The American Journal of Managed Care December 2015
Physician Attitudes on Ease of Use of EHR Functionalities Related to Meaningful Use
Objectives: To assess physician attitudes on ease of use of electronic health record (EHR) functionalities related to “Meaningful Use” (MU) and whether perceived ease of use was associated with EHR characteristics, including meeting MU criteria, technical assistance from EHR vendors or regional extension centers, and the amount of clinical staff training.
Study Design: A cross sectional analysis of the 2011 Physician Workflow study, nationally representative of US office-based physicians.
Methods: Cross-sectional data were used to examine physician attitudes on ease of use of 14 EHR functionalities related to MU, among physicians with any EHR system.
Results: For 11 of the 14 EHR functions examined, physicians with EHRs that met MU criteria were significantly more likely than physicians that also utilized EHR systems to report that EHR functions were easy to use. For 8 of the functions examined, physicians receiving technical assistance from a vendor or regional extension center were significantly more likely to report that the EHR function was easy to use.
Conclusions: Our study of a nationally representative survey of office-based physicians found that physicians’ adoption and perceived ease of use of EHR functionalities related to MU was generally high.
Am J Manag Care. 2015;21(12):e684-e692
- Among a nationally representative sample of office-based physicians, EHR adoption and perceived ease of use of EHR functionalities related to Meaningful Use (MU) were relatively high.
- Physicians using an EHR that met MU criteria were much more likely to report that EHR functionalities were easy to use.
- Technical assistance and training were associated with ease of use for some but not all EHR functionalities.
To achieve the aims of HITECH, it is important to understand physician attitudes toward the use of EHRs after adoption. A key factor in physician acceptance of EHRs is the extent to which users perceive the technology to be easy to use and useful in enhancing patient care.2,3 Since certification requires that functionalities meet technical standards, physician attitudes toward newer, more robust EHRs that meet MU criteria may differ from older systems. Attitudes may also depend on EHR implementation, such as receipt of technical assistance and amount of training.4 Anecdotal reports suggest growing physician dissatisfaction with the usability of EHRs,5 and physician difficulties in using EHR systems may lead to unintended consequences such as new work and safety issues.6 Thus, understanding the factors related to physician attitudes on ease of use of specific EHR functions has important clinical and policy implications.
Prior research on physician attitudes regarding EHRs has focused on the barriers and benefits of EHR adoption,7-9 satisfaction with EHRs overall10,11 and during implementation,12,13 and influences of EHR use on professional and workplace satisfaction.14-16 Fewer studies have focused on the association of EHR characteristics with ease of use related to specific EHR functions.17,18 Physician surveys from single states have found relationships between EHR robustness and physician satisfaction with EHRs overall,10,19 and a recent study using national data found that physicians using certified EHRs were more likely to report clinical benefits.20 However, these studies were limited to EHR robustness in relation to perceptions of satisfaction and usefulness, but not ease of use. Important gaps remain in our understanding of the associations between EHR characteristics with perceived ease of use, particularly for newer functionalities, such as secure messaging and public health reporting.
This study used nationally representative survey data from 2011 to examine physician attitudes on the ease of use of EHR functionalities related to MU. We also assessed whether perceived ease of use varied by EHR characteristics, including EHR certification, receipt of technical assistance from vendors or regional extension centers, and the amount of clinical staff training. Findings have important policy implications for the potential role of robustness and implementation support to influence physician attitudes on usability of some EHR functions.
The data source was the 2011 National Ambulatory Medical Care Survey (NAMCS) Physician Workflow study, the first wave of a longitudinal panel survey of US office-based physicians.1 The Physician Workflow study was conducted by the National Center for Health Statistics and collected information on physicians’ attitudes toward and experiences with EHRs across many domains. Survey content was developed with the guidance of an expert advisory panel, and separate questionnaires were developed for physicians using an EHR and physicians who had not yet adopted an EHR. Questions about ease of use of specific EHR functionalities were included on the EHR adopter questionnaire only.
The sample for the Physician Workflow study was a subset of physicians who were contacted to participate in the 2011 NAMCS Electronic Health Records Survey (NEHRS). The target universe for the NAMCS was nonfederal, office-based physicians in the United States, excluding radiologists, anesthesiologists, and pathologists. A total of 5232 physicians were sampled for the Physician Workflow study; the response rate for the 2011 survey was 61%, yielding a final sample size of 3180. This analysis was limited to respondents who used an EHR at their primary practice location in 2011 (n = 1793). Information on adoption of specific EHR functions was obtained from corresponding respondents of the 2011 NEHRS. Additional information on the survey methods is available elsewhere.1
Rates of Adoption and Physician Attitudes on Ease of Use of Specific EHR Functions
We examined rates of adoption and physician attitudes on the ease of use of EHR functionalities related to MU. Adoption of specific EHR functions was measured using a NEHRS question asking whether the physician’s reporting location had computerized capabilities for each function. Fourteen of the 16 EHR functions listed in the Physician Workflow study mapped to MU Stage 1 or Stage 2 core or menu requirements; we focused our analyses on these 14 functions.
Perceived ease of use was measured from physician responses to the question: “Please indicate your level of ease or difficulty for each EHR function.” Response categories included: “very easy,” “easy,” “difficult,” “very difficult,” and “not applicable.” Physicians were instructed to select “not applicable” if they did not have or did not use a particular EHR function. Physicians were considered as having adopted and been using a specific function if they had a response other than “not applicable” for the question about ease of use of the function. We reported on physicians’ perceived ease of use of EHR functionalities, conditional on their adoption and use of that specific function. To report on ease of use, we used dichotomous variables that combined the “very easy” and “easy” responses into 1 group and combined “difficult,” “very difficult,” and missing responses in the comparison group. Missing responses across items ranged between 1% and 13% of physicians. Because we coded missing responses as “difficult” or “very difficult” in the analysis, rather than excluding them from the denominator, the estimates of ease of use may be conservative. Results were not sensitive to the exclusion of missing responses.
EHR Characteristics Associated With Perceived Ease of Use
The study hypothesized that EHR characteristics, including certification and implementation support, would be positively associated with perceived ease of use.
To measure EHR certification, we created a dichotomous variable indicating whether or not the respondent’s EHR was certified to meet the Stage 1 MU criteria. This variable was created based on responses to the question: “Does your current system meet Meaningful Use criteria as defined by the Centers for Medicare & Medicaid Services (CMS)?” Response categories were “yes,” “no,” and “uncertain.” Physicians who answered “yes” were considered to have EHRs that met MU criteria. Of the entire sample, 8.4% answered “no,” 14.4% answered “uncertain,” and 1.4% did not answer the question. Sensitivity analyses using an alternative measure of whether physicians had 9 of the 15 computerized capabilities that compose the core MU requirements yielded similar results to the main analysis.
To measure EHR implementation support, we created variables for technical assistance from EHR vendors or regional extension centers and the amount of clinical staff training. Receipt of technical assistance was measured using the questions: “Did you receive help from EHR vendors in analyzing your practice work flow?” and “Did you receive help from regional extension centers (RECs) in analyzing your practice work flow?” Since respondents may have received assistance from both vendors and RECs, we combined “yes” responses to either question as having received technical assistance. The amount of clinical staff training was determined using the question: “How many hours, on average, did clinical staff spend in training to implement your practice’s EHR system?” To balance cell sizes, we created 3 categories for the amount of training as 0 to 8 hours (combining responses “1 to 8 hours” and “did not receive training”), 9 to 40 hours, and 41 or more hours (combining “41 to 80 hours” and “over 80 hours”).
In multivariate analyses, we included additional controls for physician (age, specialty) and office characteristics (size [number of physicians], ownership, practice type, metropolitan status, region) that have been associated with EHR adoption and physician attitudes toward EHRs in previous research (listed in Table 1).21,22
Univariate descriptive statistics were calculated to describe the percent of physicians that adopted specific EHR functions, and among EHR adopters, the percent of physicians who reported the EHR function was easy to use (either “very easy” or “easy”). Multivariate logistic regression analyses were used to examine whether perceived ease of use varied by EHR characteristics while controlling for other physician and office characteristics. All analyses were conducted using Stata version 11.2 software (StataCorp LP, College Station, Texas) using weights to account for nonresponse and adjusting standard errors for the complex survey design of the data.
Using a nationally representative sample of EHR adopters, more than three-fourths (76%) reported that their EHR met MU criteria (Table 2). Fewer than half (45%) of EHR adopters reported the receipt of technical assistance with analyzing practice work flow from EHR vendors or RECs. About 1 in 5 (22%) physicians with any EHR received 41 or more hours in clinical staff training to implement their EHR system.
Adoption and Perceived Ease of Use of EHR Functionalities Related to Meaningful Use
Among physicians that had adopted an EHR, physicians’ rate of adopting and using 14 EHR functions related to MU ranged from 98% (recording a comprehensive list of medications and allergies) to 40% (public health reporting) (Table 3). Overall, at least 75% of EHR adopters reported adopting and using 9 of the 14 EHR functions we examined. Functions related to documentation had the highest rates of adoption and use; exchanging secure messages with patients and public health reporting had the lowest adoption rates.