns
with adjustments made prior to distribution. The
survey took approximately 15–20 minutes to complete. Institutional Review Board approval was obtained from ACOG.
Participants were asked a series of 18 questions
related to demographics and their practice. One
question asked physicians, “Do you currently have
an Electronic Medical Records (EMR) system or
plan to implement one within the next year?” Those
physicians who currently use an EHR system were
asked, “Overall, have you been satisfied with the
EMR system?” and “Why?” Two additional freeresponse questions asked “What have you found to
be the most useful feature of the EMR system and
97
Volume 60, Number 3-4/March-April 2015
why?” and “What have you found to be the least
useful/most frustrating feature of the EMR system
and why?” The survey included additional questions that are addressed elsewhere.26
A focus group consisting of 6 board-certified ob/
gyns working at a university hospital was also conducted. The focus group was largely participantguided, but questions focused on overall satisfaction with EHR systems and improvements that the
physicians would suggest.
Procedures
Paper mailings, which included a cover letter, a
questionnaire, and a stamped return envelope, were
sent to the 1,200 invited participants. The questionnaire contained open-ended queries about the participants’ level of satisfaction with their EHR system
and strengths and weaknesses of the system. The
questionnaire also included demographics questions and a binary question asking whether physicians were satisfied with their EHR system. Those
who did not respond to the paper mailing were sent
3 paper reminders. After the fourth mailing those
who had not responded were sent a brief follow-up
letter containing only the 4 questions above and a
question regarding the physician’s year of birth.
The focus group was conducted in one 1-hour
session. Participants were questioned by a single
researcher, and the proceedings were digitally recorded. After the focus group, recordings were
transcribed into computer files. Care was taken by
the researcher to assure the anonymity of the participants.
Transcripts and free-response answers were coded based on categories that arose through respondents’ answers. Two independent researchers were
asked to verify the accuracy of the category system,
and minor modifications were made.
Participants
The survey was sent to 1,200 ACOG fellows. Of
those, 600 were members of the Collaborative Ambulatory Research Network (CARN). CARN members are ACOG fellows and junior fellows in practice who have volunteered to participate in survey
studies on a regular basis without compensation;
they are typically recruited through advertising or
random selection from ACOG’s membership rolls.
CARN was established to improve the response
rate on ACOG Research Department survey studies while maintaining a participant pool representative of practicing ACOG members. The remaining
600 participants consisted of a computer-generated, random sample of ACOG fellows and junior
fellows in practice who had not received a survey
from ACOG during the previous two years (nonCARN group). Of the 686 surveys and letters returned, 15 participants did not complete the survey
and were therefore excluded from analyses. A total
of 402 participants reported currently using an EHR
system.
The focus group consisted of 6 board-certified
ob/gyns working at a university hospital. Participants were recruited through personal requests.
Results
Surveys or letters were returned by 686 physicians
(57.2%), and 671 that had been completed were included in these analyses. Over three-quarters of respondents reported that they currently used an EHR
system or that they had plans to implement one in
the next year (23.0% reported not using an EHR system). Those physicians who currently use an EHR
system were younger than those who did not and
were less likely to belong to a solo practice (Table I).
Of the 402 participants who reported current use of
an EHR system, 61.4% reported being satisfied with
that system, while 34.8% reported being dissatisfied
(3.7% did not answer). Based on free-response questions from physicians who currently use an EHR
system, several categories emerged, including barriers to use of an EHR system as well as strengths
of the systems.
Barriers to EHR Use––Survey Free Response
Time. The most commonly reported barrier to EHR
use (34.3%) was that it is time consuming and decreases efficiency. Participants reported that the
time they spend on notes and paperwork has greatly increased since implementing an EHR system. As
one physician noted:
I could see 18–20 gyns in a day with dictation
to paper chart. Now 12 is a full day. It dumps
VAST amounts of clerk work on overqualified
physicians. I spend 15 hours/month just nursing the mammograms!
Another said:
EHR has added about 30 hours to my work
week, from about 50 to about 80 hours a week. I
spend all my weekends and almost all vacation
time trying to keep up.
Technical/Hardware Problems. Physicians (18.7%) also
regularly commented on difficulties with aged
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The Journal of Reproductive Medicine®
Table I Physician Demographics
Total
Has EHR
Demographic
(N = 671)
(N = 402)
No EHR/will
implement
(N = 269)
Age, mean yrs (SD)
55.4 (9.38)
53.96 (9.01)
57.63 (9.40)
Gender, female (%)
47.6
50.6
43.1
Race (%)
White/European American
82.1
82.6
81.4
Black/African American
4.6
5.0
4.0
Asian/Pacific Islander
7.9
7.8
8.0
Other/ > 1 specified
5.4
4.6
6.6
Clinical practice setting (%)
Solo/private practice
17.8
17.7
32.3
Partnership/group practice
45.2
43.1
43.8
Multispecialty group
14.3
20.3
5.8
University full time
10.5
13.2
6.6
Other
12.2
15.7
7.1
Practice location (%)
Urban, inner city
16.4
18.2
13.8
Urban, non–inner city
28.0
28.0
28.0
Suburban
37.5
37.2
37.8
Town of 5,000–50,000
14.0
13.5
14.7
Rural/other
4.1
3.1
5.7
Specialty (%)
General ob-gyn
74.3
76.7
70.9
Gynecology only
17.0
13.8
21.5
Other
8.7
9.5
7.6
Significance
p < 0.001**
p = 0.057
p = 0.678
p < 0.001**
p = 0.405
p = 0.059
**Indicates statistical significance at an alpha of 0.01.
hardware or system crashes that interfered with the
functionality of the system:
The EHRs that I have been involved in ALL do
not make medical sense—they are designed
and coded by computer engineers who do not
know how to communicate to physicians. We
have our own system, not theirs and they don’t
get it—it wastes more of my time looking up
stuff whereas it should be at my fingertips.
The hardware at our hospital runs on software
from 1998 and DOS with a linus shell. Give me
a break.
They also talked about difficulties accessing technical support once the systems were running:
Very frustrating dealing with the vendor—
very difficult to get ahold of and we are always
talking to someone different or new personnel.
Interference with Patient Interactions. Many participants (12.4%) noted that, particularly in the context of a gynecological visit, EHR systems interfere
with their ability to speak with patients and to make
good eye contact. As one participant noted:
My nose is in the EHR clicking away and
spending too much time signing in, resigning
in. I want to look at my [patient]!! [Patients] are
spinning their heads around to face me using
the EHR because it is placed in the room near
BP cuff, monitors that cannot be moved.
A survey responder wrote:
EHR limits a very important aspect of human
communication––nonverbal communication
from the patient when I am viewing the screen
and the patient sees my negative nonverbal expression when I am frustrated when the screen
doesn’t respond as I think it should.
Templates. Physicians (8.2%) noted that the templates for notes were not geared toward ob/gyns or
that they were difficult to adapt to certain circumstances. As one participant put it:
The formulaic nature of templates; everyone
“looks & tastes” the same; need to add mental
“hooks or triggers” to note to remember the
visit.
Many participants also criticized the lack of flexibility of the notes:
Cannot accommodate individual practice dif-
Volume 60, Number 3-4/March-April 2015
ferences/preferences for information/organization. Very rigid, cannot find things as it
doesn’t understand misspelling or incorrectly
formatted requests—i.e., antimullerian hormone vs. anti-mullerian hormone vs. hormone,
antimullerian.
In addition, many physicians found that notes and
flow sheets were not well tailored to obstetrics practices. For instance:
EHR is not geared to OB-GYN. The prenatal
rec­ord it has does not have a good flowsheet,
so one must go back through each prenatal visit
for details.
Note Quality. Participants in this study frequently mentioned note quality as a barrier to EHR use
(8.2%), saying that the quality of notes had declined
since implementing an EHR system. Many attributed this to the need to “check boxes” or to complete
a template even if it did not apply to a particular
patient visit. For instance:
My colleagues using this system consistently
repeatedly exaggerate the exam to meet coding requirements (how can you take a complete
history, review systems, do a visual, auditory,
neurological exam, percuss the chest, counsel,
and prescribe all within 8 minutes?).
Or:
Patients lose their individuality. All records
look the same. All exams look the same. The
program also puts words into your mouth. You
click normal and 2–3 sentences come out that
is not what you want to say. The notes are not
helpful.
Expense. The expense of purchasing and keeping
up an EHR system also continues to be a burden
for some providers (6.5%), with one participant saying:
Cost: constant upgrades that not only cost
money but almost always require use of [information technology] personnel because of problems with new software.
Along these lines, many physicians expressed the
desire for additional funding assistance in implementing EHR systems:
EHR is not worth the time and financial investment. We need to finance this through insurance companies and government.
Positives of EHR Systems––Survey Free Response
Ease of Access. Physicians responding to the survey
99
and in the focus group generally agreed (44.3%) that
the ease of access to charts was an excellent feature
of EHR systems. As these two respondents noted, it
allows for access off-site as well as easy sharing of
information between providers:
Accessibility of records both in and out of office. Ease of communications amongst staff and
physicians regarding [patient] care.
Getting lab results to patients without carrying
around pieces of paper; doing patient emails
instead of having to do phone calls; smart
phones/smart books to help with repetitive
tasks; ability to get outside records.
Record Quality/Legibility. Contrary to those who felt
that EHR notes were of poor quality, some physicians reported improved note quality (16.2%). In addition, the most commonly noted positive feature of
EHR systems was the legibility of notes:
Readable notes, better medication-allergy
checks. Better documentation of notes between
nursing and MDs. Ability to pull charts remotely from hospital or ER or at home on weekends.
In many cases, these notes were perceived to improve quality of care:
Accessibility to a complete/up-to-date/shared,
legible record on each [patient]; use of prompts
and reminders for greater patient safety and
better coordination of care.
E-scribing. Medication management was seen as a
generally positive feature of EHR systems. Many
(10.9%) mentioned the features that allowed them
to see drug interactions on the chart or to follow a
patient’s medication history:
Monitoring medications, especially narcotic
use. Able to see other physician notes.
Or, as one physician simply stated:
I love e-prescribing.
Efficiency/Time. While many physicians reported
greater time spent on notes due to an EHR system,
some (6.0%) also commented on improved efficiency because of their system:
Efficient record of documenting patient phone
calls and how addressed. Phone calls handled
better—faster, ability to see chart, ability for my
nurse to mark “urgent,” there is no misfiling.
Many also noted that it allowed for easier and faster
transmission of information:
I can refer to specialist notes, labs, [mammo-
100
The Journal of Reproductive Medicine®
grams] instantly and not “wait for the chart”
like the old days (or wait for a fax).
Focus Group Feedback
Members of the focus group had concerns and
praises similar to those of the survey responders.
Members of the focus group found that legibility of
notes was one of the biggest benefits to electronic
charting. In addition, ease of access was also frequently mentioned as a positive:
When I see a person in-clinic, it’s very easy to
click through their notes and get a sense of what
they’ve been through and what their history is
or also if I’m specifically interested in one thing,
like they have some clotting problem, but they
really don’t know what it is, oh but they have
hematology notes, I can go and look at those
and that makes things…much more…efficient
than it would be if it was a paper chart.
Another participant noted:
Before this job, I was in a place where we had
nothing electronic, so we had paper. Charts
that got shifted around, and labs that got attached to charts, and it was a nightmare. A
good chunk of our day was spent looking for
paper results and charts and things like that.
So, closing the loop on an ordered test is one of
the biggest advantages.
Physicians also appreciated the prescription writing
aids that the EHR offered, with one saying:
That’s been a big, I think, a really big help to us.
I mean, we deal with prescriptions less because
we send them electronically.
Because the physicians participating in the focus
group were staff members at a large hospital system, they did not report concerns about the cost of
EHR. They did note that electronic notes (in the absence of dictation services) increased the time that
they spent documenting care. Several also said that
the note templates “made everyone look the same.”
They had additional concerns that notes might be
inaccurate or that they did not necessarily have
a means of correcting inaccurate information in
charts:
When an internist or family medicine doc is
populating the problem summary list of the
medical history with a bunch of gyns stuff, it’ll
say a bunch of stuff that’s wrong like cervix
cancer, when she had [cervical intraepithelial
neoplasia], dysplasia, or whatever. And certainly that’s our job to fix that. And then the
surgeon and the family medicine and the inter-
nist can fix whether she had diverticulosis or
diverticulitis or unexplained abdominal pain or
whatever it was.
Several members of the group expressed the wish to
have a more mobile hardware system due to their
concerns that the computer-based EHR interfered
with their interactions with patient. As one male
ob/gyn noted:
You walk in the room and you have to make a
very quick rapport and if I’m going in to see a
woman who’s never seen a male doctor before
or something and now I have to sit down, it’s
already a strike against me, and I have to go in
and I have to turn my back to them.
The hospital at which they worked was in the process of transitioning to a new EHR system at the
time of the focus group. As a result, the focus group
members did report worries that their efficiency
would decrease, particularly during the transition
period:
Right now…maybe if you came a month or
six months from now maybe we’d all feel differently, but I think we’re all anticipating the
next several many months being very painful
getting used to this new system. And I think
certainly we are not going to be efficient in any
way.
Concerns of this nature were the dominant topic of
conversation among the focus group members and
highlight physicians’ struggle to adapt to new and
ever-changing systems of medical record keeping.
Several physicians in the focus group also described
their dissatisfaction with training:
That’s the most frustrating thing for me; the
training was. That the four hours were wasted
on telling me three ways to do something for
every single thing. Just tell me one and then I’ll
be surprised later on when I figure out a faster
way on my own.
Or:
I mean, it just, I felt like the whole day was like
a hodge-podge of things that I couldn’t ever…
and the other thing that I kept asking was, I felt
like they were kind of poor at explaining why
you were doing something. So they would show
us how to do something, but they wouldn’t
ever put it into context. And I kept asking. “I
followed the steps that you just went through
and what you clicked on and everything, but
why am I doing that?” And it was, I mean, like
I agree with you that to do large-scale education for … this many people for an EHR is, I’m
Volume 60, Number 3-4/March-April 2015
sure, very difficult, but I wasn’t impressed with
it, in particular.
Discussion
This survey found that over three-quarters of the
ob/gyns surveyed had implemented, or were planning to implement, an EHR system. This number
indicates an overall increase in EHR implementation over the last 5–10 years compared to previous
estimates.1 Based on responses to this survey and
focus group, ease of access, E-scribing and mediation information, record quality and legibility, and
efficiency were seen as the main benefits of using
an EHR system for ob/gyns. Additionally, the majority of the survey responders (59.5%) and focus
group participants (100%) reported being satisfied
with their EHR system. In spite of this, many physicians reported problems implementing or using
their EHR systems, even among those physicians
who reported being generally satisfied.
Reported obstacles to the use of EHR systems
included time, templates, note quality, interference
with patient interaction, technical/hardware issues, and expense. Importantly, many participants
mentioned that obstetrics reports are particularly
challenging to document using EHR templates, reducing the usefulness of the system and decreasing the quality of the notes. Additionally, several
respondents noted that the systems’ interference
with patient interactions was particularly challenging for ob/gyns given the challenges that ob/gyns
may face in rapport building because of the nature
of their work.
Based on these findings, ob/gyns face many of
the same obstacles to EHR implementation as do
other physician groups. These include the high cost
of starting an EHR system and the continued costs of
maintaining and upgrading the system. These costs
can be particularly high for individuals who are in a
private or group practice not directly affiliated with
a hospital. Many of those questioned also reported
challenges with the technical aspects of EHR systems, particularly the effects of system crashes and
inaccessibility of technical support services.
Time was frequently listed as both a positive and
a negative of EHR systems. The most frequent obstacle that ob/gyns reported encountering when
using an EHR system was that it increased the time
they needed for record keeping. Many other respondents, however, reported that EHR had decreased
the time they spent on documentation and increased
their efficiency. It is possible that immediately af-
101
ter implementation EHR systems increase the time
spend on notes, but that after several months they
are just as fast, or faster, than traditional paper
methods.27 Future studies addressing the time since
implementation would provide important information about this possibility.
Note quality was also frequently mentioned as
both a positive and a negative of EHR systems. In
particular, legibility was one of the most commonly
cited positives of EHR, with many physicians saying
that the readability of notes made them more useful
and allowed for better record keeping. Many, however, said that the quality of the information in notes
declined with the implementation of an EHR system. This seemed especially true in obstetrics notes,
which physicians generally reported as lacking functionality. In this regard, it would seem that there is
room for improvement in creating an EHR system
that works toward addressing the specific needs of
ob/gyns and the multifaceted nature of their work.
Another area of particular concern for ob/gyns
was the disruption of patient-doctor interactions
that they perceived as a result of EHR. Many physicians reported that it was difficult to keep eye contact with their patients and that they felt they spent
more time typing than directly interfacing with the
patient. In a setting in which women may feel especially vulnerable, this can create significant discomfort for patients, and some physicians expressed
concern that it might make it less likely for women to return for follow-up appointments. As technology advances, efforts should be made to adapt
EHR systems to increasingly portable and discreet
interfaces that can allow physicians to communicate
more directly with their patients while still taking
advantage of the potential benefits of EHR systems.
It is also evident from some studies of the effects of
EHR systems28 that time spent on direct patient interactions are not decreased—and may actually be
increased—as a result of EHR systems.
This study showed an overall increase in EHR
utilization by ob/gyns in the U.S. Of those who are
currently using an EHR system, the majority are
generally satisfied with that system. While physicians reported many benefits to implementing EHR
systems, many still noted significant obstacles to the
use of an EHR system. Some of these may be more
salient in an ob/gyn practice than in other medical
fields and raise the idea that an EHR system that is
more specifically tailored to ob/gyns might be beneficial to patient care and would likely increase the
use, and usefulness, of EHR among ob/gyns.
102
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