Keywords electronic health records - satisfaction - usability - user experience - practice
setting
Background and Significance
Background and Significance
Surgery accounts for a vast swath of health care services. In 2014, 14.1 million inpatient
procedures were performed in the United States, accounting for 28.6% of all hospitalizations.[1 ] In 2019, 15.7 million ambulatory procedures occurred in hospital-owned facilities
with additional procedures performed in physician-owned centers.[2 ] Although most patients recover well, these procedures can generate significant morbidity
and cost. As many as 5% of outpatient surgeries result in unplanned hospital visits.[3 ] Meanwhile, 10% of patients undergoing major inpatient surgery are readmitted.[4 ] In total, surgery accounts for 50% of Medicare expenditures.[5 ]
In 2009, the Health Information Technology for Economic and Clinical Health Act promoted
the adoption and meaningful use of health information technology (IT).[6 ] Since then, the adoption of electronic health records (EHRs) has increased dramatically.[7 ]
[8 ]
[9 ] Now that EHRs have become widespread, attention has shifted toward leveraging the
EHR to improve health care delivery. Already, hospitals use EHR data to guide care
delivery, particularly for quality improvement and patient safety.[10 ] Yet, the EHR's impact on outcomes has been mixed with growing recognition that EHR-based
tools and interventions need to be more user-centered to facilitate implementation
and effectiveness.[11 ]
[12 ]
[13 ]
[14 ] Most of this work has focused on primary care or medical physicians. However, surgeons
and surgical care are inherently different as they are more episode and procedure
based. Prior studies have characterized differences in EHR adoption among nonsurgical
and surgical specialties and differences in time and usage patterns.[9 ]
[15 ]
[16 ]
[17 ]
[18 ]
[19 ]
[20 ]
[21 ]
[22 ]
[23 ] Very few though have investigated surgeon perceptions of the EHR or the underlying
reasons (e.g., clinical practice, culture) for their experience.[24 ]
[25 ]
Objective
Therefore, efforts to improve quality and efficiency in surgery through the EHR require
greater contextual detail. Accordingly, we conducted a mixed methods study in urology—a
diverse surgical specialty that covers the breadth of modern surgical care (e.g.,
office-based, endoscopy, ambulatory, minimally invasive, and open surgery)—to characterize
current usage patterns and uncover underlying perceptions. This information may inform
more usable and useful EHR-based tools to improve care in surgery.
Methods
Study and Survey Design
To assess the use and perceptions of the EHR, we performed a sequential explanatory
mixed methods study that connected and integrated a national survey with qualitative
interviews from practicing urologic surgeons.[26 ] The national survey was administered through the 2019 American Urological Association
(AUA) Census from May to September 2019 followed by qualitative interviews conducted
from June to July 2020. The AUA Census is a large-scale, electronic survey of the
urologic workforce conducted annually. It encompasses core questions on demographics
(e.g., gender, race/ethnicity, and geography), training/experience (e.g., specialty/subspecialty,
years in practice, and fellowship), and clinical practice (e.g., practice type/size,
ownership, patient volume, major inpatient cases, and work effort), and it provides
sampling weights for national estimates. The AUA Census begins with onsite administration
at the AUA Annual Meeting followed by email invitations every 4 to 6 weeks. Token
incentives (e.g., t-shirts and raffle items) are given to promote participation.
In the 2019 AUA Census, practicing urologic surgeons reporting the use of an EHR completed
supplemental questions on EHR use and perceptions adapted from the National EHR survey.
The National EHR Survey is conducted annually by the National Center for Health Statistics
on behalf of the Office of the National Coordinator for Health Information Technology
and has been shown to have content validity through cognitive interviewing.[18 ] Respondents were asked to select which of nine specific EHR functions they use “regularly”
([Fig. 1 ]) and were also provided an open text field to add additional functions. On a 5-point
Likert scale (1: strongly disagree to 5: strongly agree), respondents also rated their
agreement with two statements: (1) using the EHR increases clinical efficiency and
(2) the EHR helps me deliver better patient care.
Fig. 1 Routine use of EHR functions—individual and cumulative. Figure displays the percent
reporting routine use of individual EHR functions. Cumulative use is the percent using
the individual function and preceding ones. Tables report use by years in practice
and practice type. Population estimates and 95% confidence intervals generated from
sampling weights based on gender, geographic location, certification status, and years
since initial certification.
Connection and Qualitative Interviews
Building upon the survey, we developed an interview guide based on conceptual frameworks
in medical decision-making, clinical informatics, and implementation science to explore
two primary topic areas: (1) surgical decision-making and (2) EHR-based clinical decision
support (https://www.med.unc.edu/urology/wp-content/uploads/sites/637/2022/12/Interview-Guide.pdf ). The interview guide was iteratively refined through two pilot interviews to ensure
that it would elicit detail and insight from participants in the allotted time. Specific
to the EHR, participants were asked about their experiences with the EHR and the effects
on clinical efficiency and patient care. Trained qualitative researchers with extensive
experience facilitating conversations with health care stakeholders conducted the
interviews.
Among AUA Census respondents who consented to follow-up contact (62.9%), we completed
25 qualitative interviews by telephone, each lasting approximately 45 minutes. Participants
provided verbal informed consent and received a $100 gift card upon completion. An
unadjusted analysis of the survey data indicated relationships between EHR use/perceptions
and years in practice and weekly patient encounters. Connecting these preliminary
results, we randomly sampled urologists based on these attributes (<18 vs. 18+ years
in practice, <75 vs. 75+ patient encounters/week). Nearing theme saturation by interview
18, we then purposively sampled urologists with negative attitudes to capture diverse
views with secondary consideration given to gender, geography, and practice type.
By interview 25, the qualitative interviewers no longer elicited new information,
indicating theme saturation.
Data Analysis and Integration
For the survey questions, a standard poststratification weighting technique was applied
based on gender, geographic location, certification status, and years since initial
certification to generate summary statistics. For clinical efficiency and patient
care, we created a net favorability rating defined as the difference between the proportion
agreeing minus the proportion disagreeing. Next, we created binary measures for EHR
use (above the median number of functions vs. not), clinical efficiency (strongly
agree/agree vs. not), and patient care (strongly agree/agree vs. not). For each outcome,
we performed bivariable analysis with chi-squared testing and built multivariable
logistic regression models to identify relating characteristics. Covariates included
years in practice, gender, race (white vs. nonwhite), fellowship training, AUA section,
rurality, scope of practice (general vs. subspeciality), practice setting (solo, urology
group, multispecialty, private hospital, academic medical center, public, and other),
ownership status, practice size, patient encounters/week, minutes/visit, major inpatient
cases/month, clinical hours/week, and nonclinical hours/week.
All interviews were recorded, transcribed, and deidentified. Transcripts were imported
into Dedoose, a qualitative research software management tool, to facilitate analysis.
Based on the interview guide and field notes, we developed a codebook and then pilot
tested it by independently coding several transcripts, which led to fine-tuning concept
definitions and revising decision rules. The research team then applied the resulting
codebook (https://www.med.unc.edu/urology/wp-content/uploads/sites/637/2022/12/ACS-Codebook.pdf ) to the remaining interview transcripts, capturing emerging themes and reconciling
discrepancies through discussion and consensus. Standard consensus coding procedures
were followed.[27 ] The study team generated code reports for each code and crafted narrative summaries
describing themes and subthemes along with illustrative quotes. Finally, we integrated
quantitative and qualitative findings to gain deeper insight into EHR use and perceptions.
This was completed iteratively through the use of a weaving narrative and joint displays
linking survey responses to qualitative themes. This analysis focuses on codes and
themes specific to the EHR.
This study received approval from the UNC Institutional Review Board (IRB# 18-3166).
The survey questions underwent additional clearance through AUA statistical services.
Statistical analyses were performed using SAS v9.4 (Cary, NC) with significance set
at the 0.05 level.
Results
Electronic Health Records Usage
In total, 2,081 of 2,159 (96.4%) practicing urologic surgeons completing the AUA Census
reported using an EHR and completed the supplemental questions (weighted sample n = 12,366). Characteristics of survey respondents and interview participants are reported
in [Table 1 ]. [Fig. 1 ] depicts the use of EHR functions. Nationally, urologic surgeons used a median of
six functions (95% CI = 5.8–6.1) with 90.6% (95% CI = 89.0–91.2%) using the EHR for
charting, reviewing results, and order entry. Most urologic surgeons made use of information
exchange functions, ranging from 59.0% (95% CI = 56.6–61.5%) for exchanging messages
with patients to 79.6% (95% CI = 77.6–81.6%) for communicating with health care providers
internally, though this varied with years in practice and practice type ([Fig. 1 ]). Less than half regularly made use of pop-up alerts (43.4%, 95% CI = 41.0–45.9%)
or reported data to clinical registries (28.4%, 95% CI = 26.2–30.5%). Additional functions
reported include billing, scheduling, research/quality improvement, and clinical reminders.
Table 1
Characteristics of survey respondents and interview participants
Covariate
Level
Surveys (N = 12,366)
Interviews (N = 25)
Years in practice, median (interquartile range)
19.4 (7.7–32.0)
15 (6-21)
Gender
Male
89.7% (88.4–91.1)
64%
Female
10.3% (8.9–11.7)
36%
Race
White
79.4% (77.4–81.4)
80%
All other races
20.7% (18.7–22.7)
20%
AUA section
North Central
18.6% (16.7–20.6)
16%
South Central
14.0% (12.3–15.7)
4%
Mid-Atlantic
10.2% (8.7–11.7)
20%
Northeastern
3.7% (2.8–4.5)
8%
New England
5.7% (4.6–6.7)
4%
Western
18.8% (16.8–20.7)
16%
Southeast
21.3% (19.4–23.3)
32%
New York
7.8% (6.4–9.2)
0%
Fellowship
Yes
39.5% (37.1–41.8)
56%
No
60.5% (58.2–62.9)
44%
Clinical scope
General
58.3% (55.9–60.7)
48%
Subspecialty
41.7% (39.3–44.1)
52%
Rurality
Metro
90.0% (88.5–91.5)
92%
Rural
10.0% (8.5–11.5)
8%
Ownership
Employed
61.7% (59.3–64.1)
72%
Any
38.3% (36.0–40.7)
28%
Practice type
Academic
28.7% (26.5–30.9)
36%
Multispecialty
14.4% (12.8–16.1)
12%
Private hospital
8.0% (6.6–9.4)
8%
Urology group
30.0% (27.8–32.2)
20%
Solo practice
7.0% (5.6–8.3)
8%
Public
8.6% (7.1–10.0)
8%
Other
3.4% (2.5–4.4)
8%
Practice size, median (interquartile range)
6.1 (2.3–14.5)
10 (3–29)
Major inpatient cases/month, median (interquartile range)
4.5 (1.3–9.6)
6 (3–16)
Patient encounters/week, median (interquartile range)
69.5 (48.6–99.1)
70 (40–90)
Minutes/visit, median (interquartile range)
14.6 (11.3–19.3)
15 (10–20)
Clinical hours/week, median (interquartile range)
49.1 (35.0–59.2)
45 (35–60)
Nonclinical hours/week, median (interquartile range)
4.9 (1.8–9.9)
10 (4–20)
Joint Display 1: perceptions of the EHR
Survey question
Survey response
% (95% CI)
Qualitative themes and exemplar quotes
Improve clinical efficiency
Strongly agree
13.3 (11.6–15.0)
Information management–access to data
“You can see records from a long time ago, and so I think that's a positive of electronic
health records. We have it all there at our fingertips. I can see more records from
outside hospitals, which is also great.”
Information management–information overload
“The other problem is you've got like 1,000 notes. You can't read all thousand notes.
You got to figure out where is the information that you actually require in here.
That can be really difficult to find.”
Administrative burden
“I spend way too much time [on] unimportant things. If it won't affect my clinical
management or recommendation, it won't affect the medical care of that patient that
I have to spend time either after hours, between patients, making sure that my computer
chart is correct.”
Agree
22.5 (20.5–24.6)
Neutral
16.8 (15.0–18.6)
Disagree
22.2 (20.2–24.2)
Strongly disagree
25.2 (23.1–27.4)
Better patient care
Strongly agree
15.2 (13.4–16.9)
Patient safety
“I hate it, but then again, the occasional pop-up that says, 'Oh, this patient is
deathly allergic to the drug you're trying to write for 'em.' It's like, I'm glad
I got this electronic policeman here. It has its benefits.”
(Not) practicing at top of license
“It dummies down the providers a bit. You want everybody to work at their highest
level, and I think that physicians were lowered...We're answering emails. We're looking
at inboxes…We didn't go to medical school to click boxes.”
Patient-provider interaction
“I know a lot of people are doing their notes while they talk to the patients, but
I think it distracts from your attention to them…I hear so many patients complain,
'Oh, my gosh. He doesn't even look up anymore,'…I think it takes a little bit away
from the interaction.”
Agree
27.9 (25.7–30.1)
Neutral
23.5 (21.4–25.6)
Disagree
17.5 (15.6–19.4)
Strongly disagree
15.9 (14.1–17.6)
Abbreviations: AUA, American Urological Association; CI, confidence interval; EHR,
electronic health record; OR, odds ratio.
Electronic Health Record Impact on Clinical Efficiency
Joint Display 1 conveys the reported impact of the EHR on clinical care alongside
qualitative themes and exemplar quotes. Overall, 35.8% (95% CI = 33.5–38.2%) of urologic
surgeons agreed that using the EHR increases clinical efficiency, while 47.4% (95%
CI = 45.0–49.9%) disagreed, resulting in a negative net favorability rating of −11.6%.
Qualitatively, interview participants focused on information management (access to
data vs. information overload) and administrative burden. The EHR enables greater
access to data (e.g., notes, results, and medications) across different encounters
and providers and through interoperability (e.g., data from external settings) that
facilitates information gathering. Additionally, participants voiced appreciation
for enhanced connectivity (e.g., at home and mobile device) that allows for more timely
and convenient access with reduced effort.
“Now it's very efficient…On the phone, I can do most things, look at x-rays from the
ER, things like that. It's really saved me a lot of time.”
However, the expanded, templated, and often redundant documentation to meet billing
requirements can result in information overload that renders the EHR incoherent and
cumbersome to use. Participants described a “sea of superfluous” documentation arising
from pages of copied information. As an additional subtheme, participants highlighted
the nonintuitive design of the EHR that further exacerbates this problem.
“I feel like I could be far more efficient if I could just do it on paper in a simpler
format… Every EHR I've ever used organizes things in a nonintuitive way… you're having
to navigate through all these screens to try to find the last message or the last
lab result.”
Furthermore, participants described an overarching sense of administrative burden.
Participants referenced the innumerable, clerical tasks that slow each clinical encounter
and negate other efficiency gains. In addition to the voluminous documentation and
nonintuitive design, participants listed closing encounters, scheduling visits, applying
codes, managing inboxes, answering messages, clicking boxes, and toggling tabs that
require extra effort and time. As one participant voiced, “I'm not an Epic-input specialist.
I'm a physician.”
Electronic Health Record Impact on Patient Care
In contrast, more urologic surgeons agreed (43.1% [95% CI = 40.6–45.5%]) that the
EHR helps them deliver better patient care than disagreed (33.4% [95% CI = 31.1–35.7%])
with a positive net favorability of +9.7%. As reported in [Joint Display 1 ], this positive outlook relates qualitatively to patient safety and the avoidance
of adverse events due to systems within the EHR. Participants also highlighted the
benefit of having more complete information when providing recommendations or treatment.
Despite these benefits, participants found poor information management to be harmful,
citing how excessive and disorganized documentation can lead to missed or incorrect
information and worse patient care.
“On some level, [it's] good. When I write prescriptions, it all goes through Epic.
It automatically checks my prescriptions against everything else they have…It lets
me see things from other doctors' offices. In the old days, somebody would be treating
something for one thing. You'd be treating for another. You'd never know that you
were having this issue or crossing over. The flip side is there's so much information
that sometimes it's hard to pull out the important stuff…because of that people can
miss things.”
Related to administrative burden, participants voiced frustration over how the EHR
prevents them from “practicing at the top of license” and interferes with patient-provider
interactions. Compared to pre-EHR, participants spent much more time performing tasks
that could be completed by other staff. As a result, some expressed a sense of “lowering”
with less time to practice medicine. At a more basic level, participants described
significant disruptions in their interactions with patients and voiced concerns about
how this affects patient perceptions, rapport, and trust. As one participant noted,
“we treat the chart more than the patient.”
Factors Influencing Electronic Health Record Use and Perceptions
Finally, EHR use and perceptions varied by several factors. [Table 2 ] reports the results from the multivariable analyses. Use and perceptions differed
significantly based on practice setting (e.g., type, size, and location) with years
in practice as a significant determinant for clinical efficiency and patient care.
[Joint Display 2 ] stratifies net favorability ratings by these factors superimposed with related themes.
More recent surgeons rated the EHR more favorably, explaining how the EHR was part
and parcel of their medical training. Several used multiple different systems from
the beginning of their training so felt less daunted and more prepared for using and
optimizing the EHR for practice. In contrast, participants with more years in practice
described a steep “learning curve” with feelings ranging from excitement to resignation.
Table 2
Respondent characteristics and EHR use and perceptions (multivariable regression results)
Seven or more EHR functions
Improve clinical efficiency
Better patient care
Variable
OR (95% CI)
p -Value
OR (95% CI)
p -Value
OR (95% CI)
p -Value
Years in practice (5-y increments)
0.96 (0.92–1.00)
0.065
0.94 (0.89–0.98)
0.005
0.92 (0.88–0.96)
<0.001
Gender—female
1.05 (0.75–1.47)
0.768
0.91 (0.65–1.27)
0.559
0.99 (0.71–1.38)
0.935
Race—all other races
1.02 (0.79–1.32)
0.880
1.43 (1.10–1.86)
0.007
1.27 (0.98–1.64)
0.066
AUA section
North Central
1.29 (0.93–1.79)
0.122
1.25 (0.89–1.78)
0.201
1.66 (1.20–2.32)
0.003
South Central
1.29 (0.91–1.82)
0.155
1.34 (0.94–1.91)
0.833
1.30 (0.92–1.84)
0.136
Mid Atlantic
1.46 (0.99–2.15)
0.056
1.66 (1.11–2.49)
0.014
1.71 (1.15–2.54)
0.008
Northeastern
1.02 (0.60–1.74)
0.934
1.20 (0.69–2.08)
0.519
1.40 (0.81–2.41)
0.231
New England
1.49 (0.93–2.40)
0.096
1.78 (1.12–2.84)
0.015
1.21 (0.76–1.90)
0.422
Western
1.34 (0.97–1.87)
0.078
1.23 (0.88–1.73)
0.230
1.47 (1.06–2.05)
0.022
Southeast
Ref
Ref
Ref
New York
0.59 (0.37–0.95)
0.029
1.81 (1.15–2.83)
0.010
1.39 (0.89–2.17)
0.151
Fellowship—yes
0.95 (0.70–1.28)
0.721
1.25 (0.91–1.71)
0.173
1.01 (0.74–1.36)
0.973
Clinical scope—subspecialty
1.15 (0.83–1.60)
0.402
0.73 (0.53–1.01)
0.060
1.03 (0.75–1.41)
0.866
Rurality—rural
1.02 (0.71–1.47)
0.917
1.57 (1.04–2.36)
0.030
1.36 (0.93–2.00)
0.113
Ownership—any
0.73 (0.56–0.97)
0.027
0.98 (0.74–1.29)
0.877
0.82 (0.62–1.08)
0.150
Type
Academic
1.56 (1.07–2.28)
0.021
1.17 (0.80–1.71)
0.414
1.48 (1.01–2.16)
0.044
Multispecialty
1.80 (1.28–2.52)
<0.001
1.21 (0.86–1.71)
0.277
1.48 (1.06–2.07)
0.021
Private hospital
1.18 (0.74–1.88)
0.478
1.03 (0.62–1.72)
0.902
1.05 (0.65–1.71)
0.841
Urology group
Ref.
Ref.
Ref.
Solo practice
0.99 (0.58–1.69)
0.978
1.53 (0.92–2.57)
0.104
1.47 (0.88–2.45)
0.141
Public
0.75 (0.47–1.20)
0.237
1.55 (0.95–2.51)
0.078
1.58 (0.98–2.56)
0.061
Other
1.81 (1.00–3.29)
0.125
1.97 (1.06–3.67)
0.033
2.07 (1.13–3.80)
0.019
Practice size
1.02 (1.01–1.03)
<0.001
1.01 (1.00–1.02)
0.071
1.01 (1.00–1.02)
0.019
Major inpatient cases/month
1.00 (0.99–1.02)
0.551
1.01 (1.00–1.02)
0.152
0.99 (0.98–1.01)
0.278
Patients encounters/week
1.00 (1.00–1.01)
0.072
1.00 (1.00–1.00)
0.685
1.00 (1.00–1.00)
0.924
Minutes/visit
1.01 (0.99–1.02)
0.621
1.01 (0.99–1.03)
0.204
1.01 (1.00–1.03)
0.157
Clinical hours/week
1.01 (1.00–1.01)
0.055
0.99 (0.99–1.00)
0.006
1.00 (0.99–1.00)
0.397
Nonclinical hours/week
1.00 (0.99–1.01)
0.945
0.99 (0.98–1.00)
0.101
0.99 (0.98–1.00)
0.140
Joint Display 2—EHR perceptions by key characteristics
Key characteristics
Perceived impacta (quantitative)
Themes with exemplar quotes (qualitative)
Clinical efficiency
Patient care
Overall
−11.6%
+9.7%
Years in practice
≤10
+7.5%
+29.9%
EHR exposure/adoption
Early exposure: “VA had one EHR, clinical setting had Epic, [hospital] had Cerner. To me, I've always
had to use a bunch. I'm not stressed out about it. My partners hate it. All the younger
ones can handle…”
Later adoption: “I'd just say I remember when EHRs first came out, there was a little bit of pushback.
I mean, there were docs who refused…and they would fight it for years and years, and
they got left behind”
11–20
−11.2%
+12.3%
21–30
−28.0%
−7.5%
>30
−20.8%
−1.8%
Practice size
<5
−16.4%
+0.3%
Infrastructure
Fragmented: “In the office, we use UroChart. Two hospitals, Epic, then one is Cerner or PowerChart
or something like that. It would be really nice if I could use at least one of my
hospital's EHRs.”
Integrated: “I think it's a dramatic improvement. We literally had seven computer systems we had
to go through. It was a nightmare trying to coordinate all that stuff. At least everything's
collated in one system now.”
Support
External support: “Epic requires the use of scribes in our clinics. I would say it's significantly decreased
our efficiency and increased our overhead...If it was stand-alone, we would never
use that product. It's just not cost-effective for a private practice.”
System optimization: “What I do use is a lot of templates. My documentation and order sets are so well
fine-tuned that I really have very minimal to fill in…It's just a lot of simple things
to prompt myself through, so my documentation time is very quick because of that.”
≥5
−8.6%
+15.5%
Practice type
Academic
−9.5%
+22.7%
Multispecialty
−6.5%
+16.0%
Public
−2.4%
+20.6%
Private hospital
−18.7%
−0.1%
Urology group
−19.7%
−5.5%
Solo practice
−11.2%
−4.7%
Rurality
Urban
−9.2%
+11.8%
Rural
−33.1%
−9.4%
Abbreviations: AUA, American Urological Association; CI, confidence interval; EHR,
electronic health record; OR, odds ratio.
EHR use and perceptions also differed between larger, more integrated, higher-resourced
systems (e.g., academic, multispecialty groups, and public and private systems) and
smaller, private practices, due likely to infrastructure and support. Some participants
described their use of multiple and separate EHR systems, operational differences
between systems, and the inefficiency this fragmentation brings compared to a single
EHR system. With respect to support, participants across practice settings highlighted
ongoing disruptions with system updates and the need to optimize within the EHR (e.g.,
templated notes, order sets) or rely on external support (e.g., medical scribes, dictation/transcription)
to overcome challenges and maintain clinical productivity. Yet, those in smaller,
private practices expressed added concern about the cost and overhead of these services.
Discussion
The near-universal adoption of EHRs in the United States has led to widespread changes
in the practice of medicine. While this has been described broadly, surgeons have
a specialized clinical workflow that combines patient care and procedures across multiple
settings that may affect how the EHR can be leveraged to improve surgical quality.
In this mixed methods study, we found that urologic surgeons use a multitude of EHR
functions and feel that the EHR improves patient care. However, the negative impact
on clinical efficiency continues to be an ongoing challenge and primarily relates
to information management and administrative burden. This study also uncovers an emerging
digital divide based on years in practice and lower versus higher-resourced settings
that could limit the implementation and scalability of EHR-based tools.
While some negative sentiment persists, these data underscore the ubiquitous nature
of EHR systems and growing acceptance. In the 2014 National EHR Survey, 78% of surgical
specialists had adopted an EHR and 47% used all basic functions (i.e., prescription
order entry, record clinical notes/medications/allergies/problem lists, and view laboratory
results).[28 ] That same year, in another national survey of physicians, 23% agreed that the EHR
improved efficiency and 62.5% disagreed (net favorability −39.5%), while 36.3% agreed
that the EHR improved patient care and 41.0% disagreed (net favorability −4.7%).[29 ] Although specialty-specific responses to these questions were not reported, those
in urology and other surgical specialties reported similar overall satisfaction with
the EHR and less satisfaction with the clerical burden relative to the entire cohort.[29 ] Five years later, our findings indicate substantive progress with urologic surgeons
reporting near universal use of EHR and its core functions, less negative attitudes
with respect to clinical efficiency, and net positive perceptions on patient care.
Moreover, newer entrants into the urologic workforce (i.e., ≤10 years in practice)
have even better ratings for clinical efficiency (+7.5%) and patient care (+29.9%),
likely due to the significant EHR exposure in contemporary training.[30 ] In summation, these findings suggest growing acceptance of the EHR, which may continue
with subsequent generations of surgeons.
While encouraging, our findings also highlight ongoing challenges with the EHR that
surgeons feel hamper clinical efficiency and patient care. Similar to other specialties,
these center on information management and administrative burden.[31 ] Although the EHR provides greater access to information, surgeons often find it
to be excessive, unstructured, and disorganized, increasing their work burden to sort
and process it, interfering with patient interactions, and potentially leading to
patient harms.[32 ] Additionally, surgeons expressed dissatisfaction with frequent, nonclinical tasks
in the EHR that take significant time to complete.[31 ] Prior time-motion studies involving orthopedic and head and neck surgeons showed
that physicians spend one-third of their in-room time with patients on EHR tasks while
an EHR log study found that academic surgeons spend 14 h/wk in the EHR.[20 ]
[21 ]
[22 ] Although less than primary care and medical physicians, surgeons may be particularly
pressed due to time spent in the operating room.[19 ] Notably, 35% of total EHR time for surgeons take place in remote and after-hour
settings compared to 26 to 31% for nonsurgeons.[19 ]
[21 ] These demands, in turn, can interfere with the interpersonal dynamic between patients
and physicians.[33 ] While prior studies mostly in the medical setting suggest a negligible impact on
patient satisfaction, changes in face-to-face encounters in surgery have been shown
to hamper communication, perceived empathy, and potentially trust, which are instrumental
in avoiding adverse events and subsequent dissatisfaction and litigation.[32 ]
[34 ]
[35 ] When considered along with the feeling of not “practicing at top of license,” it
should be unsurprising that the EHR has been found to be a major driver of burnout
and dissatisfaction in the urologic and surgical workforces.[36 ]
[37 ]
Finally, our study highlights differences across practice settings that may affect
how surgeons use the EHR and their embrace of EHR-based tools. In this study, urologic
surgeons in private practice used fewer EHR functions and had more negative perceptions
of the EHR compared to colleagues in academic practices or large, integrated health
systems. These findings may represent carryover from the slower uptake of the EHR
by solo providers and physician-owned practices and may now be manifesting as less
optimal utilization and lower user satisfaction.[8 ]
[15 ]
[28 ]
[38 ] At the same time, private practice surgeons report more burnout and less career
satisfaction than counterparts in academics due in part to the EHR.[39 ] While this difference is likely multifactorial, private practice surgeons typically
see more patients and take more call and may not have residents or advanced practice
providers to share in the workload.[21 ] Similarly, resource constraints, especially among smaller practices, may limit access
to medical scribes, new dictation technology, redesigned staffing models, and other
staff support that improve productivity and provider satisfaction with the EHR.[40 ]
[41 ] So while broader trends are encouraging, a divide with respect to the EHR appears
to be emerging between higher and lower-resourced practices.
These findings should be considered in the context of several limitations. First,
there is potential for nonresponse bias. To address this concern, the AUA administers
the survey through mixed modes and provides sampling weights to generate national
estimates. Additionally, the 2,081 survey responses rank among the highest for surgeons
in this topic area, while the 21% response rate compares favorably to similar studies.[9 ]
[16 ]
[29 ]
[36 ] Second, nonresponse bias could trickle down to the qualitative interviews. For this
reason, we purposefully sampled based on years in practice, workload, and attitudes
to ensure diverse views, and our cohort appears reflective of the overall workforce
as indicated in [Table 1 ]. Third, though this study examines a single surgical specialty, our cohort captures
those practicing office-based urology, endourology, female pelvic floor and reconstruction,
pediatric urology, and urologic oncology that have similarities to other surgical
specialties. Furthermore, whereas medical specialties varied greatly in their EHR
adoption, surgical specialties clustered closer together, suggesting some degree of
homogeneity.[9 ]
[15 ]
[16 ]
[17 ]
[18 ] Fourth, interviews occurred during the coronavirus disease 2019 (COVID-19) pandemic,
which could have altered the experiences and feelings elicited about the EHR. To the
extent possible, the trained qualitative interviewers redirected conversations toward
the interviewees' broader experience with the EHR as opposed to COVID-specific issues.
Finally, based on the study design, we do not quantify the relative importance of
themes identified in the qualitative interviews. On balance, this should be considered
along with the strengths of the mixed methods study design that enable greater contextualization
and insight into the survey findings.
These limitations notwithstanding, our findings have important implications for health
IT in urology and potentially surgery more broadly. Increasingly, surgeons have looked
to the EHR as a quality lever. This includes recent efforts to develop automated performance
measurement, risk prediction, and clinical decision support among other interventions.[42 ]
[43 ] While promising, these EHR-based tools have been primarily developed and tested
in the academic setting. Nearly half of urologists and surgeons, however, provide
care in the private practice setting, which have both different experiences and resources.[36 ]
[37 ] Given this divide, it may be prudent to specifically engage the community and private
practice surgeons in design to optimize workflows and ensure usability.[31 ] In fact, when engaged, surgeons in private practice can be quick adopters relative
to counterparts in larger institutional settings. As an example, an electronic national
quality registry in urology that extracts information automatically from EHRs has
seen much greater uptake among private practice urologists as the initiative also
addressed a specific need of private groups to meet quality reporting requirements.[44 ] In taking such an approach and in combination with broader efforts to improve the
usability of the EHR, new EHR-based tools may see accelerated success, scaled across
the surgical landscape.
Conclusion
Even with near universal adoption, urologic surgeons harbor mixed feelings for the
EHR, particularly those in practice longer and in smaller, less resourced settings.
Based on these findings, EHR-based tools designed to facilitate information management
and minimize administrative burden, promote patient safety and the patient-surgeon
relationship, and engage surgeons from varied settings, may be best positioned for
effective use and provider satisfaction in the future.
Clinical Relevance Statement
Clinical Relevance Statement
While the use and perceptions of EHRs have improved, multiple challenges remain, particularly
information management and administrative burden. Among surgeons, these dissatisfiers
appear to be amplified by the procedure-based nature of the specialty, especially
for those with less EHR exposure, infrastructure, and support. Efforts to transform
surgical care delivery through the EHR will need to engage these surgeons specifically
to find scalable success.
Multiple-Choice Questions
Multiple-Choice Questions
Which EHR function is used by only a minority of practicing urologic surgeons?
Chart review
Order entry
Pop-up/alerts
Secure messaging
Correct Answer : The correct answer is option c. In 2019, 43.4% of survey respondents reported that
they routinely use information from pop-up or alerts such as BPAs.
Which characteristic is significantly associated with differences in EHR perceptions?
Subspecialty
Fellowship
Practice type
Minutes per visit
Correct Answer : The correct answer is option c. In the multivariable analysis, practice type was
significantly associated with EHR use and positive perception for impact on clinical
efficiency and patient care.
