How Physician Perspectives on E-Prescribing Evolve over TimeA Case Study Following the Transition between EHRs in an Outpatient ClinicThe authors thank Drs. Curtis Cole and Adam Cheriff for their support in the conceptual design of this project. The authors thank Dr. Joan Ash and Arwen Bunce, MA for providing external expertise as to the qualitative methodology utilized in this study. The authors also thank Alison Edwards, MS for statistical contributions.
03. August 2016
accepted: 17. September 2016
18. Dezember 2017 (online)
Background Physicians are expending tremendous resources transitioning to new electronic health records (EHRs), with electronic prescribing as a key functionality of most systems. Physician dissatisfaction post-transition can be quite marked, especially initially. However, little is known about how physicians’ experiences using new EHRs for e-prescribing evolve over time. We previously published a qualitative case study about the early physician experience transitioning from an older to a newer, more robust EHR, in the outpatient setting, focusing on their perceptions of the electronic prescribing functionality.
Objective Our current objective was to examine how perceptions about using the new HER evolved over time, again with a focus on electronic prescribing.
Methods We interviewed thirteen internists at an academic medical center-affiliated ambulatory care clinic who transitioned to the new EHR two years prior. We used a grounded theory approach to analyze semi-structured interviews and generate key themes.
Results We identified five themes: efficiency and usability, effects on safety, ongoing training requirements, customization, and competing priorities for the EHR. We found that for even experienced e-prescribers, achieving prior levels of perceived prescribing efficiency took nearly two years. Despite the fact that speed in performing prescribing-related tasks was highly important, most were still not utilizing system short cuts or customization features designed to maximize efficiency. Alert fatigue remained common. However, direct transmission of prescriptions to pharmacies was highly valued and its benefits generally outweighed the other features considered poorly designed for physician workflow.
Conclusions Ensuring that physicians are able to do key prescribing tasks efficiently is critical to the perceived value of e-prescribing applications. However, successful transitions may take longer than expected and e-prescribing system features that do not support workflow or require constant upgrades may further prolong the process. Additionally, as system features continually evolve, physicians may need ongoing training and support to maintain efficiency.
Citation: Abramson EL, Patel V, Pfoh RE, Kaushal R. How physician perspectives on E-prescribing evolve over time: A case study following the transition between EHRs in an outpatient clinic.
- 1 Health information technology: initial set of standards, implementation specifications, and certification criteria for electronic health record technology. Final rule. Fed Regist 2010; 75 (144) 44589-654.
- 2 Charles D, King J, Patel V, Furukawa M. Adoption of Electronic Health Record Systems among U.S. Nonfederal Acute Care Hospitals: 2008–2012. Office of the National Coordinator for Health Information Technology. 2013
- 3 Hsiao C-J, Hing E. Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001–2013. NCHS data brief, no 143. Hyattsville, MD: National Center for Health Statistics; 2014
- 4 Gabriel M, Swain M. E-prescribing Trends in the United States. The Office of the National Coordinator for Health Information Technology. 2014
- 5 Yoon-Flannery K, Zandieh SO, Kuperman GJ, Langsam DJ, Hyman D, Kaushal R. A qualitative analysis of an electronic health record (EHR) implementation in an academic ambulatory setting. Inform Prim Care 2008; 16: 277-284.
- 6 Cedars-Sinai Medical Center Taps Thomson Healthcare to Improve Clinical Performance and Standards Compliance. Patient Safety and Quality Healthcare Business News. Farmington Hills, Michigan: PR Newswire Association LLC; 2007
- 7 Bentley T, Rizer M, McAlearney AS, Mekhjian H, Siedler M, Sharp K, Teater P, Huerta T. The journey from precontemplation to action. Transitioning between electronic medical record systems. Health Care Manage Rev. 2014
- 8 Gettinger A, Csatari A. Transitioning from a Legacy EHR to a Commercial, Vendor-supplied, EHR: One Academic Health System’s Experience. Appl Clin Inform 2012; 03: 367-376.
- 9 Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff (Millwood) 2011; 30: 464-471.
- 10 Abramson EL, Malhotra S, Fischer K, Edwards A, Pfoh ER, Osorio SN, Cheriff A, Kaushal R. Transitioning between electronic health records: effects on ambulatory prescribing safety. J Gen Intern Med 2011; 26: 868-874.
- 11 Abramson EL, Patel V, Malhotra S, Pfoh ER, Nena SOsorio, Cheriff A, Cole CL, Bunce A, Ash J, Kaushal R. Physician experiences transitioning between an older versus newer electronic health record for electronic prescribing. Int J Med Inform 2012; 81 (08) 539-548.
- 12 Abramson EL, Malhotra S, Osorio SN, Edwards A, Cheriff A, Cole C, Kaushal R. A long-term follow-up evaluation of electronic health record prescribing safety. J Am Med Inform Assoc. 2013; 20 (e1): e52-e58.
- 13 Grossman JM, Gerland A, Reed MC, Fahlman C. Physicians’ experiences using commercial e-prescribing systems. Health Aff (Millwood) 2007; 26: w393-404.
- 14 Crosson JC, Isaacson N, Lancaster D, McDonald EA, Schueth AJ, DiCicco-Bloom B, Newman JL, Wang CJ, Bell DS. Variation in electronic prescribing implementation among twelve ambulatory practices. J Gen Intern Med 2008; 23: 364-371.
- 15 Wang CJ, Patel MH, Schueth AJ, Bradley M, Wu S, Crosson JC, Glassman PA, Bell DS. Perceptions of standards-based electronic prescribing systems as implemented in outpatient primary care: a physician survey. J Am Med Inform Assoc 2009; 16: 493-502.
- 16 Weingart SN, Massagli M, Cyrulik A, Isaac T, Morway L, Sands DZ, Weissman JS. Assessing the value of electronic prescribing in ambulatory care: a focus group study. Int J Med Inform 2009; 78: 571-578.
- 17 Lapane KL, Rosen RK, Dube C. Perceptions of e-prescribing efficiencies and inefficiencies in ambulatory care. Int J Med Inform 2011; 80: 39-46.
- 18 Makam AN, Lanham HJ, Batchelor K, Samal L, Moran B, Howell-Stampley T, Kirk L, Cherukuri M, Santini N, Leykum LK, Halm EA. Use and satisfaction with key functions of a common commercial electronic health record: a survey of primary care providers. BMC Med Inform Decis Mak 2013; 13: 86.
- 19 Hanauer DA, Branford GL, Greenberg G, Kileny S, Couper MP, Zheng K, Choi SW. Two-year longitudinal assessment of physicians’ perceptions after replacement of a longstanding homegrown electronic health record: does a J-curve of satisfaction really exist?. J Am Med Inform Assoc. 2016 e-pub ahead of print.
- 20 Zandieh SO, Abramson EL, Pfoh ER, Yoon-Flannery K, Edwards A, Kaushal R. Transitioning between ambulatory EHRs: a study of practitioners’ perspectives. J Am Med Inform Assoc 2012; 19: 401-406.
- 21 Pfoh ER, Abramson E, Zandieh S, Edwards A, Kaushal R. Satisfaction after the transition between electronic health record systems at six ambulatory practices. J Eval Clin Pract 2012; 18 (06) 1133-1139.
- 22 Strauss AC. Juliet Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2nd ed. Thousand Oaks, CA: Sage Publications, Inc; 1998
- 23 Glaser B. The Constant Comparative Method of Qualitative Analysis. Grounded Theory Review. 2008: 07.
- 24 Fleming NS, Becker ER, Culler SD, Cheng D, McCorkle R, da Graca B, Ballard DJ. The impact of electronic health records on workflow and financial measures in primary care practices. Health Serv Res 2014; 49: 405-420.
- 25 Terry AL, Brown JB, Bestard LDenomme, Thind A, Stewart M. Perspectives on electronic medical record implementation after two years of use in primary health care practice. J Am Board Fam Med 2012; 25: 522-527.
- 26 McAlearney AS, Hefner JL, Sieck C, Rizer M, Huerta TR. Evidence-based management of ambulatory electronic health record system implementation: an assessment of conceptual support and qualitative evidence. Int J Med Inform 2014; 83: 484-494.
- 27 McAlearney AS, Hefner JL, Sieck CJ, Huerta TR. The Journey through Grief: Insights from a Qualitative Study of Electronic Health Record Implementation. Health Serv Res 2015; 50 (02) 462-488.
- 28 Lee F, Teich JM, Spurr CD, Bates DW. Implementation of physician order entry: user satisfaction and selfreported usage patterns. J Am Med Inform Assoc 1996; 03: 42-55.
- 29 Ash JS, Sittig DF, Seshadri V, Dykstra RH, Carpenter JD, Stavri PZ. Adding insight: a qualitative cross-site study of physician order entry. Int J Med Inform 2005; 74: 623-628.
- 30 Bates DW, Kuperman GJ, Wang S, Gandhi T, Kittler A, Volk L, Spurr C, Khorasani R, Tanasijevic M, Middleton B. Ten commandments for effective clinical decision support: making the practice of evidencebased medicine a reality. J Am Med Inform Assoc 2003; 10: 523-530.
- 31 Middleton B, Bloomrosen M, Dente MA, Hashmat B, Koppel R, Overhage JM, Payne TH, Rosenbloom ST, Weaver C, Zhang J. Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. J Am Med Inform Assoc 2013; e1: e2-e8.
- 32 Bramble JD, Abbott AA, Fuji KT, Paschal KA, Siracuse MV, Galt K. Patient safety perspectives of providers and nurses: the experience of a rural ambulatory care practice using an EHR with E-prescribing. J Rural Health 2013; 29: 383-391.
- 33 Nanji KC, Slight SP, Seger DL, Cho I, Fiskio JM, Redden LM, Volk LA, Bates DW. Overrides of medication-related clinical decision support alerts in outpatients. J Am Med Inform Assoc 2014; 21: 487-491.
- 34 Shah NR, Seger AC, Seger DL, Fiskio JM, Kuperman GJ, Blumenfeld B, Recklet EG, Bates DW, Gandhi TK. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am Med Inform Assoc 2006; 13: 5-11.
- 35 van der Sijs H, Aarts J, Vulto A, Berg M. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc 2006; 13: 138-147.
- 36 Phansalkar S, van der Sijs H, Tucker AD, Desai AA, Bell DS, Teich JM, Middleton B, Bates DW. Drug-drug interactions that should be non-interruptive in order to reduce alert fatigue in electronic health records. J Am Med Inform Assoc 2013; 20: 489-493.
- 37 Phansalkar S, Desai A, Choksi A, Yoshida E, Doole J, Czochanski M, Tucker AD, Middleton B, Bell D, Bates DW. Criteria for assessing high-priority drug-drug interactions for clinical decision support in electronic health records. BMC Med Inform Decis Mak 2013; 13: 65.
- 38 Phansalkar S, Zachariah M, Seidling HM, Mendes C, Volk L, Bates DW. Evaluation of medication alerts in electronic health records for compliance with human factors principles. J Am Med Inform Assoc 2014; 21: e332-340.
- 39 Institute of Medicine: Health IT and Patient Safety: Building Safer Systems for Better Care. Washington: DC; 2012
- 40 Reider J. “Usability of EHRs remains a priority for ONC”. 2014 http://www.healthit.gov/buzz-blog/electronic-health-and-medical-records/usability-ehrs-remains-priority-onc/ Access date September 2, 2016.
- 41 Lynch K, Kendall M, Shanks K, Haque A, Jones E, Wanis MG, Furukawa M, Mostashari F. The Health IT Regional Extension Center Program: evolution and lessons for health care transformation. Health Serv Res 2014; 49: 421-437.
- 42 Boas SJ, Bishop TF, Ryan AM, Shih SC, Casalino LP. Electronic health records and technical assistance to improve quality of primary care: Lessons for regional extension centers. Healthc (Amst) 2014; 02: 103-106.