Following on from our deep dive last month in which we explored electronic health records in Africa, today we’re turning the spotlight on the United States and taking a look at two studies to gain insights on trends in EHR usage, and to examine the how clinicians perceive the impact of EHR on their roles, delivery of healthcare, and patient safety.
Frequency and diversity of EHR use in the US
A study published last summer through the National Library of Medicine explores the use of electronic health records in the United States by performing an analysis of national surveys, with the aim of examining trends in EHR use, and exploring the effects of three health-related factors and three technology-related enablers on EHR use (perceived health status, self-efficacy in health management and doctor-patient communication, and access to digital devices, access to the internet, and perceived usefulness of EHRs, respectively).
The researchers analysed “nationally representative samples” from the 2017, 2018 and 2019 iterations of the Health Information National Trends Survey (HINTS) as the basis for their study, using a sample of over 12,000 respondents in total, and found that both frequency and diversity have slightly increased over the years, though “overall usage remained low”. They identified that the three technology-related enablers were “positively related to EHR usage” in all three studies, whilst perceived health status “was a constant and negative predictor of EHR usage over years”. However, doctor-patient communication had a positive association with frequency of EHR usage in two of the surveys.
The study came about as a result of the research team identifying that whilst plenty of research has analysed EHR usage in different healthcare settings, “limited research has explored how different types of factors contribute to EHR usage”. This research has tended to focus on socio-demographic characters, the researchers explain, adding: “Although useful, a more theoretical and in-depth understanding of why these individual differences matter is needed.”
Results showed that 30 percent of respondents reported accessing their EHR at least one to two times in the past 12 months, with the rate increasing to 31.4 percent in 2018 and 38.8 percent in 2019. “Similarly, the average diversity of EHR usage also had a small but steady rise during the three years,” the authors write; 4.4 percent of respondents reported using two functions of the EHR in 2017, compared to 5.6 percent in 2018 and 6.7 percent in 2019.
Looking at factors associated with frequency and diversity of EHR use, the study found that participants falling into the categories of female, white people of an older age, higher education and higher household income were more likely to use their EHR frequently, and females of an older age along with those of a higher education and household income were more likely to use diverse functions.
With regards to the three health-related factors (perceived health status, self-efficacy in health management and doctor-patient communication), the researchers found that perceived health status was negatively associated with EHR usage across all three surveys; “in other words, the poorer health, the more frequent and diverse use of EHRs”. The study suggests that this could be due to people with chronic disease who have a need to conduct medical tests periodically and use a variety of services in the EHR to track medical records and seek information; another reason could be that people of a perceived low health status could be prompted by anxiety to use EHRs for self-management.
In two of the surveys, perceived high-quality doctor-patient communication was found to increase frequency of EHR usage, with the researchers stating: “A positive communicative experience with doctors can enhance patients’ trust toward the healthcare system, where EHRs have offered a new approach to delivering health services.” In addition, they suggest that “patient trust built upon quality medical communication” could be a “key driver of subsequent EHR adoption.”
Looking at the technology-related factors (access to digital devices, access to the internet, and perceived usefulness of EHRs), the researchers confirm that these were “significant predictors of EHR usage over time”, particularly access to the internet and digital devices. “In addition, we found that the perceived usefulness of EHRs had a significant effect on EHR usage,” the study notes. “This is consistent with the technology acceptance model, which states that when people view a particular technology as useful and beneficial, they would have a favourable attitude toward the technology, leading to greater use of it.”
Overall, the researchers state, the study “demonstrates the discrepancy between access to EHR provided to the public and the actual use of it”. They add that although there have been “many national initiatives” to facilitate EHR adoption, “the low adoption of EHRs might suggest that individuals’ barriers or concerns regarding EHR use were not effectively addressed by past health education and promotion efforts.”
The study shares a number of practical implications. For example, the researchers say, it is “critical” to promote online health services via multiple communication channels, including communications directly from healthcare providers and through mass media campaigns, along with targeted intervention programmes. The importance of tackling digital exclusion is raised, and the researchers also “advocate for more patient-centred communication training in medical education as well as continuing education for health professionals” so that the doctor-patient relationship can support EHR adoption. Another implication notes that when designing an EHR system, health informatics professionals should work out the functions or services that could be useful to potential users through formative research to understand target audience preferences and barriers. Finally, the researchers call for regulatory initiatives to better promote EHR adoption, emphasising that focus should be placed on addressing dat security concerns and stricter law enforcement to prevent disclosure of patient data to unauthorised parties.
The study can be accessed in full here.
Citation: Zheng H, Jiang S. Frequent and diverse use of electronic health records in the United States: A trend analysis of national surveys. Digit Health. 2022 Jul 6;8:20552076221112840. doi: 10.1177/20552076221112840. PMID: 35832476; PMCID: PMC9272053.
US clinician perceptions of EHR
In another study published in Sage Journals, researchers undertook a qualitative analysis of the perceived impact of EHR on healthcare quality and safety, by examining the lived experiences of clinicians from Nevada and California.
For the purposes of the study, the research team gathered input from physicians, hospitalists, nurse practitioners, nurses and patient safety officers. Overall, they found mixed perspectives on EHR;
Nurses said that EHR makes their work more efficient by enabling them to review patient history before seeing the individual; they liked the usage of abbreviations to make documentation “more effective”, and also commented positively on the ability to check side effects and clarify notes with physicians before administering medication. In terms of challenges, nurse feedback indicated issues with accuracy and a perceived risk that patient notes could be “just copied and pasted from one shift to the next” and as such “may not represent accurate patient information”.
Physicians said that implementing an EHR can help to improve care quality and patient safety through the provision of reminders and alerts; they also praised how the EHR enables reporting of adverse events, and said that it is “easier to find patient data and easier to read their information clearly”. However, they believed that the EHR takes time away from patient care, and said that the lack of a national and integrated EHR makes the experience “very fragmented”.
Patient safety officers liked the fact that doctors notes and patient history are included within an EHR from a safety perspective; but they said that EHR creates an issue in quality of care as it can be difficult to extract data and too much time is spent on documentation. They also said that they find the experience fragmented.
Hospitalists said that EHR reduces the time they have to spend on paper documentation, and praised the ability to gather large amounts of data from the system for research and analysis. However, they said: “It takes time to get used to the EHR system and requires plenty of documentation, making EHR less efficient.”
Finally, nurse practitioners were positive about how EHR “promotes an understanding of the doctor’s plan in real-time” and also liked the audit and compliance elements to help detect medical errors in real-time. On the challenges side, they noted that the software can be “extremely slow and slows down clinicians’ practice”, leading to longer waiting times for patients. They also said that “EHR has become more complex over time, and completing EHR documentation makes them exhausted”.
The main themes from interviews indicated that EHR training is “superficial and of insufficient duration”; and that EHR documentation can “consume time away from patients”, with some noting that “excessive documentation and regulatory requirements” leads to fatigue. They added that EHR complexity can make them feel that they spend more time clicking buttons than engaging in conversations with patients.
However, respondents said that EHR “assists with clinical activities by preventing important information from being lost and allowing the flexibility to accomplish documentation needs even while being away from a clinic”, and that it helps clinicians to keep organised by “providing them with a systematic way of recording patient information”. They also praised the fact that EHR makes it “easier to read clearly and find pertinent data”, and liked having a central system of patient records which provides a more comprehensive clinical history of patients.
Overall, the researchers said, clinicians’ experience using EHR was positive. Based on the findings, they noted that “data accuracy could be a key in EHR implementation outcomes, in terms of healthcare quality and safety. Every clinician, including physicians and nurses, must enter the notes accurately; the subsequent medical decisions and medication administration can be made correctly based on the prior note history.”
The study goes on to offer practical suggestions for EHR redesign along with suggested improvements for the implementation progress. They state that EHR systems “should be resigned to reduce the learning curve”, and functions for documentation should be enhanced to minimise data entry errors and track changes in patient notes. In addition, more training should be offered, and “the physical environment for using EHR should also be updated to lessen interference clinicians’ interactions with patients.”
Citation: 1. Upadhyay S, Hu H. A Qualitative Analysis of the Impact of Electronic Health Records (EHR) on Healthcare Quality and Safety: Clinicians’ Lived Experiences. Health Services Insights. 2022;15. doi:10.1177/11786329211070722
