Beyond Electronic Health Record Adoption

It was with great interest that I read the recent article by Al-Rayes et al. Within the authors' institution, not all inpatient physicians have adopted a recently implemented electronic health record (EHR) system. This pilot cross-sectional quantitative study investigated the factors limiting adoption of EHR systems among physicians at King Fahd Military Medical Complex in Saudi Arabia. Using the theoretical Technology Acceptance Model, they found that to increase the EHR systems' adoption rate, the design, social influence, and perception of the system's benefits need to be improved.[1] The authors' efforts should be commended in their systematic approach to improve EHR adoption for their institution and throughout their region.

Paper-based record keeping and documentation has many disadvantages. It is not immediately available, it can be easily lost and destroyed, and is less reliable.[2] [3] In addition to enhancing the reliability of clinical documentation, EHR adoption can potentially lead to reduced human medical error, costs, and patient mortality.[4] It can also aid clinical decision making and may help in the identification and management of complex diseases.[5] [6] Overall, this has led to initiatives encouraging EHR adoption worldwide.[7] [8] [9] [10] [11] But, achieving EHR adoption may be difficult. Some of the known challenges stem from issues that Al-Rayes et al faced in their present study.[1] In addition, interoperability, usability, technical limitations, and patient acceptance also impact the facilitation of EHR adoption.[12] Identifying these barriers early on may assist in successful implementation by allowing healthcare systems to anticipate and avoid these common barriers.[12]

While the adoption of EHR systems is a priority, these are only the first steps. An examination of EHR systems postimplementation has described various effects and unintended consequences. These should not be overlooked after EHR adoption. This may include workflow interruptions, decreased efficiency in documentation, and documentation redunancy.[13] Users may develop workarounds, such as “copy-and-paste” functions, as they adapt to the new EHR system that can perpetuate redundant information and error.[13] There is a significant investment required to ensure the EHR system receives software maintenance and updates.[4] Any new clinician employed will require training to understand the current EHR and may require retraining if major updates to the software are made.[4] EHR systems are promoted to improve the quality and safety of patients, but medical errors can occur due to workflow disruption or software design flaws.[14] Thus, healthcare systems may have to establish policies and procedures to develop best EHR practices, track EHR safety events, and regularly review these events.[15] While EHR adoption is an important first step, maintenance and monitoring of an effective and an efficient EHR should also be an early objective.

Another early objective is ensuring clinician well-being. Physician burnout has become a major issue in the United States.[16] It is associated with high physician turnover, poor productivity, decreased patient satisfaction, and may compromise the quality of patient care.[16] While there are various factors attributed to physician burnout, the EHR has received increasing attention.[17] Studies examining this relationship suggest that EHR systems may be driving physicians to spend more time performing clerical tasks and documentation while spending less time with patients.[18] EHR systems may be contributing to clinician frustration as some designs are suboptimal contributing to usability issues, information, and cognitive overload.[19] Finally, the EHR may render certain processes to deliver medical care, such as simple ordering, arduous, and time-consuming.[20]

While Al-Rayes et al have determined how to facilitate EHR adoption and are rightfully focused on this initial step, the anticipation of the effects of full EHR adoption, both short-term and long-term, should also be stressed. This may require preimplementation workflow analyses to try uncover issues within clinician workflow that may continue to be present or possibly become worse postimplementation. After-hours usage has gained increasing attention in the outpatient setting and may be linked to physician burnout.[21] [22] Any facility adopting an EHR should consider assessing this possibility early on and determine if it is occurring preimplementation. If clinicians are starting to work after-hours after EHR implementation, it may lead to difficulties in EHR acceptance. An assessment of physician burnout may be need to be considered preimplementation to allow time to develop strategies to curb this possibility. Finally, a method of communication with clinicians postimplementation may be required.[15] By having an open dialogue with EHR experts, clinicians may be more open to discuss EHR issues and be willing to implement high-quality solutions.

Overall, the systematic approach to EHR adoption that Al-Rayes et al have outlined should be applauded. By increasing their understanding of the barriers to EHR adoption, they will have a higher likelihood of success. This thoughtfulness, however, should not end with EHR adoption. While there are positive aspects of EHR adoption, there could be undesirable effects. Al-Rayes et al and stakeholders involved in EHR adoption should consider being prepared for both computer and human considerations that can occur post-implementation.

• References

• 1 Al-Rayes SA, Alumran A, AlFayez W. The adoption of the electronic health record by physicians. Methods Inf Med 2019; 58 (2-03): 63-70
• 2 Raposo VL. Electronic health records: is it a risk worth taking in healthcare delivery?. GMS Health Technol Assess 2015; 11: Doc02
• 3 Ratwani R. Electronic health records and improved patient care: opportunities for applied psychology. Curr Dir Psychol Sci 2017; 26 (04) 359-365
• 4 Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy 2011; 4: 47-55
• 5 Ballard DW, Vemula R, Chettipally UK. , et al; KP CREST Network Investigators. Optimizing clinical decision support in the electronic health record. Clinical characteristics associated with the use of a decision tool for disposition of ED patients with pulmonary embolism. Appl Clin Inform 2016; 7 (03) 883-898
• 6 Murray SG, Avati A, Schmajuk G, Yazdany J. Automated and flexible identification of complex disease: building a model for systemic lupus erythematosus using noisy labeling. J Am Med Inform Assoc 2019; 26 (01) 61-65
• 7 Payne TH, Lovis C, Gutteridge C. , et al. Status of health information exchange: a comparison of six countries. J Glob Health 2019; 9 (02) 0204279
• 8 Lee Y-T, Park YT, Park JS, Yi BK. Association between electronic medical record system adoption and healthcare information technology infrastructure. Healthc Inform Res 2018; 24 (04) 327-334
• 9 Odekunle FF, Odekunle RO, Shankar S. Why sub-Saharan Africa lags in electronic health record adoption and possible strategies to increase its adoption in this region. Int J Health Sci (Qassim) 2017; 11 (04) 59-64
• 10 Blumenthal D. Launching HITECH. N Engl J Med 2010; 362 (05) 382-385
• 11 Srivastava SK. Adoption of electronic health records: a roadmap for India. Healthc Inform Res 2016; 22 (04) 261-269
• 12 Kruse CS, Kristof C, Jones B, Mitchell E, Martinez A. Barriers to electronic health record adoption: a systematic literature review. J Med Syst 2016; 40 (12) 252
• 13 Cusack CM, Hripcsak G, Bloomrosen M. , et al. The future state of clinical data capture and documentation: a report from AMIA's 2011 Policy Meeting. J Am Med Inform Assoc 2013; 20 (01) 134-140
• 14 Bowman S. Impact of electronic health record systems on information integrity: quality and safety implications. Perspect Health Inf Manag 2013; 10 (Fall): 1c
• 15 Walker JM, Carayon P, Leveson N. , et al. EHR safety: the way forward to safe and effective systems. J Am Med Inform Assoc 2008; 15 (03) 272-277
• 16 West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med 2018; 283 (06) 516-529
• 17 Murphy DR, Giardina TD, Satterly T, Sittig DF, Singh H. An exploration of barriers, facilitators, and suggestions for improving electronic health record inbox-related usability: a qualitative analysis. JAMA Netw Open 2019; 2 (10) e1912638-e1912638
• 18 Kroth PJ, Morioka-Douglas N, Veres S. , et al. Association of electronic health record design and use factors with clinician stress and burnout. JAMA Netw Open 2019; 2 (08) e199609
• 19 Khairat S, Burke G, Archambault H, Schwartz T, Larson J, Ratwani RM. Perceived burden of EHRs on physicians at different stages of their career. Appl Clin Inform 2018; 9 (02) 336-347
• 20 Baysari MT, Hardie R-A, Lake R. , et al. Longitudinal study of user experiences of a CPOE system in a pediatric hospital. Int J Med Inform 2018; 109: 5-14
• 21 Attipoe S, Huang Y, Schweikhart S, Rust S, Hoffman J, Lin S. Factors associated with electronic health record usage among primary care physicians after hours: retrospective cohort study. JMIR Human Factors 2019; 6 (03) e13779
• 22 Collier R. Electronic health records contributing to physician burnout. CMAJ 2017; 189 (45) E1405-E1406