Jerry L. Halverson, MD
Rogers Memorial Hospital
WPA President, WMS President- Elect
December 5, 2014
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Privacy
Incentives and penalties/ meaningful use
AMA/ RAND study
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Factors Affecting Physician Professional
Satisfaction and Their Implications for
Patient Care, Health Systems, and Health
Policy
 What factors influence physician professional
satisfaction?
 What are the implications of these factors for
patient care, health systems, and health policy?
 EHRs were found to be a significant dissatisfier
Physicians approved of EHRs in concept and appreciated
having better ability to remotely access patient
information and improvements in quality of care.
 However, for many physicians, the current state of EHR
technology significantly worsened professional
satisfaction in multiple ways.
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poor usability
time-consuming data entry
interference with face-to-face patient care
inefficient and less fulfilling work content
inability to exchange health information
degradation of clinical documentation
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"Physicians in multiple specialties and
practice models noted that their EHRs
improved their abilities to access patient
data, both in health care settings and at
home."
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"Physicians and administrators in some
practices described how EHRs improved their
ability to provide guideline-based care and
track patients’ markers of disease control
over time. These advantages were
predominantly noted in primary care
practices."
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"Interviewees described enhanced
communication through the medical record
itself (e.g., by facilitating access to other
providers’ notes and eliminating illegible
handwriting) and through EHR-based messaging
applications (e.g., patient portals).
Improvements in between-provider
communication were most commonly noted in
larger practices, where all providers were on the
same EHR."
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"The majority of physicians who interacted
with EHRs directly (i.e., without using a scribe
or other assistant) described cumbersome,
time-consuming data entry.”
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"Beyond data entry, physicians and their
colleagues described EHR user interfaces
that, in important ways, hampered rather
than facilitated their clinical workflow.
Nonintuitive order entry was particularly
problematic."
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Multiple physicians who entered their notes via
keyboard described their EHRs as interfering
with face-to-face patient care. Many of these
physicians blamed themselves for lacking the
ability to type without compromising the level of
attention they could devote to patients.
These physicians faced a difficult trade-off:
divide attention between the patient and the
computer, or defer data entry until after leaving
the patient, lengthening overall work hours.
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Physicians in multiple specialties and a range
of practice settings described frustration
when health information was not exchanged
between EHRs.
Even when practices invested in EHRs, faxes
were a common mode of communicating
patient information between care settings
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Some EHR products feature automatic email
alerts to physicians.
For primary care physicians in particular, this
has created a sense of information overload—
the unceasing volume of messages reaching
them has expanded beyond the number that
they believe they can handle diligently
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Both primary care and subspecialist
physicians noted a mismatch between
meaningful-use criteria and what they
considered to be the most important
elements of patient care.
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Some physicians, especially those who
owned or who were partners in their
practices, reported that investing in EHRs
exposed their practices to significant financial
risks.
In particular, the costs of switching EHRs—
which could become necessary due to factors
beyond a practice’s control—were of high
concern.
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Physicians who did not use scribes reported
that their EHRs required them to perform
tasks below their level of training, decreasing
their efficiency.
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While some physicians described using
templates (or “macros”) to ease the writing of
clinical notes (i.e., to overcome data entry
problems), many described misuse of templatebased notes as a significant threat to both
clinical quality and professional satisfaction.
Such notes were described as complicating the
task of retrieving useful clinical information. This
problem was reported by physicians in all
specialties and practice models included in the
study.
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"In our sample, there was no significant
relationship between overall satisfaction and
the length of time since EHR installation."
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"In addition, physicians whose practices
reported having greater numbers of EHR
functions (with higher numbers indicating
more advanced and possibly more complex
EHRs) were less likely to have high overall
professional satisfaction."
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Physicians and practice managers described
the cumulative burden of externally imposed
rules and regulations as having
predominantly negative effects on
professional satisfaction.
At the time of the study, "meaningful use"
rules for EHRs were the regulations most
commonly singled out by physicians and
practice leaders.
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Better EHR usability should be an
industrywide priority and a precondition for
EHR certification.
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To leverage the power of EHRs for enhancing patient care,
improving productivity, and reducing administrative costs,
the AMA framework outlines the following usability
priorities along with related challenges:
 Enhance Physicians' Ability to Provide High-Quality Patient
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Care
Support Team-Based Care
Promote Care Coordination
Offer Product Modularity and Configurability
Reduce Cognitive Workload
Promote Data Liquidity
Facilitate Digital and Mobile Patient Engagement
Expedite User Input into Product Design and PostImplementation Feedback
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The EHR should fit seamlessly into the
practice and not distract physicians from
patients.
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EHR design and configuration must:
 (1) facilitate clinical staff to perform work as
necessary and to the extent their licensure and
privileges permit and
 (2) allow physicians to dynamically allocate and
delegate work to appropriate members of the
care team as permitted by institutional policies.
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EHRs should have enhanced ability to
automatically track referrals and
consultations as well as ensure that the
referring physician is able to follow the
patient’s progress/activity throughout the
continuum of care.
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Modularity of technology will result in EHRs
that offer flexibility to meet individual
practice requirements.
Application program interfaces (APIs) can be
an important contributor to this modularity.
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EHRs should support medical-decision
making by providing concise, context
sensitive and real-time data uncluttered by
extraneous information.
EHRs should manage information flow and
adjust for context, environment and user
preferences.
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EHRs should facilitate connected health
care—interoperability across different venues
such as hospitals, ambulatory care settings,
laboratories, pharmacies and post-acute and
long-term care settings.
This means not only being able to export data
but also to properly incorporate external data
from other systems into the longitudinal
patient record. Data sharing and open
architecture must address EHR data “lock in.”
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Whether for health and wellness and/or the
management of chronic illnesses,
interoperability between a patient’s mobile
technology and the EHR will be an asset.
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An essential step to user-centered design is
incorporating end-user feedback into the
design and improvement of a product. EHR
technology should facilitate this feedback.