Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use?

BACKGROUND: Electronic health record (EHR) adoption is a national priority in the USA, and well-designed EHRs have the potential to improve quality and safety. However, physicians are reluctant to implement EHRs due to financial constraints, usability concerns, and apprehension about unintended consequences, including the introduction of medical errors related to EHR use. The goal of this study was to characterize and describe physicians' attitudes towards three consequences of EHR implementation: (1) the potential for EHRs to introduce new errors; (2) improvements in healthcare quality; and (3) changes in overall physician satisfaction. METHODS: Using data from a 2007 statewide survey of Massachusetts physicians, we conducted multivariate regression analysis to examine relationships between practice characteristics, perceptions of EHR-related errors, perceptions of healthcare quality, and overall physician satisfaction. RESULTS: 30% of physicians agreed that EHRs create new opportunities for error, but only 2% believed their EHR has created more errors than it prevented. With respect to perceptions of quality, there was no significant association between perceptions of EHR-associated errors and perceptions of EHR-associated changes in healthcare quality. Finally, physicians who believed that EHRs created new opportunities for error were less likely be satisfied with their practice situation (adjusted OR 0.49, p=0.001). CONCLUSIONS: Almost one third of physicians perceived that EHRs create new opportunities for error. This perception was associated with lower levels of physician satisfaction.

Physician satisfaction following electronic health record adoption in three massachusetts communities.

BACKGROUND: Despite mandates and incentives for electronic health record (EHR) adoption, little is known about factors predicting physicians' satisfaction following EHR implementation. OBJECTIVE: To measure predictors of physician satisfaction following EHR adoption. METHODS: A total of 163 physicians completed a mailed survey before and after EHR implementation through a statewide pilot project in Massachusetts. Multivariable logistic regression identified predictors of physician satisfaction with their current practice situation in 2009 and generalized estimating equations accounted for clustering. RESULTS: The response rate was 77% in 2005 and 68% in 2009. In 2005, prior to EHR adoption, 28% of physicians were very satisfied with their current practice situation compared to 25% in 2009, following EHR adoption (P < .001). In multivariate analysis, physician satisfaction following EHR adoption was correlated with self-reported ease of EHR implementation (adjusted odds ratio [OR] = 5.7, 95% CI 2.1 - 16), resources for practice improvement (adjusted OR = 2.6, 95% CI 1.2 - 6.1), pre-intervention satisfaction (adjusted OR = 4.8, 95% CI 1.5 - 15), and stress (adjusted OR = 5.3, 95% CI 1.1 - 25). Male physicians reported lower satisfaction following EHR adoption (adjusted OR = 0.3, 95% CI 0.2 - 0.6). CONCLUSIONS: Interventions to expand EHR use should consider additional support for practices with fewer resources for improvement and ensure ease of EHR implementation. EHR adoption may be a factor in alleviating physicians' stress. Addressing physicians' satisfaction prior to practice transformation and anticipating greater dissatisfaction among male physicians will be essential to retaining the physician workforce and ensuring the quality of care they deliver.

Relationship between use of electronic health record features and health care quality: results of a statewide survey.

BACKGROUND: Electronic health records (EHRs) are widely viewed as useful tools for supporting the provision of high quality healthcare. However, evidence regarding their effectiveness for this purpose is mixed, and existing studies have generally considered EHR usage a binary factor and have not considered the availability and use of specific EHR features. OBJECTIVE: To assess the relationship between the use of an EHR and the use of specific EHR features with quality of care. RESEARCH DESIGN: A statewide mail survey of physicians in Massachusetts conducted in 2005. The results of the survey were linked with Healthcare Effectiveness Data and Information Set (HEDIS) quality measures, and generalized linear regression models were estimated to examine the associations between the use of EHRs and specific EHR features with quality measures, adjusting for physician practice characteristics. SUBJECTS: A stratified random sample of 1884 licensed physicians in Massachusetts, 1345 of whom responded. Of these, 507 had HEDIS measures available and were included in the analysis (measures are only available for primary care providers). MEASURE: Performance on HEDIS quality measures. RESULTS: The survey had a response rate of 71%. There was no statistically significant association between use of an EHR as a binary factor and performance on any of the HEDIS measure groups. However, there were statistically significant associations between the use of many, but not all, specific EHR features and HEDIS measure group scores. The associations were strongest for the problem list, visit note and radiology test result EHR features and for quality measures relating to women's health, colon cancer screening, and cancer prevention. For example, users of problem list functionality performed better on women's health, depression, colon cancer screening, and cancer prevention measures, with problem list users outperforming nonusers by 3.3% to 9.6% points on HEDIS measure group scores (all significant at the P < 0.05 level). However, these associations were not universal. CONCLUSIONS: Consistent with past studies, there was no significant relationship between use of EHR as a binary factor and performance on quality measures. However, availability and use of specific EHR features by primary care physicians was associated with higher performance on certain quality measures. These results suggest that, to maximize health care quality, developers, implementers and certifiers of EHRs should focus on increasing the adoption of robust EHR systems and increasing the use of specific features rather than simply aiming to deploy an EHR regardless of functionality.

Physician attitudes toward health information exchange: results of a statewide survey.

OBJECTIVE: To assess physicians' attitudes toward health information exchange (HIE) and physicians' willingness to pay to participate in HIE. DESIGN: We conducted a cross-sectional mail survey of 1296 licensed physicians (77% response rate) in Massachusetts in 2007. MEASUREMENTS: Perceptions of the potential effects of HIE on healthcare costs, quality of care, clinicians' time, patients' privacy concerns, and willingness to pay for HIE. RESULTS: After excluding 253 physicians who did not see any outpatients, we analyzed 1043 responses. Overall, 70% indicated that HIE would reduce costs, while 86% said it would improve quality and 76% believed that it would save time. On the other hand, 16% reported being very concerned about HIE's effect on privacy, while 55.0% were somewhat concerned and 29% not at all concerned. Slightly more than half of the physicians (54%) said they would be willing to pay an unspecified monthly fee to participate in HIE, but only 37% said they would be willing to pay $150 per month for it. Primary care physicians and those in larger practices tended to have more positive attitudes toward HIE. CONCLUSIONS: Physicians perceive that HIE will have generally positive effects, though a considerable fraction harbor concerns about privacy. While physicians may be willing to participate in HIE, they are not consistently willing to pay to participate. HIE business models that require substantial physician subscription fees may face significant challenges.

Ability to generate patient registries among practices with and without electronic health records.

BACKGROUND: The ability to generate registries of patients with particular clinical attributes, such as diagnoses or medications taken, is central to measuring and improving the quality of health care. However, it is not known how many providers have the ability to generate such registries. OBJECTIVES: To assess the proportion of physician practices that can construct registries of patients with specific diagnoses, laboratory results, or medications, and to determine the relationship between electronic health record (EHR) usage and the ability to perform registry functions. METHODS: We conducted a mail survey of a stratified random sample of physician practices in Massachusetts in the northeastern United States (N = 1884). The survey included questions about the physicians' ability to generate diagnosis, laboratory result, and medication registries; the presence of EHR; and usage of specific EHR features. RESULTS: The response rate was 71% (1345/1884). Overall, 79.8% of physician practices reported being able to generate registries of patients by diagnosis; 56.1% by laboratory result; and 55.8% by medication usage. In logistic regression analyses, adjusting for urban/rural location, practice size and ownership, teaching status, hospital affiliation, and specialty, physician practices with an EHR were more likely to be able to construct diagnosis registries (adjusted odds ratio [OR] 1.53, 95% confidence interval [CI] 1.25 - 1.86), laboratory registries (OR 1.42, 95% CI 1.22 - 1.66), and medication registries (OR 2.30, 95% CI 1.96 - 2.70). CONCLUSIONS: Many physician practices were able to generate registries, but this capability is far from universal. Adoption of EHRs appears to be a useful step toward this end, and practices with EHRs are considerably more likely to be able to carry out registry functions. Because practices need registries to perform broad-based quality improvement, they should consider adopting EHRs that have built-in registry functionality.

Imminent adopters of electronic health records in ambulatory care.

BACKGROUND: Although evidence suggests electronic health records (EHRs) can improve quality and efficiency, provider adoption rates in the US ambulatory setting are relatively low. Prior studies have identified factors correlated with EHR use, but less is known about characteristics of physicians on the verge of adoption. OBJECTIVE: To compare characteristics of physicians who are imminent adopters of EHRs with EHR users and non-users. DESIGN AND PARTICIPANTS: A survey was mailed (June - November 2005) to a stratified random sample of all medical practices in Massachusetts. One physician from each practice (n=1884) was randomly selected to participate. Overall, 1345 physicians (71.4%) responded to the survey, with 1082 eligible for analysis due to exclusion criteria. 'Imminent adopters' were those planning to adopt EHRs within 12 months. MEASUREMENTS: We assessed physician and practice characteristics, availability of technology, barriers to adoption or expansion of health information technology (HIT), computer proficiency, and financial considerations. RESULTS: Compared to non-users, imminent adopters were younger, more experienced with technology, and more often in practices engaged in quality improvement. More imminent adopters owned or partly owned their practices (57.4%) than users (33.5%; p<0.001), but fewer imminent adopters owned their practices than non-users (65.7%; p<0.001). Additionally, more imminent adopters (26.0%) reported personal financial incentives for HIT use than users (14.8%; p<0.001) and non-users (10.8%; p<0.001). CONCLUSIONS: Imminent adopters of EHRs differed from users and non-users. Financial considerations appear to play a major role in adoption decisions. Knowledge of these differences may assist policy-makers and healthcare leaders as they work to increase EHR adoption rates.

The relationship between electronic health record use and quality of care over time.

OBJECTIVE Electronic health records (EHRs) have the potential to advance the quality of care, but studies have shown mixed results. The authors sought to examine the extent of EHR usage and how the quality of care delivered in ambulatory care practices varied according to duration of EHR availability. METHODS The study linked two data sources: a statewide survey of physicians' adoption and use of EHR and claims data reflecting quality of care as indicated by physicians' performance on widely used quality measures. Using four years of measurement, we combined 18 quality measures into 6 clinical condition categories. While the survey of physicians was cross-sectional, respondents indicated the year in which they adopted EHR. In an analysis accounting for duration of EHR use, we examined the relationship between EHR adoption and quality of care. RESULTS The percent of physicians reporting adoption of EHR and availability of EHR core functions more than doubled between 2000 and 2005. Among EHR users in 2005, the average duration of EHR use was 4.8 years. For all 6 clinical conditions, there was no difference in performance between EHR users and non-users. In addition, for these 6 clinical conditions, there was no consistent pattern between length of time using an EHR and physicians performance on quality measures in both bivariate and multivariate analyses. CONCLUSIONS In this cross-sectional study, we found no association between duration of using an EHR and performance with respect to quality of care, although power was limited. Intensifying the use of key EHR features, such as clinical decision support, may be needed to realize quality improvement from EHRs. Future studies should examine the relationship between the extent to which physicians use key EHR functions and their performance on quality measures over time.

Physicians' use of key functions in electronic health records from 2005 to 2007: a statewide survey.

OBJECTIVE Electronic health records (EHRs) have potential to improve quality and safety, but many physicians do not use these systems to full capacity. The objective of this study was to determine whether this usage gap is narrowing over time. DESIGN Follow-up mail survey of 1,144 physicians in Massachusetts who completed a 2005 survey. MEASUREMENTS Adoption of EHRs and availability and use of 10 EHR functions. RESULTS The response rate was 79.4%. In 2007, 35% of practices had EHRs, up from 23% in 2005. Among practices with EHRs, there was little change between 2005 and 2007 in the availability of nine of ten EHR features; the notable exception was electronic prescribing, reported as available in 44.7% of practices with EHRs in 2005 and 70.8% in 2007. Use of EHR functions changed inconsequentially, with more than one out of five physicians not using each available function regularly in both 2005 and 2007. Only electronic prescribing increased substantially: in 2005, 19.9% of physicians with this function available used it most or all the time, compared with 42.6% in 2007 (p < 0.001). CONCLUSIONS By 2007, more than one third of practices in Massachusetts reported having EHRs; the availability and use of electronic prescribing within these systems has increased. In contrast, physicians reported little change in the availability and use of other EHR functions. System refinements, certification efforts, and health policies, including standards development, should address the gaps in both EHR adoption and the use of key functions.

Do electronic health records create more errors than they prevent?

While use of electronic health records (EHRs) and electronic prescribing can prevent many medication errors, it may also create opportunities for new errors. Therefore, we conducted a study to examine providers' perception of opportunities for errors introduced by the use of EHRs.

Electronic health records and malpractice claims in office practice.

BACKGROUND: Electronic health records (EHRs) may improve patient safety and health care quality, but the relationship between EHR adoption and settled malpractice claims is unknown. METHODS: Between June 1, 2005, and November 30, 2005, we surveyed a random sample of 1884 physicians in Massachusetts to assess availability and use of EHR functions, predictors of use, and perceptions of medical practice. Information on paid malpractice claims was accessed on the Massachusetts Board of Registration in Medicine (BRM) Web site in April 2007. We used logistic regression to assess the relationship between the adoption and use of EHRs and paid malpractice claims. RESULTS: The survey response rate was 71.4% (1345 of 1884). Among 1140 respondents with data on the presence of EHR and available BRM records, 379 (33.2%) had EHRs. A total of 6.1% of physicians with an EHR had a history of a paid malpractice claim compared with 10.8% of physicians without EHRs (unadjusted odds ratio, 0.54; 95% confidence interval, 0.33-0.86; P = .01). In logistic regression analysis controlling for sex, race, year of medical school graduation, specialty, and practice size, the relationship between EHR adoption and paid malpractice settlements was of smaller magnitude and no longer statistically significant (adjusted odds ratio, 0.69; 95% confidence interval, 0.40-1.20; P = .18). Among EHR adopters, 5.7% of physicians identified as "high users" of EHR had paid malpractice claims compared with 12.1% of "low users" (P = .14). CONCLUSIONS: Although the results of this study are inconclusive, physicians with EHRs appear less likely to have paid malpractice claims. Confirmatory studies are needed before these results can have policy implications.

Ability to perform registry functions among practices with and without electronic health records.

Patient care registries allow physicians to identify patients based on a subset of conditions, including medicine prescribed, laboratory results and diagnosis. The presence of EHRs and a physician's ability to query across patient medical records is unknown in Massachusetts. A survey was conducted to examine the presence of EHRs in medical practices, and the degree to which EHRs enable physicians to carry out registry functions. EHR adoption was correlated with the use of registry functions.

Readiness for electronic health records: comparison of characteristics of practices in a collaborative with the remainder of Massachusetts.

OBJECTIVE: The Massachusetts e-Health Collaborative (MAeHC) is implementing electronic health records (EHRs) in physicians' offices throughout three diverse communities. This study's objective was to assess the degree to which these practices are representative of physicians' practices statewide. DESIGN: We surveyed all MAeHC physicians (n=464) and compared their responses to those of a contemporaneously surveyed statewide random sample (n=1884). MEASUREMENTS: The survey questionnaire assessed practice characteristics related to EHR adoption, prevailing office culture related to quality and safety, attitudes toward health information technology (HIT) and perceptions of medical practice. RESULTS: A total of 355 MAeHC physicians (77%) and 1345 physicians from the statewide sample (71%) completed the survey. MAeHC practices resembled practices throughout Massachusetts in terms of practice size, physician age and gender, prevailing financial incentives for quality performance and HIT adoption and available resources for practice expansion. MAeHC practices were more likely to be located in rural areas (9.5% vs 4.4%, P=0.004). Physicians in both samples responded similarly to six of seven self-assessments of the office practice environment for quality and safety. Internet connections were more prevalent among MAeHC practices than across the state (96% vs 83%, P<0.001), but similar proportions of MAeHC physicians (83%) and statewide physicians (86%) used the internet daily (P=0.19). CONCLUSION: MAeHC is implementing EHRs and health information exchange among communities with physicians and practices that appear generally representative of Massachusetts. The lessons learned from this pilot project should be applicable statewide and to other states with large numbers of physicians in small office practices.

Electronic health records: which practices have them, and how are clinicians using them?

BACKGROUND: Limited data exist to estimate the use of electronic health records (EHRs) in ambulatory care practices in the United States. METHODS: We surveyed a stratified random sample of 1829 office practices in Massachusetts in 2005. The one-page survey measured use of health information technology, plans for EHR adoption and perceived barriers to adoption. RESULTS: A total of 847 surveys were returned, for a response rate of 46%. Overall, 18% of office practices reported having an EHR. Primary-care-only and mixed practices reported similar adoption rates (23% and 25%, respectively, P = 0.70). The adoption rate in specialty practices (14%) was lower compared with both primary-care-only (P < 0.01) and mixed (P < 0.05) practices. The number of clinicians in the practice strongly correlated with EHR adoption (P < 0.001), with fewer small practices adopting EHRs. Among practices that have EHRs with laboratory and radiology result retrieval capabilities, at least 87% of practices report that a majority of their clinicians actively use these functionalities, while 74% of practices with electronic decision support report that the majority of clinicians actively use it. Among the practices without an EHR, 13% plan to implement one within the next 12 months, 24% within the next 1-2 years, 11% within the next 3-5 years, and 52% reported having no plans to implement an EHR in the foreseeable future. The most frequently reported barrier to implementation was lack of adequate funding (42%). CONCLUSIONS: Overall, fewer than 1 in 5 medical practices in Massachusetts have an EHR. Even among adopters, though, doctor usage of EHR functions varied considerably by functionality and across practices. Many clinicians are not actively using functionalities that are necessary to improve health care quality and patient safety. Furthermore, among practices that do not have EHRs, more than half have no plan for adoption. Inadequate funding remains an important barrier to EHR adoption in ambulatory care practices in the United States.

Physicians and electronic health records: a statewide survey.

BACKGROUND: Electronic health records (EHRs) allow for a variety of functions, ranging from visit documentation to laboratory test ordering, but little is known about physicians' actual use of these functions. METHODS: We surveyed a random sample of 1884 physicians in Massachusetts by mail and assessed availability and use of EHR functions, predictors of use, and the relationships between EHR use and physicians' perceptions of medical practice. RESULTS: A total of 1345 physicians responded to the survey (71.4% response rate), and 387 (28.8%) reported that their practice had adopted EHRs. More than 80% of physicians with EHRs reported having the ability to view laboratory reports (84.8%) and document visits electronically (84.0%), but considerably fewer reported being able to order laboratory tests electronically (46.8%) or transmit prescriptions to a pharmacy electronically (44.7%). Fewer than half of the physicians who had systems with clinical decision support, transmittal of electronic prescriptions, and radiology order entry actually used these functions most or all of the time. Compared with physicians who had not adopted EHRs, EHR users reported more positive views of the effects of computers on health care; there were no significant differences in these attitudes between high and low users of EHRs. Overall, about 1 in 4 physicians reported dissatisfaction with medical practice; there was no difference in this measure by EHR adoption or use. CONCLUSIONS: There is considerable variability in the functions available in EHRs and in the extent to which physicians use them. Future work should emphasize factors that affect the use of available functions.

Correlates of electronic health record adoption in office practices: a statewide survey.

OBJECTIVE: Despite emerging evidence that electronic health records (EHRs) can improve the efficiency and quality of medical care, most physicians in office practice in the United States do not currently use an EHR. We sought to measure the correlates of EHR adoption. DESIGN: Mailed survey to a stratified random sample of all medical practices in Massachusetts in 2005, with one physician per practice randomly selected for survey. MEASUREMENTS: EHR adoption rates. RESULTS: The response rate was 71% (1345/1884). Overall, while 45% of physicians were using an EHR, EHRs were present in only 23% of practices. In multivariate analysis, practice size was strongly correlated with EHR adoption; 52% of practices with 7 or more physicians had an EHR, as compared with 14% of solo practices (adjusted odds ratio, 3.66; 95% confidence interval, 2.28-5.87). Hospital-based practices (adjusted odds ratio, 2.44; 95% confidence interval, 1.53-3.91) and practices that teach medical students or residents (adjusted odds ratio, 2.30; 95% confidence interval, 1.60-3.31) were more likely to have an EHR. The most frequently cited barriers to adoption were start-up financial costs (84%), ongoing financial costs (82%), and loss of productivity (81%). CONCLUSIONS: While almost half of physicians in Massachusetts are using an EHR, fewer than one in four practices in Massachusetts have adopted EHRs. Adoption rates are lower in smaller practices, those not affiliated with hospitals, and those that do not teach medical students or residents. Interventions to expand EHR use must address both financial and non-financial barriers, especially among smaller practices.

Do minority-serving physicians have comparable rates of use of electronic health records?

Given concerns that efforts to improve quality using tools such as electronic health records (EHR) could increase the digital divide among racial groups, we sought to determine whether minority-serving physicians in Massachusetts use EHR at the same rate as non-minority serving physicians. We found that physicians who cared for large minority populations had comparable rates of EHR use, identified similar barriers and reported similar benefits.