The Health Information Technology for Economic and Clinical Health Act (HITECH) passed by Congress in 2009 established the use of the electronic medical record (EMR) in the health care setting as a critical national goal.1a, 1b However, the "goal is not adoption alone but 'meaningful use' of EMRs — that is, their use by providers to achieve significant improvements in care."2
Redesign of how we document care and treatment provided to patients has moved us from paper to an electronic form of documentation in a very short period of time. Documentation of assessments, plan of care, treatment parameters, vital signs, medications, and patient teaching has transformed from a handwritten narrative SOAP note to checklists, radio buttons, check boxes, and pull down pick lists. The intent is to provide a tool that captures as well as provides patient data at the point of care, is shared across the health care continuum for that specific patient, and aides the health care professional in clinical decision-making. This progressive change has not come without challenges.
The multi-use EMR
Assuring that the EMR screens are in keeping with health care provider (HCP) workflow is a huge challenge given that the system must meet the needs of multiple users. The ability to seamlessly find the necessary data for treatment and evaluation and to document clinical actions is difficult at best when there are more than one type of user, as in the case of the dialysis environment that includes at least six individual disciplines.
Another challenge is to ensure access to other HCPs outside the main facility, allowing doctors and nurses regardless of the point of care setting and across multiple EMR systems to view patient data. Communication across providers and health care institutions is essentially the glue that binds the entire health care system in place for the patient. Further, the HITECH legislation also stipulates that by 2015, all EMR systems must be designed to “report specific cases to registries.”1 For dialysis facilities, this includes ESRD forms and CROWNWeb data.
Meaningful use will be realized if the EMR is easy to learn, the vendor is responsive to requests for changes, and provides prompt ongoing support. Multiple reports from the health care community at large describe the loss of nursing time and extensive frustration of physicians when they cannot effectively leverage the EMR system and manage patients simultaneously. In these cases, the EMR becomes a burden rather than the enabling tool it was meant to be.
Currently, there are no reports on the use or impact of EMRs in the dialysis setting by the HCP closest to the patient. This study uses a survey to explore which EMR are utilized, profiles users, identifies the most important attributes of an EMR system, and assesses satisfaction with all EMR attributes.
Materials and Methods
Nephrology Clinical Solutions (NCS) Research surveyed 170 U.S. dialysis health care professionals regarding satisfaction with electronic medical record systems. The objectives were to:
- Evaluate satisfaction with current and previous EMR/EHR systems
- Evaluate most important attributes of EMR/EHR systems
- Evaluate satisfaction with various attributes/functions of EMR/EHR systems
The questionnaire was constructed by interviewing experts on objectives, formulation of questions, questionnaire flow, and answer choices. In addition, experts in the field verified content validity and beta testing was conducted.
Questionnaire data were collected via Internet survey tools and analyzed in Excel. Frequency tables, means, median, and percentages were calculated. Satisfaction responses were converted to a numerical score based on the following: “Very Satisfied” = 3, “Somewhat Satisfied” = 2, “Somewhat Dissatisfied” =1, “Very Dissatisfied” = 0, and “N/A” or no response excluded from “average satisfaction score.” Means/proportions between groups were tested for significant differences at the 95% confidence interval if appropriate. Members of the NCS Research Council were the target participants for this research. The NCS Research Council comprises over 600 nephrology health care professionals across various clinical practice settings, education backgrounds, roles, employers, certifications, and geographies.
Invitations to the May 2013 Satisfaction with EMR Survey were sent to 439 qualified health care professionals with 170 respondents (39% response rate). The following screening criteria were applied: nephrology health care professional, U.S. setting, dialysis or CKD office as the primary practice setting, and in practice for longer than one year in nephrology. The 170 respondents represent the following key practice settings: home and in-center dialysis, various sizes of dialysis organizations, for profit and not for profit, and hospital-based and freestanding dialysis facilities.
The participants held various management and clinical positions (see Table 1). They reported their own education, years’ experience in dialysis, role within the dialysis organization, dialysis organization segments (size and profit status), and dialysis facility settings (freestanding and hospital). There was a nearly equal representation among small (SDO), medium (MDO) and large dialysis organizations (LDO).
When asked to describe comfort level in learning new computer functions or tasks in new software, nearly 50% of respondents describe themselves as competent. While 30% feel that they are proficient or expert, 24% rate their comfort level at a novice or beginner. Only 17% of the respondents report that they are decision makers with 37% describing themselves as Influencers. Of the respondents, 46% identify themselves as Users.
EMR/ EHR systems represented
More than 30 different EMRs were represented in the survey (see Table 2). Of the 170 respondents, 9% indicated that their facility does not currently use an EMR. While 38% are not sure as to why an EMR is not used, an equal percent responded that they are currently evaluating systems. Thirteen percent report that their current paper system is “working fine so there is no need to change.”
Satisfaction with current and previous EMR systems
When asked their level of satisfaction with their current EMR, 24% are very satisfied and 52% are somewhat satisfied, leaving 25% somewhat or very dissatisfied. However, respondents who had previous experience with an EMR were twice as likely to be dissatisfied with their current EMR.
SPIN, Allscripts, and Acumen were the top EMR systems by satisfaction score in the dialysis setting (see Figure 1). Respondents from larger dialysis organizations (LDO) are more satisfied with their current EMR compared to those from moderate or small dialysis organizations.
Level of influence tends to influence satisfaction. Those who indicated that they were Decision Makers or Influencers in the selection of EMR system tended to be more satisfied with the current EMR. However, respondents who previously had used a different EMR were less satisfied with their current EMR, and this held true for all respondents regardless of dialysis organization size, profit status, or facility type.3
Most important attributes of EMR/EHR systems
EMR attributes were divided into three categories: workflow support, access and communications, and application training and support. Within each category, the respondents were asked to select from a prepared list of attributes/functions that they felt were most important when choosing an EMR.
Described by category, the top three attributes for EMR systems are noted in Figure 1.
Workflow support. The top three attributes were ease and efficiency of documenting care provided (72%), ease and efficiency of finding information and completing tasks (68%), and evaluation of patient trends (30%). This finding held true across dialysis organization size, profit status, and facility type.3
Access and communications. Remote access for health care provider (55%), CROWNWeb connection and data transfers (47%), and interface to outside organizations (44%) were the top three attributes of Access and Communications. Respondents reported similar attributes regardless of dialysis organization size, type, or profit status.3
Training and support. In this category, 62% of respondents included ease of learning, 49% problem resolution/upgrades and 44% flexible customization as the top three attributes. One major difference was found. The group of respondents considered novice/beginner rated initial training/tutorial provision and ongoing communication/training for upgrades as an important training and support attributes.3
Satisfaction with various attributes/functions of EMR/EHR systems
Workflow support. While respondents considered Ease and Efficiency in documenting care and Ease and Efficiency of finding information and completing tasks most important, satisfaction with each were not in the top three (see Figure 3). In subset analyses, not-for-profit facility respondents were more satisfied across all workflow attributes.3
Access and communications. While remote access for health care providers gained a high satisfaction score, interface to outside organizations and CROWNWeb connect and data transfers rank at the bottom. This held true for all dialysis organization sizes and types.3
EMR training and support. Reporting “Somewhat Satisfied” with Ease of Learning to use the system, the remaining two most important attributes, Timely Problem Resolution and Flexibility in Customization, ranked the lowest in satisfaction (see Figure 3).
This research is the first to report satisfaction with current EMR systems, identify the top 3 attributes of an EMR, and evaluate satisfaction with each attribute. Over 30 EMR systems were represented in the survey. Twenty five percent of respondents are dissatisfied with their current EMR system. Respondents reported less satisfaction for at least two of the top three attributes identified for Workflow Support, Access and Communication, and Training and Support.
It is anticipated that EMRs will help to improve health care provider decisions and patient outcomes. That goal may be realized when EMR systems are closer to the ideal as described in this research study. A more ideal EMR is one that provides timely and ease of access to essential information in keeping with HCP workflow. Also, it must allow ready access for communications with all members of the health care team, including the patient, as well as permit the transmission of forms and reports to registries and other entities. And, the EMR system must be easy to learn and provide prompt service and flexibility.
The authors would like to express their gratitude to all of the Council Members from the NCS Research Council for their contributions to this important research.
1a. Centers for Medicare & Medicaid Services, Electronic Health Record Incentive Program — Stage 2, Feb. 23; Medicare & Medicaid EHR Incentive Program, Meaningful Use Stage 1 Requirements Summary, 2010.
1b. Centers for Medicare & Medicaid Services, Electronic Health Record Incentive Program — Stage 2, Feb. 23.
2. Blumenthal D, Tavenner M. The “Meaningful Use” regulation for electronic health records, N Engl J Med 2010; 363:501-504August 5, 2010 DOI: 10.1056/NEJMp1006114
3. Satisfaction with electronic medical record systems in nephrology, NCS Research Report (2013).