Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

The complex case of EHRs: examining the factors impacting the EHR user experience

The complex case of EHRs: examining the factors impacting the EHR user experience Abstract Physicians can spend more time completing administrative tasks in their electronic health record (EHR) than engaging in direct face time with patients. Increasing rates of burnout associated with EHR use necessitate improvements in how EHRs are developed and used. Although EHR design often bears the brunt of the blame for frustrations expressed by physicians, the EHR user experience is influenced by a variety of factors, including decisions made by entities other than the developers and end users, such as regulators, policymakers, and administrators. Identifying these key influences can help create a deeper understanding of the challenges in developing a better EHR user experience. There are multiple opportunities for regulators, policymakers, EHR developers, payers, health system leadership, and users each to make changes to collectively improve the use and efficacy of EHRs. electronic health records, burnout, administrative burden INTRODUCTION Challenges with using electronic health records (EHRs) continue to be among the top complaints of physicians, yet most physicians recognize the value and do not want to return to paper-based records.1 While some research has suggested improved workflow, productivity, and efficiency with EHR use,2,3 other evidence shows that end users are dissatisfied with many aspects of the EHR.4–8 Many of the frustrations physicians experience with EHRs are related to the time required for documentation. One study of physicians determined that for every hour a physician spent on direct clinical care, he or she spent nearly 2 additional hours on EHR and desk work during the day and another 1-2 hours each evening.9 Another study of family physicians found they spent almost 6 hours per day interacting with the EHR during and after work; half of this time used for clerical and administrative tasks such as documentation, order entry, billing, coding, and system security.10–12 The primary goal of the EHR should be to support patient care. However, many physicians feel the time spent interacting with the EHR is on non–value-added tasks. The American College of Physicians developed a framework to categorize administrative tasks by the source of task, intent of the task, effect of the task, and approach to addressing the task. While there is important administrative work for physicians or their delegates to complete, we define burdensome administrative tasks as those that “have a negative effect on quality and patient care, that unnecessarily question the judgment of physicians and other clinicians, and/or that increase costs.”13 These could include tasks that are mandated to be performed by the physician but could safely be delegated to trained and supervised staff. Many of these incremental administrative tasks are requested by external entities, including government regulators, payers, and oversight entities. In addition, many do not require the unique skill set of a physician and thus are inappropriately consuming physician resources. EHR USER EXPERIENCE While much of physician frustration is directed at the EHR system, the user experience with an EHR is multidimensional with a variety of influences, some visible to and controllable by the end user, and others outside the end user’s control. Decisions made by vendors, healthcare organizations, payers, lawmakers, and regulatory bodies impact the EHR user experience. The key influences can be represented in a conceptual framework to demonstrate overarching categories and areas of overlap (Figure 1). This conceptual framework considers the complexity of the EHR user experience and the elements that affect physician interactions with the technology in practice. Figure 1. Open in new tabDownload slide Electronic health record (EHR) user experience influences. Source: Authors’ analysis of environmental factors contributing to EHR end-user experience as documented in current literature. Figure 1. Open in new tabDownload slide Electronic health record (EHR) user experience influences. Source: Authors’ analysis of environmental factors contributing to EHR end-user experience as documented in current literature. The U.S. healthcare system influences EHR usability through government regulation, payment and quality reporting, and lack of widespread interoperability. Organizational decisions include those about governance, practice design, task distribution, resource allocation, implementation, and training. In addition, EHR vendors are often unable to devote significant resources to user-centered design or consider physician cognitive workload which can shape a physician’s experience with an EHR. Vendors also make recommendations to institutions about implementation, role-type permissions, and workflows, and have an important role in the interoperability of an EHR. U.S. HEALTHCARE SYSTEM INFLUENCES Factors rooted in the U.S. healthcare system influence how EHRs are designed, implemented, and utilized in practice. Various government and industry entities have created some valuable, yet time-consuming and sometimes costly and burdensome, administrative tasks that affect the use of the EHR. Government regulation The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) implemented meaningful use standards in 2011.14 These regulations add to the amount of data entry required by clinicians to comply with regulatory requirements, above and beyond the data needed solely for patient care.15 In addition, these regulations provide standards by which EHR developers must design and update their systems to maintain certification and be listed on the certified health information technology (IT) product list. Furthermore, the ONC’s safety-enhanced design standards provide precise requirements for user-centered design. Despite these criteria, evidence suggests there is a lack of vendor adherence to ONC certification requirements and usability testing standards in their certified EHR products.16 There is no current government requirement or mechanism for assessing and quantifying the user experience across EHR vendors and across different installations of an EHR vendor’s product.17 In addition, vendors have misperceptions about and variability with their approach to user-centered design practices.18 There is no evidence that the ONC requirements for user-centered design have resulted in better patient outcomes or user experiences.19,20 The Health Insurance Portability and Accountability Act of 1996 (HIPAA), which provides privacy and security provisions for protecting personal health information, also raises EHR compliance concerns for healthcare organizations.21 Payment and quality reporting CMS consolidated reporting through the Advancing Care Information requirements in the Merit-based Incentive Payment System (MIPS) track of the Quality Payment Program (QPP) in 2017. Certified EHR technology is required for participation in this performance category of the QPP. Reporting requirements for MIPS have been phased in to provide organizations time to ramp up to the requirements; however, navigating the shifting targets has proven challenging, as only 65% of physicians surveyed in 2017 felt prepared to meet the 2018 MIPS requirements.22 Lack of clarity and frequent changes in reporting requirements for the use of certified EHRs and EHR-related measures, including electronic clinical quality measures, add further barriers to the efficient use of EHRs in daily practice.22 Administrative tasks completed in EHRs include those mandated by payers, such as collecting data required for claim submission, prior authorization, prescription coverage, billing, and quality reporting. Quality reporting, specifically, has become progressively more important as both CMS and private payers increasingly link quality and performance to payment. Physician practices spend more than 3 staff and physician hours per physician per day on quality reporting.23 Furthermore, there is a disconnect between quality reporting requirements among private and public payers24 that creates additional complexity. There are also concerns about the perceived misalignment between data entered into an EHR for the purposes of patient care, and data entered for quality reporting and meeting MIPS and QPP requirements.1,25,26 The increasing demands that the EHR be used as a tool for documenting mandatory payment data and quality reporting, paired with the possibility that EHR functionality may not be sufficient to support all of these demands, affect EHR usability.27 Modifying EHRs to collect data needed to succeed in alternative payment models also continues to be a challenge for physicians and their practices.26 Systems interoperability Improving interoperability has been a focus of many regulatory programs; however, progress has been slow. Despite significant investments in technology, physicians do not always have access to patient records that originated in another clinic or hospital, or even from within their organization, which creates frustration, delays in care, and patient safety risks.28 Some organizations share information internally and interface with laboratories, pharmacies, and imaging centers; however, interoperability with external health systems, vendors, registries, and state and local public health systems remains a challenge.28,29 There are several organizations working to achieve interoperability through the creation of technical standards, principles on governance and use, and connecting health information exchanges; however, these disparate efforts have yet to realize their collective impact.28 While the 21st Century Cures Act, MIPS, and the need for information to support value-based care create incentives for interoperability, strong disincentives such as cost and business interests continue to limit information exchange.30 In addition, fearing penalties for HIPAA violations, some organizations have adopted conservative approaches to sharing information, which often hinders interoperability and can have a negative impact on both patients and physicians.31,32 Finally, lack of education about or misinterpretation of HIPAA regulations can result in unnecessary information blocking.33 ORGANIZATIONAL INFLUENCES Decisions made at the organizational level have significant implications for how effectively an EHR is implemented and used in a practice, and can have lasting effects on the end-user experience. Governance Healthcare organizations have created complex governance practices related to the implementation and management of their EHR.34 These governance policies include those related to compliance and risk management. Policies adopted at the organizational level can aim to ensure patient safety, maximize efficiency, improve reporting data, or favorably impact financial performance, but may also have inadvertent effects on end users of the EHR, and even instigate the use of workarounds that expose new risks. For example, “note bloat” has become an issue with the rise of copy-and-paste functions in the EHR as physicians and organizations attempt to maximize efficiency and guard against legal disputes.35 This note bloat can make it more difficult to find and read key clinical information, perpetuating documentation errors and enabling new errors.36 Some governance decisions limit the ability to adopt team-based care because they require the physician to complete all documentation and order entry. While these decisions on the surface appear to limit the risk for the organization, requiring the physician alone to complete all documentation can increase burnout and the risk for other potential errors in the workflow, such as diagnostic, therapeutic, and communication errors related to inattention, multitasking, and cognitive and information overload. Implementation and training Implementing or upgrading an EHR is a major endeavor for any healthcare organization. Factors that can negatively impact implementation include lack of engagement across stakeholders, overly cautious or misinformed compliance departments, inadequate allocation of IT resources pre- and postimplementation, poor system design and functionality decisions, intensity and delivery of training, inadequate staffing levels, and inattention to workflow redesign necessary to effectively integrate new technology.37 The costs of implementation can include not only the staff time for implementation and the purchase of the software, but also the additional hardware, workflow redesign, and training, as well as decreased productivity and revenue.38 Decisions on the implementation process, including user training and customization of the product, can have long-term implications for the usability of the EHR. While many EHR vendors offer a suggested implementation process and product design, customization decisions made by the purchasing organization can contribute to long-term challenges in upgrades, variability in product design across locations, and difficulty in training. Practice design and resource allocation The way a practice is designed requires consideration when deploying or updating an EHR. Practice design—defined as the way in which members of a healthcare team are organized and assigned, how the delivery of patient care is coordinated and executed, and how clinical care space is utilized—is an important factor that impacts the EHR user experience. Attention to team workflow, including diagraming organizational processes, can allow organizations to compare their EHR to their stated workflow. Data extracted from an EHR database that show time spent on specific activities by physicians may be a useful tool to assess practice design.10 Many practices are designed in ways that require the physician to be primarily responsible for documentation. In a practice using a team-based care model, however, various members of the care team, such as documentation assistants, medical assistants, nurses, and advanced practice clinicians, help facilitate medical record documentation in the EHR. Dictation and transcription devices can also help streamline the documentation process. This additional support enables physicians to engage in more face-to-face time with their patients.9 Clinical care space is another key aspect of practice design that can affect the way EHRs are used and how their use can impact the patient-physician relationship. For example, widescreen monitors and printers in every exam room can increase efficiency. In addition, improving the patient room arrangement can enable better eye contact and the ability to share the computer screen with a patient.18,39 Finally, a leadership decision to maintain outdated servers or EHR software to reduce operational costs could result in slow systems, loss of information, unplanned downtime, or dangerous workarounds—all which have the potential to cause loss of productivity or risks to patients. EHR VENDOR INFLUENCES The ONC has established criteria that require vendors to use a user-centered design process and test 8 specific EHR functions to become certified; however, physicians still report clunky interfaces and confusing displays.18 Variation in user-centered design processes and nonadherence to postcertification standards have resulted in disparate practices and usability.16,18 Additionally, it is not uncommon for there to be no clinician or physician participation in the usability testing of vendor products.16 Many EHR products were designed with billing, payer requirements, and meaningful use criteria in mind, rather than clinician use, resulting in a user experience laden with data entry that causes decreased productivity and efficiency, and a diminished patient-physician relationship.40 Health IT vendors can also have a significant influence on interoperability. Across vendors, there is variation in data formats (technical interoperability), lack of shared meaning (semantic interoperability), and unusable delivery to physicians, further limiting interoperability.21,41 Lack of health IT standards conformance testing, validation, and transparency continues to hinder seamless information exchange.42 Additionally, some vendors have imposed contractual, technical, or financial limitations on their clients in an effort to thwart competition and lock customers into their products.33 These practices are a form of information blocking and hinder interoperability. Vendors play a key role in the success of an organization’s implementation of their EHR product. Vendors can provide guidance on realistic go-live timelines and make recommendations about resources and training to ensure a successful implementation.43 In addition, many vendors have product versions and training programs that have yielded positive outcomes for end users; however, due to timing, pressures to increase productivity, or cost limitations, these best practices are not always implemented. As a result, similar installations of the same EHR product at different institutions can require a different number of clicks to complete the same task.44 RECOMMENDATIONS The classifications defined here identify the influences on the EHR user experience. However, this does not imply that these factors are isolated or mutually exclusive. There are areas in which these factors overlap or even result from the effects of another influence. It is also important to emphasize that easing the administrative burden cannot be accomplished by a single-stakeholder approach because the EHR user experience is varied and influenced by a multitude of factors. EHR vendors, regulatory agencies, insurance payers, and healthcare organizations all must understand how their decisions may influence the usability of an EHR and the effects it may have on professional satisfaction and patient care. To enable progress,12,45,46 Payers and regulators can transition to less burdensome documentation requirements for payment and quality reporting, remembering clinicians’ first job is patient care. Quality officers and practice administrators can track EHR use, including click, motion, and time-in-screen data, along with “work after work” data, to measure and improve task time and activity patterns through training and staffing. Organizational leadership can actively engage physicians in the EHR implementation process, taking personal interaction needs and workflow design into consideration and supporting advanced models of team-based care, coordination of care, and new models of charting. Implementation teams can complete pre- and postimplementation testing using rigorous, real-world scenarios focused on improving safety and reducing clinician burden. Health IT vendors can increase transparency around product costs, functionality, and performance, and support advances in voice recognition, artificial intelligence, and other technologies with a focus on user-centered design that could catalyze improvements in EHR usability and interoperability and reduce cognitive work load. CONCLUSION EHRs are powerful tools that, despite the challenges experienced in their use, are an integral element of the U.S. healthcare system. There are multiple opportunities for regulators, policymakers, EHR developers, payers, health system leadership, and users each to make changes to collectively improve the use and efficacy of EHRs. Using a conceptual framework to understand the complexity of and influences on the EHR user experience is an important step in finding and implementing solutions to the burdens associated with administrative EHR tasks. AUTHOR CONTRIBUTIONS MT developed the conceptual framework; LC completed the literature review; all authors were involved in the writing and editing of the manuscript. Conflict of Interest Statement The authors are employed by the American Medical Association. The opinions expressed in this article are those of the authors and should not be interpreted as American Medical Association policy. REFERENCES 1 Friedberg MW , Chen PG, Van Busum KR, et al. . Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy . Santa Monica, CA : RAND Corporation , 2013 . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC 2 Shield RR , Goldman RE, Anthony DA, et al. . Gradual electronic health record implementation: New insights on physician and patient adaptation . Ann Fam Med 2010 ; 8 4 : 316 – 26 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Adler-Milstein J , Huckman RS. The impact of electronic health record use on physician productivity . Am J Manag Care 2013 ; 19 (10 Spec No) : SP345 – 52 . Google Scholar OpenURL Placeholder Text WorldCat 4 Meigs SL , Solomon M. Electronic health record use a bitter pill for many physicians . Perspect Health Inf Manag 2016 ; 13 (Winter) : 1d. Google Scholar OpenURL Placeholder Text WorldCat 5 Deloitte Center for Health Solutions . Deloitte 2016 Survey of US Physicians: Findings on health information technology and electronic health records. 2016 . https://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-lshc-physician-survey-hit-factsheet.pdf. Accessed August 29, 2018. 6 Heath S. 92% of Nurses Dissatisfied with EHR Technology, Health IT . EHR Intelligence ; 2016 . https://ehrintelligence.com/news/92-of-nurses-dissatisfied-with-ehr-technology-health-it. Accessed August 29, 2018. Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 7 Murphy DR , Meyer AND, Russo E, et al. . The burden of inbox notifications in commercial electronic health records . JAMA Intern Med 2016 ; 176 4 : 559 – 60 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Babbott S , Manwell LB, Brown R, et al. . Electronic medical records and physician stress in primary care: results from the MEMO Study . J Am Med Inform Assoc 2014 ; 21 ( e1 ): e100 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Sinsky C , Colligan L, Li L, et al. . Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties . Ann Intern Med 2016 ; 165 11 : 753 – 60 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Arndt BG , Beasley JW, Watkinson MD, et al. . Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations . Ann Fam Med 2017 ; 15 5 : 419 – 26 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Young RA , Burge SK, Kumar KA, et al. . A time-motion study of primary care physicians' work in the electronic health record era . Fam Med 2018 ; 50 2 : 91 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Sinsky CA , Privitera MR. Creating a “manageable cockpit” for clinicians: a shared responsibility . JAMA Intern Med 2018 ; 178 6 : 741 – 2 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Erickson SM , Rockwern B, Koltov M, et al. . Putting patients first by reducing administrative tasks in health care: A position paper of the american college of physicians . Ann Intern Med 2017 ; 166 9 : 659 – 61 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Medicare & Medicaid EHR Incentive Program Meaningful Use Stage 1 Requirements Overview . Washington, DC : Centers for Medicare & Medicaid Services ; 2010 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 15 Sheehy AM , Weissburg DJ, Dean SM. The role of copy-and-paste in the hospital electronic health record . JAMA Intern Med 2014 ; 174 8 : 1217 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 16 Ratwani RM , Benda NC, Hettinger AZ, et al. . Electronic health record vendor adherence to usability certification requirements and testing standards . JAMA 2015 ; 314 10 : 1070 – 1 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Sinsky C , Hess J, Karsh BT, Keller JP, Koppel R. Comparative user experiences of health IT products: how user experiences would be reported and used. 2012 . https://nam.edu/wp-content/uploads/2015/06/comparative-user-experiences.pdf. Accessed August 29, 2018. 18 Ratwani RM , Fairbanks RJ, Hettinger AZ, et al. . Electronic health record usability: analysis of the user-centered design processes of eleven electronic health record vendors . J Am Med Inform Assoc 2015 ; 22 6 : 1179 – 82 . Google Scholar Crossref Search ADS PubMed WorldCat 19 Singh H , Classen DC, Sittig DF. Creating an oversight infrastructure for electronic health record-related patient safety hazards . J Patient Saf 2011 ; 7 4 : 169 – 74 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Bloomrosen M , Starren J, Lorenzi NM, et al. . Anticipating and addressing the unintended consequences of health IT and policy: a report from the AMIA 2009 Health Policy Meeting . J Am Med Inform Assoc 2011 ; 18 1 : 82 – 90 . Google Scholar Crossref Search ADS PubMed WorldCat 21 Denise LA , Ajit A, Johnson ME. Institutionalizing HIPAA Compliance: organizations and competing logics in U.S. health care . J Health Soc Behav 2014 ; 55 1 : 108 – 24 . Google Scholar Crossref Search ADS PubMed WorldCat 22 KPMG, American Medical Association Are physicians ready for MACRA/QPP? Results from the KPMG-AMA survey . 2017 . https://institutes.kpmg.us/content/dam/institutes/en/healthcare-life-sciences/pdfs/2017/are-physicians-ready-for-macraqpp.pdf. Accessed August 29, 2018. 23 Casalino LP , Gans D, Weber R, et al. . US physician practices spend more than $15.4 billion annually to report quality measures . Health Affairs 2016 ; 35 3 : 401 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 24 Higgins A , Veselovskiy G, McKown L. Provider performance measures in private and public programs: achieving meaningful alignment with flexibility to innovate . Health Affairs 2013 ; 32 8 : 1453 – 61 . Google Scholar Crossref Search ADS PubMed WorldCat 25 Friedberg MW , Chen PG, White C, et al. . Effects of health care payment models on physician practice in the United States . Rand Health Q 2015 ; 5 1 : 8. Google Scholar PubMed OpenURL Placeholder Text WorldCat 26 Friedberg MW , Chen PG, Simmons M, et al. . Effects of Health Care Payment Models on Physician Practice in the United States: Follow-Up Study . Santa Monica, CA : RAND Corporation ; 2018 : 96 . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC 27 Cohen DJ , Dorr DA, Knierim K, et al. . Primary care practices’ abilities and challenges in using electronic health record data for quality improvement . Health Affairs 2018 ; 37 4 : 635 – 43 . Google Scholar Crossref Search ADS PubMed WorldCat 28 Jacob JA. On the road to interoperability, public and private organizations work to connect health care data . JAMA 2015 ; 314 12 : 1213 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat 29 Meehan RA , Mon DT, Kelly KM, et al. . Increasing EHR system usability through standards: conformance criteria in the HL7 EHR-system functional model . J Biomed Inform 2016 ; 63 (Suppl C) : 169 – 73 . Google Scholar Crossref Search ADS WorldCat 30 Lye CT , Forman HP, Daniel JG, et al. . The 21st Century Cures Act and electronic health records one year later: will patients see the benefits? J Am Med Inform Assoc 2018 ; 25 9 : 1218 – 20 . Google Scholar Crossref Search ADS PubMed WorldCat 31 Califf RM , Muhlbaier LH. Health Insurance Portability and Accountability Act (HIPAA) . Circulation 2003 ; 108 8 : 915 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 32 Greenberg MD , Ridgely MS, Bell DS. Electronic prescribing and HIPAA privacy regulation . Inquiry 2004 ; 41 4 : 461 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 33 Office of the National Coordinator for Health Information Technology . Report to Congress on Health Information Blocking . Washington, DC : U.S. Department of Health and Human Services ; 2015 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 34 Wright A , Sittig DF, Ash JS, et al. . Governance for clinical decision support: case studies and recommended practices from leading institutions . J Am Med Inform Assoc 2011 ; 18 2 : 187 – 94 . Google Scholar Crossref Search ADS PubMed WorldCat 35 Shoolin J , Ozeran L, Hamann C, Bria W 2nd. Association of medical directors of information systems consensus on inpatient electronic health record documentation . Appl Clin Inform 2013 ; 4 2 : 293 – 303 . Google Scholar Crossref Search ADS PubMed WorldCat 36 Tsou AY , Lehmann CU, Michel J, et al. . Safe practices for copy and paste in the EHR: systematic review, recommendations, and novel model for health IT collaboration . Appl Clin Inform 2017 ; 8 1 : 12 – 34 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 37 Blavin F , Ramos C, Shah A, Devers K. Lessons from the Literature on Electronic Health Record Implementation . Washington, DC : Urban Institute ; 2013 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 38 Unpacking hospitals' EHR implementation costs: what's behind the million-dollar price tags ? Becker's Hospital Review . 2016 . https://www.beckershospitalreview.com/healthcare-information-technology/unpacking-hospitals-ehr-implementation-costs-what-s-behind-the-million-dollar-price-tags.html. Accessed August 29, 2018. Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 39 Watkins N , Gandolf-Frietchen M, Siddiqui Z. Optimizing Space in Medical Practices; 2017 . https://www.stepsforward.org/modules/space-design. Accessed August 29, 2018. 40 Improving Care: Priorities to Improve Electronic Health Record Usability . Chicago : American Medical Association ; 2014 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 41 Bouamrane MM , Tao C, Sarkar IN. Managing interoperability and complexity in health systems . Methods Inf Med 2015 ; 54 1 : 1 – 4 . Google Scholar Crossref Search ADS PubMed WorldCat 42 The Future Role of Government in Health Information Technology and Digital Health . Washington, DC : Bipartisan Policy Center and Health IT Now ; 2018 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 43 Weathers AL , Esper GJ. How to select and implement an electronic health record in a neurology practice . Neurol Clin Pract 2013 ; 3 2 : 141 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 44 Ratwani RM , Savage E, Will A, et al. . A usability and safety analysis of electronic health records: a multi-center study . J Am Med Inform Assoc 2018 ; 25 9 : 1197 – 201 . Google Scholar Crossref Search ADS PubMed WorldCat 45 DiAngi YT , Lee TC, Sinsky CA, et al. . Novel metrics for improving professional fulfillment . Ann Intern Med 2017 ; 167 10 : 740 – 1 . Google Scholar Crossref Search ADS PubMed WorldCat 46 Reuben DB , Sinsky CA. From transactional tasks to personalized care: a new vision of physicians’ roles . Ann Fam Med 2018 ; 16 2 : 168 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2019. Published by Oxford University Press on behalf of the American Medical Informatics Association. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contactjournals.permissions@oup.com © The Author(s) 2019. Published by Oxford University Press on behalf of the American Medical Informatics Association. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the American Medical Informatics Association Oxford University Press

The complex case of EHRs: examining the factors impacting the EHR user experience

Loading next page...
 
/lp/oxford-university-press/the-complex-case-of-ehrs-examining-the-factors-impacting-the-ehr-user-lSJhxov3yg

References (93)

Publisher
Oxford University Press
Copyright
Copyright © 2022 American Medical Informatics Association
ISSN
1067-5027
eISSN
1527-974X
DOI
10.1093/jamia/ocz021
Publisher site
See Article on Publisher Site

Abstract

Abstract Physicians can spend more time completing administrative tasks in their electronic health record (EHR) than engaging in direct face time with patients. Increasing rates of burnout associated with EHR use necessitate improvements in how EHRs are developed and used. Although EHR design often bears the brunt of the blame for frustrations expressed by physicians, the EHR user experience is influenced by a variety of factors, including decisions made by entities other than the developers and end users, such as regulators, policymakers, and administrators. Identifying these key influences can help create a deeper understanding of the challenges in developing a better EHR user experience. There are multiple opportunities for regulators, policymakers, EHR developers, payers, health system leadership, and users each to make changes to collectively improve the use and efficacy of EHRs. electronic health records, burnout, administrative burden INTRODUCTION Challenges with using electronic health records (EHRs) continue to be among the top complaints of physicians, yet most physicians recognize the value and do not want to return to paper-based records.1 While some research has suggested improved workflow, productivity, and efficiency with EHR use,2,3 other evidence shows that end users are dissatisfied with many aspects of the EHR.4–8 Many of the frustrations physicians experience with EHRs are related to the time required for documentation. One study of physicians determined that for every hour a physician spent on direct clinical care, he or she spent nearly 2 additional hours on EHR and desk work during the day and another 1-2 hours each evening.9 Another study of family physicians found they spent almost 6 hours per day interacting with the EHR during and after work; half of this time used for clerical and administrative tasks such as documentation, order entry, billing, coding, and system security.10–12 The primary goal of the EHR should be to support patient care. However, many physicians feel the time spent interacting with the EHR is on non–value-added tasks. The American College of Physicians developed a framework to categorize administrative tasks by the source of task, intent of the task, effect of the task, and approach to addressing the task. While there is important administrative work for physicians or their delegates to complete, we define burdensome administrative tasks as those that “have a negative effect on quality and patient care, that unnecessarily question the judgment of physicians and other clinicians, and/or that increase costs.”13 These could include tasks that are mandated to be performed by the physician but could safely be delegated to trained and supervised staff. Many of these incremental administrative tasks are requested by external entities, including government regulators, payers, and oversight entities. In addition, many do not require the unique skill set of a physician and thus are inappropriately consuming physician resources. EHR USER EXPERIENCE While much of physician frustration is directed at the EHR system, the user experience with an EHR is multidimensional with a variety of influences, some visible to and controllable by the end user, and others outside the end user’s control. Decisions made by vendors, healthcare organizations, payers, lawmakers, and regulatory bodies impact the EHR user experience. The key influences can be represented in a conceptual framework to demonstrate overarching categories and areas of overlap (Figure 1). This conceptual framework considers the complexity of the EHR user experience and the elements that affect physician interactions with the technology in practice. Figure 1. Open in new tabDownload slide Electronic health record (EHR) user experience influences. Source: Authors’ analysis of environmental factors contributing to EHR end-user experience as documented in current literature. Figure 1. Open in new tabDownload slide Electronic health record (EHR) user experience influences. Source: Authors’ analysis of environmental factors contributing to EHR end-user experience as documented in current literature. The U.S. healthcare system influences EHR usability through government regulation, payment and quality reporting, and lack of widespread interoperability. Organizational decisions include those about governance, practice design, task distribution, resource allocation, implementation, and training. In addition, EHR vendors are often unable to devote significant resources to user-centered design or consider physician cognitive workload which can shape a physician’s experience with an EHR. Vendors also make recommendations to institutions about implementation, role-type permissions, and workflows, and have an important role in the interoperability of an EHR. U.S. HEALTHCARE SYSTEM INFLUENCES Factors rooted in the U.S. healthcare system influence how EHRs are designed, implemented, and utilized in practice. Various government and industry entities have created some valuable, yet time-consuming and sometimes costly and burdensome, administrative tasks that affect the use of the EHR. Government regulation The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) implemented meaningful use standards in 2011.14 These regulations add to the amount of data entry required by clinicians to comply with regulatory requirements, above and beyond the data needed solely for patient care.15 In addition, these regulations provide standards by which EHR developers must design and update their systems to maintain certification and be listed on the certified health information technology (IT) product list. Furthermore, the ONC’s safety-enhanced design standards provide precise requirements for user-centered design. Despite these criteria, evidence suggests there is a lack of vendor adherence to ONC certification requirements and usability testing standards in their certified EHR products.16 There is no current government requirement or mechanism for assessing and quantifying the user experience across EHR vendors and across different installations of an EHR vendor’s product.17 In addition, vendors have misperceptions about and variability with their approach to user-centered design practices.18 There is no evidence that the ONC requirements for user-centered design have resulted in better patient outcomes or user experiences.19,20 The Health Insurance Portability and Accountability Act of 1996 (HIPAA), which provides privacy and security provisions for protecting personal health information, also raises EHR compliance concerns for healthcare organizations.21 Payment and quality reporting CMS consolidated reporting through the Advancing Care Information requirements in the Merit-based Incentive Payment System (MIPS) track of the Quality Payment Program (QPP) in 2017. Certified EHR technology is required for participation in this performance category of the QPP. Reporting requirements for MIPS have been phased in to provide organizations time to ramp up to the requirements; however, navigating the shifting targets has proven challenging, as only 65% of physicians surveyed in 2017 felt prepared to meet the 2018 MIPS requirements.22 Lack of clarity and frequent changes in reporting requirements for the use of certified EHRs and EHR-related measures, including electronic clinical quality measures, add further barriers to the efficient use of EHRs in daily practice.22 Administrative tasks completed in EHRs include those mandated by payers, such as collecting data required for claim submission, prior authorization, prescription coverage, billing, and quality reporting. Quality reporting, specifically, has become progressively more important as both CMS and private payers increasingly link quality and performance to payment. Physician practices spend more than 3 staff and physician hours per physician per day on quality reporting.23 Furthermore, there is a disconnect between quality reporting requirements among private and public payers24 that creates additional complexity. There are also concerns about the perceived misalignment between data entered into an EHR for the purposes of patient care, and data entered for quality reporting and meeting MIPS and QPP requirements.1,25,26 The increasing demands that the EHR be used as a tool for documenting mandatory payment data and quality reporting, paired with the possibility that EHR functionality may not be sufficient to support all of these demands, affect EHR usability.27 Modifying EHRs to collect data needed to succeed in alternative payment models also continues to be a challenge for physicians and their practices.26 Systems interoperability Improving interoperability has been a focus of many regulatory programs; however, progress has been slow. Despite significant investments in technology, physicians do not always have access to patient records that originated in another clinic or hospital, or even from within their organization, which creates frustration, delays in care, and patient safety risks.28 Some organizations share information internally and interface with laboratories, pharmacies, and imaging centers; however, interoperability with external health systems, vendors, registries, and state and local public health systems remains a challenge.28,29 There are several organizations working to achieve interoperability through the creation of technical standards, principles on governance and use, and connecting health information exchanges; however, these disparate efforts have yet to realize their collective impact.28 While the 21st Century Cures Act, MIPS, and the need for information to support value-based care create incentives for interoperability, strong disincentives such as cost and business interests continue to limit information exchange.30 In addition, fearing penalties for HIPAA violations, some organizations have adopted conservative approaches to sharing information, which often hinders interoperability and can have a negative impact on both patients and physicians.31,32 Finally, lack of education about or misinterpretation of HIPAA regulations can result in unnecessary information blocking.33 ORGANIZATIONAL INFLUENCES Decisions made at the organizational level have significant implications for how effectively an EHR is implemented and used in a practice, and can have lasting effects on the end-user experience. Governance Healthcare organizations have created complex governance practices related to the implementation and management of their EHR.34 These governance policies include those related to compliance and risk management. Policies adopted at the organizational level can aim to ensure patient safety, maximize efficiency, improve reporting data, or favorably impact financial performance, but may also have inadvertent effects on end users of the EHR, and even instigate the use of workarounds that expose new risks. For example, “note bloat” has become an issue with the rise of copy-and-paste functions in the EHR as physicians and organizations attempt to maximize efficiency and guard against legal disputes.35 This note bloat can make it more difficult to find and read key clinical information, perpetuating documentation errors and enabling new errors.36 Some governance decisions limit the ability to adopt team-based care because they require the physician to complete all documentation and order entry. While these decisions on the surface appear to limit the risk for the organization, requiring the physician alone to complete all documentation can increase burnout and the risk for other potential errors in the workflow, such as diagnostic, therapeutic, and communication errors related to inattention, multitasking, and cognitive and information overload. Implementation and training Implementing or upgrading an EHR is a major endeavor for any healthcare organization. Factors that can negatively impact implementation include lack of engagement across stakeholders, overly cautious or misinformed compliance departments, inadequate allocation of IT resources pre- and postimplementation, poor system design and functionality decisions, intensity and delivery of training, inadequate staffing levels, and inattention to workflow redesign necessary to effectively integrate new technology.37 The costs of implementation can include not only the staff time for implementation and the purchase of the software, but also the additional hardware, workflow redesign, and training, as well as decreased productivity and revenue.38 Decisions on the implementation process, including user training and customization of the product, can have long-term implications for the usability of the EHR. While many EHR vendors offer a suggested implementation process and product design, customization decisions made by the purchasing organization can contribute to long-term challenges in upgrades, variability in product design across locations, and difficulty in training. Practice design and resource allocation The way a practice is designed requires consideration when deploying or updating an EHR. Practice design—defined as the way in which members of a healthcare team are organized and assigned, how the delivery of patient care is coordinated and executed, and how clinical care space is utilized—is an important factor that impacts the EHR user experience. Attention to team workflow, including diagraming organizational processes, can allow organizations to compare their EHR to their stated workflow. Data extracted from an EHR database that show time spent on specific activities by physicians may be a useful tool to assess practice design.10 Many practices are designed in ways that require the physician to be primarily responsible for documentation. In a practice using a team-based care model, however, various members of the care team, such as documentation assistants, medical assistants, nurses, and advanced practice clinicians, help facilitate medical record documentation in the EHR. Dictation and transcription devices can also help streamline the documentation process. This additional support enables physicians to engage in more face-to-face time with their patients.9 Clinical care space is another key aspect of practice design that can affect the way EHRs are used and how their use can impact the patient-physician relationship. For example, widescreen monitors and printers in every exam room can increase efficiency. In addition, improving the patient room arrangement can enable better eye contact and the ability to share the computer screen with a patient.18,39 Finally, a leadership decision to maintain outdated servers or EHR software to reduce operational costs could result in slow systems, loss of information, unplanned downtime, or dangerous workarounds—all which have the potential to cause loss of productivity or risks to patients. EHR VENDOR INFLUENCES The ONC has established criteria that require vendors to use a user-centered design process and test 8 specific EHR functions to become certified; however, physicians still report clunky interfaces and confusing displays.18 Variation in user-centered design processes and nonadherence to postcertification standards have resulted in disparate practices and usability.16,18 Additionally, it is not uncommon for there to be no clinician or physician participation in the usability testing of vendor products.16 Many EHR products were designed with billing, payer requirements, and meaningful use criteria in mind, rather than clinician use, resulting in a user experience laden with data entry that causes decreased productivity and efficiency, and a diminished patient-physician relationship.40 Health IT vendors can also have a significant influence on interoperability. Across vendors, there is variation in data formats (technical interoperability), lack of shared meaning (semantic interoperability), and unusable delivery to physicians, further limiting interoperability.21,41 Lack of health IT standards conformance testing, validation, and transparency continues to hinder seamless information exchange.42 Additionally, some vendors have imposed contractual, technical, or financial limitations on their clients in an effort to thwart competition and lock customers into their products.33 These practices are a form of information blocking and hinder interoperability. Vendors play a key role in the success of an organization’s implementation of their EHR product. Vendors can provide guidance on realistic go-live timelines and make recommendations about resources and training to ensure a successful implementation.43 In addition, many vendors have product versions and training programs that have yielded positive outcomes for end users; however, due to timing, pressures to increase productivity, or cost limitations, these best practices are not always implemented. As a result, similar installations of the same EHR product at different institutions can require a different number of clicks to complete the same task.44 RECOMMENDATIONS The classifications defined here identify the influences on the EHR user experience. However, this does not imply that these factors are isolated or mutually exclusive. There are areas in which these factors overlap or even result from the effects of another influence. It is also important to emphasize that easing the administrative burden cannot be accomplished by a single-stakeholder approach because the EHR user experience is varied and influenced by a multitude of factors. EHR vendors, regulatory agencies, insurance payers, and healthcare organizations all must understand how their decisions may influence the usability of an EHR and the effects it may have on professional satisfaction and patient care. To enable progress,12,45,46 Payers and regulators can transition to less burdensome documentation requirements for payment and quality reporting, remembering clinicians’ first job is patient care. Quality officers and practice administrators can track EHR use, including click, motion, and time-in-screen data, along with “work after work” data, to measure and improve task time and activity patterns through training and staffing. Organizational leadership can actively engage physicians in the EHR implementation process, taking personal interaction needs and workflow design into consideration and supporting advanced models of team-based care, coordination of care, and new models of charting. Implementation teams can complete pre- and postimplementation testing using rigorous, real-world scenarios focused on improving safety and reducing clinician burden. Health IT vendors can increase transparency around product costs, functionality, and performance, and support advances in voice recognition, artificial intelligence, and other technologies with a focus on user-centered design that could catalyze improvements in EHR usability and interoperability and reduce cognitive work load. CONCLUSION EHRs are powerful tools that, despite the challenges experienced in their use, are an integral element of the U.S. healthcare system. There are multiple opportunities for regulators, policymakers, EHR developers, payers, health system leadership, and users each to make changes to collectively improve the use and efficacy of EHRs. Using a conceptual framework to understand the complexity of and influences on the EHR user experience is an important step in finding and implementing solutions to the burdens associated with administrative EHR tasks. AUTHOR CONTRIBUTIONS MT developed the conceptual framework; LC completed the literature review; all authors were involved in the writing and editing of the manuscript. Conflict of Interest Statement The authors are employed by the American Medical Association. The opinions expressed in this article are those of the authors and should not be interpreted as American Medical Association policy. REFERENCES 1 Friedberg MW , Chen PG, Van Busum KR, et al. . Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy . Santa Monica, CA : RAND Corporation , 2013 . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC 2 Shield RR , Goldman RE, Anthony DA, et al. . Gradual electronic health record implementation: New insights on physician and patient adaptation . Ann Fam Med 2010 ; 8 4 : 316 – 26 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Adler-Milstein J , Huckman RS. The impact of electronic health record use on physician productivity . Am J Manag Care 2013 ; 19 (10 Spec No) : SP345 – 52 . Google Scholar OpenURL Placeholder Text WorldCat 4 Meigs SL , Solomon M. Electronic health record use a bitter pill for many physicians . Perspect Health Inf Manag 2016 ; 13 (Winter) : 1d. Google Scholar OpenURL Placeholder Text WorldCat 5 Deloitte Center for Health Solutions . Deloitte 2016 Survey of US Physicians: Findings on health information technology and electronic health records. 2016 . https://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-lshc-physician-survey-hit-factsheet.pdf. Accessed August 29, 2018. 6 Heath S. 92% of Nurses Dissatisfied with EHR Technology, Health IT . EHR Intelligence ; 2016 . https://ehrintelligence.com/news/92-of-nurses-dissatisfied-with-ehr-technology-health-it. Accessed August 29, 2018. Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 7 Murphy DR , Meyer AND, Russo E, et al. . The burden of inbox notifications in commercial electronic health records . JAMA Intern Med 2016 ; 176 4 : 559 – 60 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Babbott S , Manwell LB, Brown R, et al. . Electronic medical records and physician stress in primary care: results from the MEMO Study . J Am Med Inform Assoc 2014 ; 21 ( e1 ): e100 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Sinsky C , Colligan L, Li L, et al. . Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties . Ann Intern Med 2016 ; 165 11 : 753 – 60 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Arndt BG , Beasley JW, Watkinson MD, et al. . Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations . Ann Fam Med 2017 ; 15 5 : 419 – 26 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Young RA , Burge SK, Kumar KA, et al. . A time-motion study of primary care physicians' work in the electronic health record era . Fam Med 2018 ; 50 2 : 91 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Sinsky CA , Privitera MR. Creating a “manageable cockpit” for clinicians: a shared responsibility . JAMA Intern Med 2018 ; 178 6 : 741 – 2 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Erickson SM , Rockwern B, Koltov M, et al. . Putting patients first by reducing administrative tasks in health care: A position paper of the american college of physicians . Ann Intern Med 2017 ; 166 9 : 659 – 61 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Medicare & Medicaid EHR Incentive Program Meaningful Use Stage 1 Requirements Overview . Washington, DC : Centers for Medicare & Medicaid Services ; 2010 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 15 Sheehy AM , Weissburg DJ, Dean SM. The role of copy-and-paste in the hospital electronic health record . JAMA Intern Med 2014 ; 174 8 : 1217 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 16 Ratwani RM , Benda NC, Hettinger AZ, et al. . Electronic health record vendor adherence to usability certification requirements and testing standards . JAMA 2015 ; 314 10 : 1070 – 1 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Sinsky C , Hess J, Karsh BT, Keller JP, Koppel R. Comparative user experiences of health IT products: how user experiences would be reported and used. 2012 . https://nam.edu/wp-content/uploads/2015/06/comparative-user-experiences.pdf. Accessed August 29, 2018. 18 Ratwani RM , Fairbanks RJ, Hettinger AZ, et al. . Electronic health record usability: analysis of the user-centered design processes of eleven electronic health record vendors . J Am Med Inform Assoc 2015 ; 22 6 : 1179 – 82 . Google Scholar Crossref Search ADS PubMed WorldCat 19 Singh H , Classen DC, Sittig DF. Creating an oversight infrastructure for electronic health record-related patient safety hazards . J Patient Saf 2011 ; 7 4 : 169 – 74 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Bloomrosen M , Starren J, Lorenzi NM, et al. . Anticipating and addressing the unintended consequences of health IT and policy: a report from the AMIA 2009 Health Policy Meeting . J Am Med Inform Assoc 2011 ; 18 1 : 82 – 90 . Google Scholar Crossref Search ADS PubMed WorldCat 21 Denise LA , Ajit A, Johnson ME. Institutionalizing HIPAA Compliance: organizations and competing logics in U.S. health care . J Health Soc Behav 2014 ; 55 1 : 108 – 24 . Google Scholar Crossref Search ADS PubMed WorldCat 22 KPMG, American Medical Association Are physicians ready for MACRA/QPP? Results from the KPMG-AMA survey . 2017 . https://institutes.kpmg.us/content/dam/institutes/en/healthcare-life-sciences/pdfs/2017/are-physicians-ready-for-macraqpp.pdf. Accessed August 29, 2018. 23 Casalino LP , Gans D, Weber R, et al. . US physician practices spend more than $15.4 billion annually to report quality measures . Health Affairs 2016 ; 35 3 : 401 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 24 Higgins A , Veselovskiy G, McKown L. Provider performance measures in private and public programs: achieving meaningful alignment with flexibility to innovate . Health Affairs 2013 ; 32 8 : 1453 – 61 . Google Scholar Crossref Search ADS PubMed WorldCat 25 Friedberg MW , Chen PG, White C, et al. . Effects of health care payment models on physician practice in the United States . Rand Health Q 2015 ; 5 1 : 8. Google Scholar PubMed OpenURL Placeholder Text WorldCat 26 Friedberg MW , Chen PG, Simmons M, et al. . Effects of Health Care Payment Models on Physician Practice in the United States: Follow-Up Study . Santa Monica, CA : RAND Corporation ; 2018 : 96 . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC 27 Cohen DJ , Dorr DA, Knierim K, et al. . Primary care practices’ abilities and challenges in using electronic health record data for quality improvement . Health Affairs 2018 ; 37 4 : 635 – 43 . Google Scholar Crossref Search ADS PubMed WorldCat 28 Jacob JA. On the road to interoperability, public and private organizations work to connect health care data . JAMA 2015 ; 314 12 : 1213 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat 29 Meehan RA , Mon DT, Kelly KM, et al. . Increasing EHR system usability through standards: conformance criteria in the HL7 EHR-system functional model . J Biomed Inform 2016 ; 63 (Suppl C) : 169 – 73 . Google Scholar Crossref Search ADS WorldCat 30 Lye CT , Forman HP, Daniel JG, et al. . The 21st Century Cures Act and electronic health records one year later: will patients see the benefits? J Am Med Inform Assoc 2018 ; 25 9 : 1218 – 20 . Google Scholar Crossref Search ADS PubMed WorldCat 31 Califf RM , Muhlbaier LH. Health Insurance Portability and Accountability Act (HIPAA) . Circulation 2003 ; 108 8 : 915 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 32 Greenberg MD , Ridgely MS, Bell DS. Electronic prescribing and HIPAA privacy regulation . Inquiry 2004 ; 41 4 : 461 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 33 Office of the National Coordinator for Health Information Technology . Report to Congress on Health Information Blocking . Washington, DC : U.S. Department of Health and Human Services ; 2015 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 34 Wright A , Sittig DF, Ash JS, et al. . Governance for clinical decision support: case studies and recommended practices from leading institutions . J Am Med Inform Assoc 2011 ; 18 2 : 187 – 94 . Google Scholar Crossref Search ADS PubMed WorldCat 35 Shoolin J , Ozeran L, Hamann C, Bria W 2nd. Association of medical directors of information systems consensus on inpatient electronic health record documentation . Appl Clin Inform 2013 ; 4 2 : 293 – 303 . Google Scholar Crossref Search ADS PubMed WorldCat 36 Tsou AY , Lehmann CU, Michel J, et al. . Safe practices for copy and paste in the EHR: systematic review, recommendations, and novel model for health IT collaboration . Appl Clin Inform 2017 ; 8 1 : 12 – 34 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 37 Blavin F , Ramos C, Shah A, Devers K. Lessons from the Literature on Electronic Health Record Implementation . Washington, DC : Urban Institute ; 2013 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 38 Unpacking hospitals' EHR implementation costs: what's behind the million-dollar price tags ? Becker's Hospital Review . 2016 . https://www.beckershospitalreview.com/healthcare-information-technology/unpacking-hospitals-ehr-implementation-costs-what-s-behind-the-million-dollar-price-tags.html. Accessed August 29, 2018. Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 39 Watkins N , Gandolf-Frietchen M, Siddiqui Z. Optimizing Space in Medical Practices; 2017 . https://www.stepsforward.org/modules/space-design. Accessed August 29, 2018. 40 Improving Care: Priorities to Improve Electronic Health Record Usability . Chicago : American Medical Association ; 2014 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 41 Bouamrane MM , Tao C, Sarkar IN. Managing interoperability and complexity in health systems . Methods Inf Med 2015 ; 54 1 : 1 – 4 . Google Scholar Crossref Search ADS PubMed WorldCat 42 The Future Role of Government in Health Information Technology and Digital Health . Washington, DC : Bipartisan Policy Center and Health IT Now ; 2018 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 43 Weathers AL , Esper GJ. How to select and implement an electronic health record in a neurology practice . Neurol Clin Pract 2013 ; 3 2 : 141 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 44 Ratwani RM , Savage E, Will A, et al. . A usability and safety analysis of electronic health records: a multi-center study . J Am Med Inform Assoc 2018 ; 25 9 : 1197 – 201 . Google Scholar Crossref Search ADS PubMed WorldCat 45 DiAngi YT , Lee TC, Sinsky CA, et al. . Novel metrics for improving professional fulfillment . Ann Intern Med 2017 ; 167 10 : 740 – 1 . Google Scholar Crossref Search ADS PubMed WorldCat 46 Reuben DB , Sinsky CA. From transactional tasks to personalized care: a new vision of physicians’ roles . Ann Fam Med 2018 ; 16 2 : 168 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2019. Published by Oxford University Press on behalf of the American Medical Informatics Association. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contactjournals.permissions@oup.com © The Author(s) 2019. Published by Oxford University Press on behalf of the American Medical Informatics Association.

Journal

Journal of the American Medical Informatics AssociationOxford University Press

Published: Jul 1, 2019

There are no references for this article.