A Two-Year Longitudinal Assessment of Ophthalmologists' Perceptions after Implementing an Electronic Health Record System

Design and evaluation of a web-based electronic health record for amblyopia

Introduction

Amblyopia, or lazy eye, is a type of visual impairment in which the eyesight is not complete, even with the use of glasses. For the treatment of this disease, accurate and continuous examinations are needed. Nowadays, patient-centered care, by relying on web-based electronic records for amblyopia, has the potential to reduce treatment costs, increase the quality of care, and improve the safety and effectiveness of treatment. Therefore, the purpose of this study is to design and evaluate an Electronic Health Record (EHR) for patients with amblyopia.

Methods

The present study is applied developmental research. Using a Morgan table as a sampling tool, a straightforward random sampling technique selected 150 records from 1,500 records that were free of flaws. The design of the electronic version proceeded in a cascading manner so that after the design of each part, it was presented to the amblyopia experts, and if approved, the next part was designed. To design this EHR, the C# programming language and MySQL database were used. A system evaluation was performed by entering and recording patient information. For this purpose, the standard Questionnaire of User Interaction Satisfaction (QUIS), consisting of 18 questions, was used.

Results

According to the amblyopia EHR data elements, the data of physician and patient, examinations, website members, and members' roles were determined. After defining the fields and classes that explain the tables, the EHR was designed. The usability evaluation of the system showed that the mean selection of very good and good options by the users of EHRs was over 90%, indicating the patients' acceptance of web-based EHRs.

Conclusion

The design of an EHR for amblyopia is an effective step toward integrating and improving the information management of these patients. It will also enable the storage and retrieval of patients' information to reduce and facilitate the control of amblyopia complications.

Assessing Electronic Health Record (EHR) Use during a Major EHR Transition: An Innovative Mixed Methods Approach

BACKGROUND

Electronic health record (EHR) transitions are inherently disruptive to healthcare workers who must rapidly learn a new EHR and adapt to altered clinical workflows. Healthcare workers' perceptions of EHR usability and their EHR use patterns following transitions are poorly understood. The Department of Veterans Affairs (VA) is currently replacing its homegrown EHR with a commercial Cerner EHR, presenting a unique opportunity to examine EHR use trends and usability perceptions.

OBJECTIVE

To assess EHR usability and uptake up to 1-year post-transition at the first VA EHR transition site using a novel longitudinal, mixed methods approach.

DESIGN

A concurrent mixed methods strategy using EHR use metrics and qualitative interview data.

PARTICIPANTS

141 clinicians with data from select EHR use metrics in Cerner Lights On Network®. Interviews with 25 healthcare workers in various clinical and administrative roles.

APPROACH

We assessed changes in total EHR time, documentation time, and order time per patient post-transition. Interview transcripts (n = 90) were coded and analyzed for content specific to EHR usability.

KEY RESULTS

Total EHR time, documentation time, and order time all decreased precipitously within the first four months after go-live and demonstrated gradual improvements over 12 months. Interview participants expressed ongoing concerns with the EHR's usability and functionality up to a year after go-live such as tasks taking longer than the old system and inefficiencies related to inadequate training and inherent features of the new system. These sentiments did not seem to reflect the observed improvements in EHR use metrics.

CONCLUSIONS

The integration of quantitative and qualitative data yielded a complex picture of EHR usability. Participants described persistent challenges with EHR usability 1 year after go-live contrasting with observed improvements in EHR use metrics. Combining findings across methods can provide a clearer, contextualized understanding of EHR adoption and use patterns during EHR transitions.

A Multiyear Survey Evaluating Clinician Electronic Health Record Satisfaction

OBJECTIVES

We assessed how clinician satisfaction with a vendor electronic health record (EHR) changed over time in the 4 years following the transition from a homegrown EHR system to identify areas for improvement.

METHODS

We conducted a multiyear survey of clinicians across a large health care system after transitioning to a vendor EHR. Eligible clinicians from the first institution to transition received a survey invitation by email in fall 2016 and then eligible clinicians systemwide received surveys in spring 2018 and spring 2019. The survey included items assessing ease/difficulty of completing tasks and items assessing perceptions of the EHR's value, usability, and impact. One item assessing overall satisfaction and one open-ended question were included. Frequencies and means were calculated, and comparison of means was performed between 2018 and 2019 on all clinicians. A multivariable generalized linear model was performed to predict the outcome of overall satisfaction.

RESULTS

Response rates for the surveys ranged from 14 to 19%. The mean response from 3 years of surveys for one institution, Brigham and Women's Hospital, increased for overall satisfaction between 2016 (2.85), 2018 (3.01), and 2019 (3.21, p < 0.001). We found no significant differences in mean response for overall satisfaction between all responders of the 2018 survey (3.14) and those of the 2019 survey (3.19). Systemwide, tasks rated the most difficult included "Monitoring patient medication adherence," "Identifying when a referral has not been completed," and "Making a list of patients based on clinical information (e.g., problem, medication)." Clinicians disagreed the most with "The EHR helps me focus on patient care rather than the computer" and "The EHR allows me to complete tasks efficiently."

CONCLUSION

Survey results indicate room for improvement in clinician satisfaction with the EHR. Usability of EHRs should continue to be an area of focus to ease clinician burden and improve clinician experience.

The Value of Electronic Health Records Since the Health Information Technology for Economic and Clinical Health Act: Systematic Review

Background

Electronic health records (EHRs) are the electronic records of patient health information created during ≥1 encounter in any health care setting. The Health Information Technology Act of 2009 has been a major driver of the adoption and implementation of EHRs in the United States. Given that the adoption of EHRs is a complex and expensive investment, a return on this investment is expected.

Objective

This literature review aims to focus on how the value of EHRs as an intervention is defined in relation to the elaboration of value into 2 different value outcome categories, financial and clinical outcomes, and to understand how EHRs contribute to these 2 value outcome categories.

Methods

This literature review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The initial search of key terms, EHRs, values, financial outcomes, and clinical outcomes in 3 different databases yielded 971 articles, of which, after removing 410 (42.2%) duplicates, 561 (57.8%) were incorporated in the title and abstract screening. During the title and abstract screening phase, articles were excluded from further review phases if they met any of the following criteria: not relevant to the outcomes of interest, not relevant to EHRs, nonempirical, and non–peer reviewed. After the application of the exclusion criteria, 80 studies remained for a full-text review. After evaluating the full text of the residual 80 studies, 26 (33%) studies were excluded as they did not address the impact of EHR adoption on the outcomes of interest. Furthermore, 4 additional studies were discovered through manual reference searches and were added to the total, resulting in 58 studies for analysis. A qualitative analysis tool, ATLAS.ti. (version 8.2), was used to categorize and code the final 58 studies.

Results

The findings from the literature review indicated a combination of positive and negative impacts of EHRs on financial and clinical outcomes. Of the 58 studies surveyed for this review of the literature, 5 (9%) reported on the intersection of financial and clinical outcomes. To investigate this intersection further, the category “Value–Intersection of Financial and Clinical Outcomes” was generated. Approximately 80% (4/5) of these studies specified a positive association between EHR adoption and financial and clinical outcomes.

Conclusions

This review of the literature reports on the individual and collective value of EHRs from a financial and clinical outcomes perspective. The collective perspective examined the intersection of financial and clinical outcomes, suggesting a reversal of the current understanding of how IT investments could generate improvements in productivity, and prompted a new question to be asked about whether an increase in productivity could potentially lead to more IT investments.

The burden of the digital environment: a systematic review on organization-directed workplace interventions to mitigate physician burnout

OBJECTIVE

To conduct a systematic review identifying workplace interventions that mitigate physician burnout related to the digital environment including health information technologies (eg, electronic health records) and decision support systems) with or without the application of advanced analytics for clinical care.

MATERIALS AND METHODS

Literature published from January 1, 2007 to June 3, 2020 was systematically reviewed from multiple databases and hand searches. Subgroup analysis identified relevant physician burnout studies with interventions examining digital tool burden, related workflow inefficiencies, and measures of burnout, stress, or job satisfaction in all practice settings.

RESULTS

The search strategy identified 4806 citations of which 81 met inclusion criteria. Thirty-eight studies reported interventions to decrease digital tool burden. Sixty-eight percent of these studies reported improvement in burnout and/or its proxy measures. Burnout was decreased by interventions that optimized technologies (primarily electronic health records), provided training, reduced documentation and task time, expanded the care team, and leveraged quality improvement processes in workflows.

DISCUSSION

The contribution of digital tools to physician burnout can be mitigated by careful examination of usability, introducing technologies to save or optimize time, and applying quality improvement to workflows.

CONCLUSION

Physician burnout is not reduced by technology implementation but can be mitigated by technology and workflow optimization, training, team expansion, and careful consideration of factors affecting burnout, including specialty, practice setting, regulatory pressures, and how physicians spend their time.

[Electronic patient files in hospital information systems]

Hintergrund

Die Einführung einer elektronischen Patientenakte (EPA) im Bereich der Ophthalmologie stellt für viele Kliniken eine Herausforderung dar. Obwohl alle Kliniken ein Krankenhausinformationssystem (KIS) besitzen, sind die wenigsten dieser Systeme für die komplexe ophthalmologische Patientenakte gerüstet.

Methodik

Wir berichten über die Implementierung einer ophthalmologischen EPA innerhalb des vorherrschenden KIS (Agfa-ORBIS; Agfa HealthCare GmbH, Bonn). Dabei werden sowohl die digitale Aktenführung als auch die Anbindung der vorhandenen Untersuchungsgeräte dargestellt.

Ergebnisse

Die von uns entwickelte EPA wird im klinischen Alltag seit 2009 genutzt und seitdem kontinuierlich weiterentwickelt. Durch eine enge Zusammenarbeit mit der IT-Abteilung konnten alle Untersuchungsgeräte digital angebunden werden und ein papierloses Arbeiten ermöglichen und die Nachteile der Papierakte vermeiden.

Diskussion

Die Nutzungsmöglichkeiten einer in das vorhandene KIS implementierten EPA sind vielfältig. Durch solch ein System kann eine lückenlose, fächerübergreifende und ubiquitäre Dokumentation erfolgen. Die Alternative stellt die Anschaffung eines Drittsystems dar, welches sowohl durch eine Schnittstelle mit dem Hauptsystem verbunden werden muss als auch deutliche höhere Anschaffungs- und Erhaltungskosten aufweist.

Electronic Health Records in Ophthalmology: Source and Method of Documentation

PURPOSE

This study analyzed and quantified the sources of electronic health record (EHR) text documentation in ophthalmology progress notes.

DESIGN

EHR documentation review and analysis.

METHODS

Setting: a single academic ophthalmology department.

STUDY POPULATION

a cohort study conducted between November 1, 2016, and December 31, 2018, using secondary EHR data and a follow-up manual review of a random samples. The cohort study included 123,274 progress notes documented by 42 attending providers. These notes were for patients with the 5 most common primary International Statistical Classification of Diseases and Related Health Problems, version 10, parent codes for each provider. For the manual review, 120 notes from 8 providers were randomly sampled. Main outcome measurements were characters or number of words in each note categorized by attribution source, author type, and time of creation.

RESULTS

Imported text entries made up the majority of text in new and return patients, 2,978 characters (77%) and 3,612 characters (91%). Support staff members authored substantial portions of notes; 3,024 characters (68%) of new patient notes, 3,953 characters (83%) of return patient notes. Finally, providers completed large amounts of documentation after clinical visits: 135 words (35%) of new patient notes, 102 words (27%) of return patient notes.

CONCLUSIONS

EHR documentation consists largely of imported text, is often authored by support staff, and is often written after the end of a visit. These findings raise questions about documentation accuracy and utility and may have implications for quality of care and patient-provider relationships.

Promoting Quality Face-to-Face Communication during Ophthalmology Encounters in the Electronic Health Record Era

OBJECTIVE

To evaluate informatics-enabled quality improvement (QI) strategies for promoting time spent on face-to-face communication between ophthalmologists and patients.

METHODS

This prospective study involved deploying QI strategies during implementation of an enterprise-wide vendor electronic health record (EHR) in an outpatient academic ophthalmology department. Strategies included developing single sign-on capabilities, activating mobile- and tablet-based applications, EHR personalization training, creating novel workflows for team-based orders, and promoting problem-based charting to reduce documentation burden. Timing data were collected during 648 outpatient encounters. Outcomes included total time spent by the attending ophthalmologist on the patient, time spent on documentation, time spent on examination, and time spent talking with the patient. Metrics related to documentation efficiency, use of personalization features, use of team-based orders, and note length were also measured from the EHR efficiency portal and compared with averages for ophthalmologists nationwide using the same EHR.

RESULTS

Time spent on exclusive face-to-face communication with patients initially decreased with EHR implementation (2.9 to 2.3 minutes, p = 0.005) but returned to the paper baseline by 6 months (2.8 minutes, p = 0.99). Observed participants outperformed national averages of ophthalmologists using the same vendor system on documentation time per appointment, number of customized note templates, number of customized order lists, utilization of team-based orders, note length, and time spent after-hours on EHR use.

CONCLUSION

Informatics-enabled QI interventions can promote patient-centeredness and face-to-face communication in high-volume outpatient ophthalmology encounters. By employing an array of interventions, time spent exclusively talking with the patient returned to levels equivalent to paper charts by 6 months after EHR implementation. This was achieved without requiring EHR redesign, use of scribes, or excessive after-hours work. Documentation efficiency can be achieved using interventions promoting personalization and team-based workflows. Given their efficacy in preserving face-to-face physician-patient interactions, these strategies may help alleviate risk of physician burnout.

Effect of Organization-Directed Workplace Interventions on Physician Burnout: A Systematic Review

To assess the impact of organization-directed workplace interventions on physician burnout, including stress or job satisfaction in all settings, we conducted a systematic review of the literature published from January 1, 2007, to October 3, 2018, from multiple databases. Manual searches of grey literature and bibliographies were also performed. Of the 633 identified citations, 50 met inclusion criteria. Four unique categories of organization-directed workplace interventions were identified. Teamwork involved initiatives to incorporate scribes or medical assistants into electronic health record (EHR) processes, expand team responsibilities, and improve communication among physicians. Time studies evaluated the impact of schedule adjustments, duty hour restrictions, and time-banking initiatives. Transitions referred to workflow changes such as process improvement initiatives or policy changes within the organization. Technology related to the implementation or improvement of EHRs. Of the 50 included studies, 35 (70.0%) reported interventions that successfully improved the 3 measures of physician burnout, job satisfaction, and/or stress. The largest benefits resulted from interventions that improved processes, promoted team-based care, and incorporated the use of scribes/medical assistants to complete EHR documentation and tasks. Implementation of EHR interventions to improve clinical workflows worsened burnout, but EHR improvements had positive effects. Time interventions had mixed effects on burnout. The results of our study suggest that organization-directed workplace interventions that improve processes, optimize EHRs, reduce clerical burden by the use of scribes, and implement team-based care can lessen physician burnout. Benefits of process changes can enhance physician resiliency, augment care provided by the team, and optimize the coordination and communication of patient care and health information.

Impact of Electronic Health Record Implementation on Ophthalmology Trainee Time Expenditures

Objective

Electronic health records (EHRs) are widely adopted, but the time demands of EHR use on ophthalmology trainees are not well understood. This study evaluated ophthalmology trainee time spent on clinical activities in an outpatient clinic undergoing EHR implementation.

Design

Prospective, manual time-motion observations of ophthalmology trainees in 2018.

Participants

Eleven ophthalmology residents and fellows observed during 156 patient encounters.

Methods

Prospective time-motion study of ophthalmology trainees 2 weeks before and 6 weeks after EHR implementation in an academic ophthalmology department. Manual time-motion observations were conducted for 11 ophthalmology trainees in 6 subspecialty clinics during 156 patient encounters. Time spent documenting, examining, and talking with patients were recorded. Factors influencing time requirements were evaluated using linear mixed effects models.

Main Outcome Measures

Total time spent by ophthalmology residents and fellows per patient, time spent on documentation, examination, and talking with patients.

Results

Seven ophthalmology residents and four ophthalmology fellows with mean (standard deviation) postgraduate year of 3.7 (1.2) were observed during 156 patient encounters. Using paper charts, mean total time spent on each patient was 11.6 (6.5) minutes, with 5.4 (3.5) minutes spent documenting (48%). After EHR implementation, mean total time spent on each patient was 11.8 (6.9) minutes, with 6.8 (4.7) minutes spent documenting (57%). Total time expenditure per patient did not significantly change after EHR implementation (+0.17 minutes, 95% confidence interval [CI] for difference in means: -2.78, 2.45; p = 0.90). Documentation time did not change significantly after EHR implementation in absolute terms (+1.42 minutes, 95% CI: -3.13, 0.29; p = 0.10), but was significantly greater as a proportion of total time (48% on paper to 57% on EHR; +9%, 95% CI: 2.17, 15.83; p = 0.011).

Conclusion

Total time spent per patient and absolute time spent on documentation was not significantly different whether ophthalmology trainees used paper charts or the recently implemented EHR. Percentage of total time spent on documentation increased significantly with early EHR use. Evaluating EHR impact on ophthalmology trainees may improve understanding of how trainees learn to use the EHR and may shed light on strategies to address trainee burnout.

Changes in Electronic Health Record Use Time and Documentation over the Course of a Decade

PURPOSE

With the current wide adoption of electronic health records (EHRs) by ophthalmologists, there are widespread concerns about the amount of time spent using the EHR. The goal of this study was to examine how the amount of time spent using EHRs as well as related documentation behaviors changed 1 decade after EHR adoption.

DESIGN

Single-center cohort study.

PARTICIPANTS

Six hundred eighty-five thousand three hundred sixty-one office visits with 70 ophthalmology providers.

METHODS

We calculated time spent using the EHR associated with each individual office visit using EHR audit logs and determined chart closure times and progress note length from secondary EHR data. We tracked and modeled how these metrics changed from 2006 to 2016 with linear mixed models.

MAIN OUTCOME MEASURES

Minutes spent using the EHR associated with an office visit, chart closure time in hours from the office visit check-in time, and progress note length in characters.

RESULTS

Median EHR time per office visit in 2006 was 4.2 minutes (interquartile range [IQR], 3.5 minutes), and increased to 6.4 minutes (IQR, 4.5 minutes) in 2016. Median chart closure time was 2.8 hours (IQR, 21.3 hours) in 2006 and decreased to 2.3 hours (IQR, 18.5 hours) in 2016. In 2006, median note length was 1530 characters (IQR, 1435 characters) and increased to 3838 characters (IQR, 2668.3 characters) in 2016. Linear mixed models found EHR time per office visit was 31.9±0.2% (P < 0.001) greater from 2014 through 2016 than from 2006 through 2010, chart closure time was 6.7±0.3 hours (P < 0.001) shorter from 2014 through 2016 versus 2006 through 2010, and note length was 1807.4±6.5 characters (P < 0.001) longer from 2014 through 2016 versus 2006 through 2010.

CONCLUSIONS

After 1 decade of use, providers spend more time using the EHR for an office visit, generate longer notes, and close the chart faster. These changes are likely to represent increased time and documentation pressure for providers. Electronic health record redesign and new documentation regulations may help to address these issues.

Impact of Electronic versus Paper-Based Recording before EHR Implementation on Health Care Professionals' Perceptions of EHR Use, Data Quality, and Data Reuse

BACKGROUND

The implementation of an electronic health record (EHR) with structured and standardized recording of patient data can improve data quality and reusability. Whether and how users perceive these advantages may depend on the preimplementation situation.

OBJECTIVE

To determine whether the influence of implementing a structured and standardized EHR on perceived EHR use, data quality, and data reuse differed for users working with paper-based records versus a legacy EHR before implementation.

METHODS

We used an electronic questionnaire to measure users' perception before implementation (2014), expected change, and perceived change after implementation (2016) on three themes. We included all health care professionals in two university hospitals in the Netherlands. Before jointly implementing the same structured and standardized EHR, one hospital used paper-based records and the other a legacy EHR. We compared perceptions before and after implementation for both centers. Additionally, we compared expected benefit with perceived benefit.

RESULTS

We received 7,611 responses (4,537 before and 3,074 after implementation) of which 5,707 (75%) were from professionals reading and recording patient data. A total of 975 (13%) professionals responded to both before and after implementation questionnaires. In the formerly paper-based center staff perceived improvement in all themes after implementation. The legacy EHR center experienced deterioration of perceived EHR use and data reuse, and only one improvement in EHR use. In both centers, for half of the aspects at least 45% of responders experienced results worse than expected preimplementation.

CONCLUSION

Our results indicate that the preimplementation recording practice impacts the perceived effect of the implementation of a structured and standardized EHR. For almost half of the respondents the new EHR did not meet their expectations. Especially legacy EHR centers need to investigate the expectations as these might be different and less clear cut than those in paper-based centers. These expectations need to be addressed appropriately to achieve a successful implementation.

Nurses’ Experience With Health Information Technology: Longitudinal Qualitative Study

Background

Nurses are the largest group of health information technology (HIT) users. As such, nurses’ adaptations are critical for HIT implementation success. However, longitudinal approaches to understanding nurses’ perceptions of HIT remain underexplored. Previous studies of nurses’ perceptions demonstrate that the progress and timing for acceptance of and adaptation to HIT varies.

Objective

This study aimed to explore nurses’ experience regarding implementation of HIT over time.

Methods

A phenomenological approach was used for this longitudinal qualitative study to explore nurses’ perceptions of HIT implementation over time, focusing on three time points (rounds) at 3, 9, and 18 months after implementation of electronic health records and bar code medication administration. The purposive sample was comprised of clinical nurses who worked on a medical-surgical unit in an academic center.

Results

Major findings were categorized into 7 main themes with 54 subthemes. Nurses reported personal-level and organizational-level factors that facilitated HIT adaptation. We also generated network graphs to illustrate the occurrence of themes. Thematic interconnectivity differed due to nurses’ concerns and satisfaction at different time points. Equipment and workflow were the most frequent themes across all three rounds. Nurses were the most dissatisfied approximately 9 months after HIT implementation. Eighteen months after HIT implementation, nurses’ perceptions appeared more balanced.

Conclusions

It is recommended that organizations invest in equipment (ie, wireless barcode scanners), refine policies to reflect nursing practice, and improve systems to focus on patient safety. Future research is necessary to confirm patterns of nurses’ adaptation to HIT in other samples.

What to expect from electronic patient record system implementation: lessons learned from published evidence

Background

Numerous studies have examined factors related to success, failure and implications of electronic patient record (EPR) system implementations, but usually limited to specific aspects.

Objective

To review the published peer-reviewed literature and present findings regarding factors important in relation to successful EPR implementations and likely impact on subsequent clinical activity.

Method

Literature review.

Results

Three hundred and twelve potential articles were identified on initial search, of which 117 were relevant and included in the review. Several factors were related to implementation success, such as good leadership and management, infrastructure support, staff training and focus on workflows and usability. In general, EPR implementation is associated with improvements in documentation and screening performance and reduced prescribing errors, whereas there are minimal available data in other areas such as effects on clinical patient outcomes. The peer-reviewed literature appears to under-represent a range of technical factors important for EPR implementations, such as data migration from existing systems and impact of organisational readiness.

Conclusion

The findings presented here represent the synthesis of data from peer-reviewed literature in the field and should be of value to provide the evidence-base for organisations considering how best to implement an EPR system.