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Physician Attitudes on Ease of Use of EHR Functionalities Related to Meaningful Use
Michael F. Furukawa, PhD; Jennifer King, PhD; and Vaishali Patel, PhD, MPH

Physician Attitudes on Ease of Use of EHR Functionalities Related to Meaningful Use

Michael F. Furukawa, PhD; Jennifer King, PhD; and Vaishali Patel, PhD, MPH
We assessed physician attitudes on ease of use of electronic health record (EHR) functionalities related to “Meaningful Use” and whether ease of use was associated with EHR characteristics.
Among physicians who reported adopting and using a given EHR function, the percent who reported the function was easy to use ranged from 91% (viewing laboratory results) to 49% (public health reporting). At least 75% of EHR adopters considered 10 of the 14 functions we examined as easy to use; this included functions related to documentation, ordering, viewing results, decision support, patient engagement, and clinical data exchange.

In general, the percent of physicians who considered a particular EHR function to be easy to use was higher for more commonly adopted EHR functions and lower for less commonly adopted EHR functions. For example, the percent of physicians who considered the least commonly adopted functions as easy to use, were relatively low; these included public health reporting (49%), viewing data on quality measures (63%), secure messaging with patients (68%), and reminders based on guidelines (69%).

EHR Characteristics and Perceived Ease of Use of Specific EHR Functions

Physician attitudes on ease of use of specific EHR functions varied according to some EHR characteristics (Table 4) (see also eAppendix Table [eAppendix available at www.ajmc.com]). For 12 of the 14 functions examined, physicians with EHRs that met MU criteria had 56% to 196% higher odds of reporting the EHR function was easy to use. EHR certification had the strongest association with perceived ease of use in providing reminders for guideline-based interventions or screening tests (+196% difference in the odds of ease of use) and providing patients with a clinical summary for each visit (+176%). EHR functions related to documentation and viewing clinical data showed smaller differences based on whether physicians’ EHRs met MU criteria. For example, EHR certification had no significant effect on ease of use for recording a comprehensive list of medication and allergies or viewing imaging reports.

Receipt of technical assistance from EHR vendors or RECs had some association with perceived ease of use (Table 4). For 8 of the 14 functions examined, physicians receiving technical assistance had 55% to 174% higher odds of reporting that the EHR function was easy to use. Technical assistance had the strongest relationships with ease of use of EHR functions related to public health reporting (+174%), viewing data on quality of care (+101%), and exchanging secure messages with patients (+98%).

The amount of clinical staff training had little association with perceived ease of use (Table 4). Relative to 0 to 8 hours, clinical staff training of 9 to 40 hours had no effect on perceived ease of use for any EHR functions. Training of 41 or more hours was associated with 51% to 60% lower odds of reporting that the EHR function was easy to use for 4 functions: viewing imaging reports, recording clinical notes, providing patients with clinical summaries, and recording problem lists.

Physician and Office Characteristics Associated With Perceived Ease of Use of Specific EHR Functions

With the exception of practice ownership, we found little association of physician and office characteristics with perceived ease of use that was consistent across the 14 EHR functions (see eAppendix Table). For 9 of the 14 functions examined, physicians in practices owned by a health maintenance organization (HMO) or other healthcare corporation had 125% to 494% higher odds of reporting the EHR function was easy to use compared with physicians working in physician-owned practices.

 

DISCUSSION
Using a nationally representative survey of office-based physicians conducted in 2011,1 in this study, we provide one of the first studies on the association of EHR characteristics with physician attitudes on ease of use of EHR functionalities related to MU.10,16,18,19 We found that both adoption of specific EHR functions and perceived ease of use were relatively high. In 2011, at least three-fourths of EHR adopters reported adopting and using 9 of 14 EHR functions related to MU; furthermore, at least 3 of 4 EHR adopters considered 10 of the 14 EHR functions as easy to use. However, we found that physicians considered less commonly available EHR functions as less easy to use.

We also found that some EHR characteristics were associated with physicians’ ease of using EHR functions. For 12 of the 14 EHR functions we examined, physicians with EHRs that met MU criteria were significantly more likely than physicians with other EHRs to report that EHR functions were easy to use. Technical assistance during EHR implementation played a significant, though less important, role in perceived ease of use compared with EHR certification. More clinical staff training was associated with lower ease of use for a few EHR functions. This finding might be due to the complexity of implementation, concomitant changes to practice work flow, or the possibility that physicians with less experience with EHRs required more initial training.13,23

Our findings suggest that EHR certification and implementation support might play a role in physician attitudes toward EHRs. Although concern has been expressed that EHR vendors have developed poorly designed systems,24 our findings offer preliminary evidence that EHR certification is associated with perceived ease of use. The MU criteria were selected with the goal of enabling EHRs to support improved safety, quality, and efficiency of patient care.25 MU criteria require that EHRs have the capabilities to enable the collection of important patient data, in addition to computerized ordering and clinical decision support capabilities considered critical to improving quality of care.26,27 Our findings are consistent with prior studies that found higher EHR satisfaction and greater reporting of EHR benefits among physicians using EHRs that were relatively robust or met MU criteria.10,19 Since the advent of HITECH, the number of certified EHR vendor products has increased dramatically.28 The role of certification in influencing physician attitudes toward EHRs warrants further examination.

We did find variation in perceived ease of use across EHR functions, with more physicians reporting that less common EHR functions were more difficult to use. Prior research has found that perceptions of EHR usefulness improved as users moved beyond the implementation stage and acquired more EHR experience.23,29-32 Physicians may have less experience with more novel and advanced EHR functions that involve more complex work flow such as decision support, engagement with patients, or clinical data exchange with outside providers. Perceived ease of use was lowest for EHR functions requiring external coordination, including public health reporting, secure messaging with patients, and viewing data on quality measures. Improvements in the adoption and ease of use of public health reporting functions of EHRs may hinge on improvements in state and local public health systems’ capacity to exchange data with physicians.33 Our findings suggest that technical assistance from EHR vendors or RECs may play a role in improving ease of use of some EHR functions.

Very few physician or practice characteristics were associated with perceived ease of use of specific EHR functions. Physicians in practices owned by HMOs or other healthcare corporations were more likely to consider 7 of the 14 EHR functions as easy to use. Integrated delivery systems have promoted EHRs as a critical part of patient care, and the rate of EHR adoption has been higher among these practices.21,34 The influence of delivery system organization on physician attitudes toward EHRs is an important subject of future research.

Policy Implications

Our findings have noteworthy implications for both policy and clinical practice. Usability has been emphasized as key to achieving the benefits from EHRs. However, current EHRs have been criticized as having poor usability, which can lead to unintended consequences such as inefficiency and harm to patients.5,35 Our findings suggest that certification and implementation support may play a role in physician attitudes on ease of use, particularly for functionalities newly required by the MU program.

Limitations

Our measure of EHR certification (ie, whether a physician was using an EHR that met MU criteria) was not directly validated, though our estimate was consistent with another government survey, and our findings were robust to sensitivity analyses. Additionally, we did not have data on physicians’ experience with, and actual use of, specific EHR functions, and we were unable to assess physician acceptance and satisfaction with their EHRs. Although the survey response rate was relatively high, nonresponse bias may lead to overestimates of physicians’ positive perceptions regarding ease of use. Given the cross-sectional nature of this analysis, we cannot conclude that our findings represent causal relationships, nor could we examine trends. Our findings may also partly reflect an “early adopter” phenomenon whereby physicians who are more willing to use new technology or had adopted EHRs at an earlier point in time were most likely to perceive EHRs as easy to use.11

Our study also did not address certain important topics of interest. The findings reflect physician attitudes on EHR ease of use only, and the survey did not examine actual usability and other predictors of technology acceptance (ie, usefulness, compatibility), which are opportunities for future research. Correlation of ease of use with satisfaction and impacts was beyond the scope of this study. Future research should examine the reasons why perceptions of ease of use vary across physicians (ie, user interface) and how usability of EHRs can be enhanced.3,36

CONCLUSIONS
Among physicians with any EHR, we found that adoption of specific EHR functions related to MU and perceived ease of use were generally high. Ease of use was significantly higher among physicians adopting EHRs that met MU criteria. Perceived ease of use was higher among those receiving technical assistance from EHR vendors or RECs for some, but not all, functionalities. More research to understand and improve EHR usability will be critical to ensuring HITECH goals are met.

Author Affiliations: Agency for Healthcare Research and Quality (MFF), Rockville, MD; Aledade (JK), Bethesda, MD; Office of the National Coordinator for Health Information Technology (VP), Washington, DC.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MFF, JK, VP); analysis and interpretation of data (MFF, JK, VP); drafting of the manuscript (MFF, JK, VP); critical revision of the manuscript for important intellectual content (MFF, JK); statistical analysis (MFF).

Address correspondence to: Michael F. Furukawa, PhD, Agency for Healthcare Research and Quality, 5600 Fishers Ln, Rockville, MD 20857. E-mail: Michael.Furukawa@ahrq.hhs.gov.
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