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Why Did Two Very Similar EHR Satisfaction Surveys Produce Two Very Different Results?

August 26, 2015
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I became quite intrigued when I read two surveys on electronic health records (EHRs) over the past few weeks that garnered very different results.

First, a 51-page report from online resource organization AmericanEHR and the American Medical Association (AMA) found that compared to five years ago, more physicians are reporting being dissatisfied or very dissatisfied with their EHR system. The survey of 940 providers that included 155 questions found that close to, or more than half of all respondents, reported a negative impact in response to questions about how their EHR system improved costs, efficiency or productivity. In a similar survey conducted by AmericanEHR five years ago, the majority of respondents said that overall they were satisfied or very satisfied with their EHR system; with 39 percent being satisfied and 22 percent being very satisfied. In the current survey, the majority of respondents indicated that overall they were dissatisfied with their EHR system; with only 22 percent indicating they were satisfied and 12 percent indicating they were very satisfied.

To the contrary, Black Book Market Research’s annual EHR satisfaction survey found that 71 percent of all large practice clinicians stated their optimization expectations of top ranked Black Book EHR vendors were being met or exceeded according to physician and clinician experience. Eighty-two percent of administrative and support staff declared upgraded operational and financial developments, as well. Comparatively, in 2013, 92 percent of multispecialty groups using electronic records were “very dissatisfied” with the ability of their systems to improve clinical workload, documentation and user functionalities. For this year’s Black Book survey, more than 27,000 EHR users participated in the 2015 polls of client experience in a sweeping five month study.

Now it’s important to remember a few things when it comes to surveys of this ilk. For one, surveys in general often generate varying results, even if on the same topic. In healthcare specifically, where physician mandates are plentiful, there are there are bound to be diverse opinions on a single matter. Take ICD-10 for instance—some surveys rate the level of physician readiness as “optimistic,”  while others find that doctors are quite “uncertain” about the transition. Depending on the physician, the timing, and the resources and size of the practice, you might get all kinds of different answers. Such is the risk you run when you report on surveys. You also have to ask yourself, Are these respondents self-selected in any way? Is there any pre-conceived biasness we should know about? Sometimes, it’s just impossible to get down to the nitty-gritty unless you conducted the survey yourself.

Looking at these two surveys and their results, you can come up with a few reasons why they might have produced different sentiments. For one, scanning over the methodology in the AmericanEHR survey, the press release reads, “AmericanEHR Partners uses a 155-question online survey to collect data on clinicians’ (Physicians, NPs, and PAs) use and satisfaction with EHRs and health information technology. The survey uses skip logic to present individuals with questions that are most relevant to them, and takes an average of 20 minutes to complete. Respondents are allowed to skip questions or indicate that they do not know the answer to the question. The core survey has been in use since 2011.”

It goes on to say, “Surveys conducted by AmericanEHR Partners in conjunction with the American Medical Association, American College of Physicians and American Academy of Family Physicians… Each society was allowed to select the population of their members to receive the survey. Information about EHR use by individual society members was not available. Therefore, the survey went to both users and non-users of EHRs. All respondents completed the same survey.”

What sticks out to me are the sentences, “Each society was allowed to select the population of their members to receive the survey. Therefore, the survey went to both users and non-users of EHRs.” Thinking about what I said earlier regarding self-selected surveys, I immediately question the validity of this survey. For one, AMA President, Steven J. Stack, M.D., has been quite the outspoken one when it comes to EHRs. Just recently, during a town hall meeting in Atlanta on July 20th hosted by AMA, Dr. Stack said, “This is not for you to hear me talking to you, but for me to hear you talking to me... Has workflow in your office changed?"  What’s more, in January, a similar AAFP report came out attesting that doctors are being forced to switch EHRs and there is widespread dissatisfaction among physicians who have switched.




A major basic problem with comparison of these two surveys is the providers selected for the surveys. Physicians in small to medium sized independent practices were the focus of the AMA/AmericanEHR survey and they represent the majority of US providers. Physicians in large and particularly hospital system linked practices were the focus of the Black Book survey. Physicians in those large practices are often employed by large hospital systems and the high expenses of such systems as Epic and Cerner are not issues that they are required to deal with. When they're hired, use of those systems is a condition of employment. Physicians in small to medium sized independent practices are must be more involved in EHR implementation decisions and deal with the lack of usability and interoperability and the expense of EHRs that is the current norm. The dysfunctional state of almost all EHR systems and the excessive and rapidly changing meaningful use and other bureaucratic requirements have a much greater impact on small and medium sized independent practices.

Thanks for your comment, Earl. Understood that the surveys focused on organizations of different sizes, and that smaller orgs have more of a problem with EHRs. I even pointed this out in the blog.

I wrote: Furthermore, it should be noted that the Black Book survey looked at larger physician practices, while the AmericanEHR/AMA survey looked at smaller practices, including solo doctor offices. In a recent article on this very topic in Medscape, Doug Brown, managing partner of Black Book, said, "Larger physician organizations are much more satisfied because of their resources and the offerings of larger EHR firms. Smaller practices bought inexpensive and/or free EHRs for meaningful use incentives with little or no support. That is a recipe which generates vocal, critical users.”

As such, my bigger point was the fact that the AMA/AmericanEHR survey used more of a self-selected sample, allowing for greater bias. In my opinion, it's always easier to find the vocal/critical rather than the quiet.

I appreciate your comments, but I think that you fail to see a bigger perspective in the difference between large, hospital and health system physician practices and small to medium sized independent physician practices. EHR systems, particularly those used in large hospitals, were built with a major focus on billing, collections, hospital and practice business management, etc. by IT developers for healthcare executives. Physicians were often involved peripherally, or after the EHR products were initially developed. There was no major focus on how physicians and other providers actually and efficiently interface with their patients -- performing a history and physical examination, including collecting the laboratory and other supporting laboratory and other studies, arriving at the assessments of the patient's problems and establishing a treatment plan. Physicians, therefore, had to learn an entirely new way to practice that takes extensive training of both physicians and staff (in some cases weeks to months), major and often prohibitive expenses for implementation, complete re-engineering of the practice of medicine, marked increases in the cost of healthcare, and much less time dealing directly with patients. While large hospitals and their associated large physician practices have managed this -- despite major disruptions and clearly dissatisfaction with this process -- small and medium practices have not had the luxury of the expense and time for those disruptions and still take care of their patients. Thankfully some of this is changing. The major ferment in the EHR market will change soon as more intuitive, easy-to-use, interoperable, inexpensive EHR systems that will actually improve productivity and efficiency of individual provider-patient visits reach the market in the near future.

Administrative and financial systems are critical for reimbursement, but biggest systems are build on old MUMPS technologies rather than on new more intuitive, useable technologies. The biggest problems with physician satisfaction are that physicians are required to markedly change their practice and are forced to focus on cumbersome, excessive administrative requirements that markedly decrease interactions and time with patients. There are now much better alternatives. See Radekal, for example, the requires only a normal, easily documented H&P (on stylist touch tablet with no typing or dictation required) driven by drill down anatomic diagrams that engage patients. When diagnoses are made, ICD-10 coding and billing is automatically completed, as are eRx and orders. Visit can be completed and billed before patient leaves examining room. This is Wrapper Technology Productivity Tool App that saves time, concentrates on patient interaction and is very inexpensive.