Vol. 00 No. 0 xxx 2014
1
Electronic Health Record Adoption among Obstetrician/Gynecologists in the United States: Physician Practices and Satisfaction Greta B. Raglan, Benyamin Margolis, Ronald A. Paulus, Jay Schulkin Electronic health record (EHR) systems, although in use for the last few decades, have been increasingly adopted by health professionals in recent years (Hsiao & Hing, 2012). The factors thought to influence the adoption of EHRs include improved system quality, increased patient interest, and the Heath Information Technology for Economic and Clinical Health (HITECH) Act that incentivized implementation of EHR systems. Few studies have directly tracked the prevalence or patterns of EHR adoption by obstetrician-gynecologists (ob-gyns). The studies that have examined this found that use of EHR systems among obgyns lagged behind many other subspecialties such as internists and primary care physicians (Burt & Sisk, 2005; Menechemi, Lee, Shepherd, & Brooks, 2006), and that ob-gyns often did not use all of the features of their EHR systems (Tundia et al., 2013). Estimates of ob-gyns utilization from 2001 to 2003 reported that only 15–20% of ob-gyns use an EHR system in the United States (Burt & Sisk, 2005; Menechemi et al., 2006). General studies of EHR adoption found that many physicians were reluctant to use an EHR system because of concerns it would increase time spent on documentation (e.g., Miller & Sim, 2004) and possibly lead to errors in documentation (Zwaanswijk, Ploem, Wiesma, Verheij, & Gevers, 2013). Additionally, concerns have been raised that EHR would decrease patient confidentiality (The Physicians Foundation, 2012; Zwaanswijk et al., 2013), and there is skepticism that EHR systems would increase effectiveness of care (Hahn et al., 2011). Existing studies on adoption and implementation have neither directly analyzed the experiences with, nor the opinions and perceptions of, EHR systems by ob-gyns. This information is particularly important to understanding why ob-gyns appear to trail other medical professionals in the adoption of EHR systems. There are unique qualities of ob-gyn practice (e.g., focus on both mother and child, officeand hospital-based, medical and surgical) relative to other subspecialties, which suggest
Abstract: Implementation of electronic health records (EHRs) has historically been lower among obstetrician-gynecologists (obgyns) than many physician groups. This study described ob-gyns’ adoption and use of EHR systems in practice, as well as barriers and benefits to implementation. Surveys asking about the physicians’ use of EHR, satisfaction with systems, and what features they found most or least helpful were mailed to 1,200 ob-gyns. An overall response rate of 57.4% was achieved, with 559 returning completed surveys. Over three-quarters of responders reported that they used an EHR system or planned to implement one. Physicians without EHR tended to be older, were more likely to be male, have a solo practice, and describe themselves as Asian/Pacific Islander. Over 63% of those physicians who use EHR reported being satisfied with their system, while 30.8% were not satisfied. Ob-gyns who reported satisfaction had a younger mean age (M = 52.98, SD = 8.87) than those not satisfied (M = 56.30, SD = 8.59; p = .002). Use of EHR systems among ob-gyns has increased in recent years and overall satisfaction with these systems is high. In spite of this, barriers to implementation are still present and increased outreach to certain groups of ob-gyns, including older practitioners and those in solo practices, is needed.
ob-gyns would have different requirements and considerations for an EHR system. Similarly, EHRs could have different impacts on ob-gyns in practice when compared to other subspecialties (McCoy, Diamond, & Strunk, 2010). Several studies have, however, demonstrated that the implementation of EHRs produces clinical benefits specific to ob-gyn practices (Campbell, Li, Mori, Osterweil, & Guise, 2008). Electronic records have been found to be more complete than paper records (Bernstein et al., 2005; Eden et al., 2008; George & Bernstein, 2009; Nielsen et al., 2000). Electronic reminders included in many EHR systems have improved rates of regular testing among patients and documentation of these services (Burack, Gimotty, Simon, Moncrease, & Dews, 2003). Checklists have been linked to improved clinical outcomes in certain procedures such as shoulder dystocia (Deering, Tobler, & Cypher, 2010). Improvements appear to increase with time since adoption, particularly as systems become more fully integrated into a practice (Tundia et al., 2013).
Keywords documentation efficiency/cost reduction research quantitative
Journal for Healthcare Quality Vol. 00, No. 0, pp. 1–8 C 2014 National Association for Healthcare Quality
2
Journal for Healthcare Quality
The current study was descriptive in nature and aimed at giving a more complete view of ob-gyns’ adoption and use of EHR systems in practice. In addition, we asked ob-gyns with and without EHR experience to comment on aspects of EHRs that may help or hinder daily practice in an effort to better understand barriers to implementation unique to ob-gyn practices. The aim of this study was to answer approximately how many ob-gyns currently use an EHR system, and how demographic and practice areas differ between that group and those who do not use an EHR system. Additionally, it addresses questions of what qualities of EHR systems were perceived as benefits versus barriers in EHR users and how EHR implementation affected practice. Among ob-gyns without EHR systems, the study focused on whether they wished to adopt EHR, and their beliefs about the effects of implementation.
Study Design and Methods A survey regarding practices, opinions, and patient characteristics was developed at the American College of Obstetricians and Gynecologists (ACOG) in consultation with practicing ob-gyns. Questions were pilot-tested on a sample of practicing ob-gyns with adjustments made based on feedback. IRB approval was obtained from ACOG. Paper mailings included a cover letter, a questionnaire, and a stamped return envelope. The survey was sent to 1,200 ACOG fellows. Six hundred were members of the Collaborative Ambulatory Research Network (CARN). CARN members are ACOG fellows and junior fellows in practice who have volunteered to participate in survey studies without compensation; they are typically recruited through advertising or random selection from ACOG’s membership rolls. CARN was established to improve the response rate on ACOG survey studies while maintaining a participant pool representative of practicing ACOG members. The remaining 600 participants consisted of a computer-generated random sample of ACOG fellows and junior fellows in practice who had not received a survey from ACOG during the previous 2 years. Fifteen participants were unreachable due to change of address or retirement from practice. Surveys asked a series of demographics questions and whether physicians currently use an EHR system. Likert-type questions asked physicians about EHR systems, barriers to imple-
mentation, reasons for implementation, and changes in practice since implementation. Physicians were also asked specific yes/no or fill-in-the-blank questions about their EHR system such as whether it communicates with their local hospital, and about utilization at their practice. Ob-gyns were also asked whether or not they were satisfied with their current EHR system. Respondents who reported not using an EHR system were asked to complete Likerttype questions about barriers to implementation, changes they anticipated if they were to implement an EHR system, and whether they would be interested in implementing an EHR system at their practice. Qualitative items about ob-gyns’ experiences are reported elsewhere (Raglan, Margolis, Paulus, & Schulkin, in press). Those who did not respond to the initial mailing were sent three reminders. Those who had not responded were sent a brief follow-up letter containing an abbreviated questionnaire. The data were analyzed using a personal computer-based software package (IBM SPSS R 20.0, IBM Corp , Armonk, NY). DeStatistics scriptive statistics were computed for the measures used in the analyses and one-way ANOVA was used to compare group means of continuous measures. Differences on dichotomous variables were assessed using chi-squares. Analyses were tested for significance using alpha of 0.05. C
Results Six-hundred-eighty-nine surveys and letters were returned for a total response rate of 58.1%. Those who responded with a letter did not differ from survey responders in terms of gender or EHR use. Letter responders were older (M = 55.63, SD = 9.26) than survey responders (M = 53.62, SD = 9.14; p = .030). Fewer letter responders (51.4%) reported being satisfied with their EHR system than survey responders (67.2%; p = .011). Unless otherwise noted, the following results reflect the responses of survey responders only because of the abbreviated questions found in letters. Of 559 ob-gyns who returned a survey, 334 (59.7%) reported that they currently use an EHR system (EHR Group), 90 (16.1%) planned to implement one in the next year (Planned EHR Group), and 135 (24.2%) did not have an EHR system or plans to implement one in the next year (No EHR Group). The No EHR Group tended to be older, was more likely to be male, was more likely to be Asian/Pacific
Vol. 00 No. 0 xxx 2014
Table 1. Physician Demographics
Age (mean years, SD) Gender (% female) Race White/European American Black/African American Asian/Pacific Islander Other/more than one Clinical practice setting Solo/private practice Partnership/group practice Multispecialty group University full time Other Practice location Urban, inner city Urban, noninner city Suburban Town of 5,000–50,000 Rural/other Specialty General ob-gyn Gynecology only Other *
Total (n = 559)
EHR/Planned EHR (n = 424)
No EHR (n = 135)
55.6, 9.25 47.6
54.64, 9.01 50.9
58.77, 9.31 38.5
82.2% 4.3% 8.2% 5.3%
83.5% 4.5% 7.2% 4.8%
78.4% 3.7% 11.2% 6.6%
17.8% 45.8% 14.4% 10.4% 11.6%
10.2% 45.3% 18.5% 13.0% 13.1%
41.5% 47.4% 1.5% 2.2% 7.4%
16.2% 28.2% 37.9% 13.8% 4.0%
17.3% 26.5% 39.2% 13.5% 3.5%
12.7% 33.6% 33.6% 14.9% 5.2%
73.8% 17.5% 8.7%
74.2% 15.9% 9.9%
72.6% 22.2% 5.2%
Significance p < .001** p = .012* p = .042*
p < .001**
p = .372
p = .292
p < .05, ** p < .01
Islander, and was more likely to have a solo practice. They did not differ from the EHR and Planned EHR Groups in terms of practice location or specialty (see Table 1). In addition, the No EHR Group reported seeing more patients per year (4,186.30 ± 8,319.28) than those in the EHR or Planned EHR Groups (3,145.91 ± SD = 2,254.20, p = .032). Just over half of physicians in the EHR Group reported that EHR decreased the time spent on pharmacy calls (50.3%) and time to receive and review lab results (50.3%). About half also reported that it increased the efficiency and comprehensiveness of billing (49.7%) and decreased the costs of managing and storing results (47.9%). Forty-one percent of respondents, however, reported that EHRs decreased overall practice efficiency, compared to 38.0% who said that efficiency increased. Additionally, 66.8% of respondents said that EHRs increased the time spent to plan, review, order, and document care. In the EHR Group, 63.2% reported that overall, they were satisfied with their EHR system (Satisfied Group), while 30.8% reported that they were not satisfied (Not Satisfied Group).
The Satisfied Group had a younger mean age (52.98 ± 8.87) than the Not Satisfied Group (56.30 ± 8.59; p = .002). The Satisfied Group was more likely than Not Satisfied to report that efficiency, decision support, offsite record access, patient portal, and satisfying patient requests were “important” or “very important” to their decision to implement an EHR system (see Table 2). Among the Not Satisfied Group, meaningful use incentives were cited as the single most compelling reason that led practitioners to implement an EHR system, while patient care and efficiency were cited for the Satisfied Group (see Table 3). Overall, the Not Satisfied Group reported more major barriers to the implementation of an EHR system. In particular, they were more likely to say that finding a system that meets the needs of their practice, loss of productivity, and system reliability and postpurchase support posed major barriers to EHR use and implementation (see Table 4). Anticipated costs of implementing and maintaining an EHR system were not associated with a physician’s reported satisfaction with that system, and other possible factors (e.g., data security) were not fully
3
4
Journal for Healthcare Quality
Table 2. Percent with EHR Reporting the Reason for Implementing EHR Was Important/Very Important Satisfied (n = 211)
Not Satisfied (n = 103)
Significance
61.1% 79.7% 49.5% 84.2% 59.5% 80.0% 40.9% 36.4% 63.6%
66.7% 70.5% 51.6% 59.6% 39.6% 68.8% 24.0% 20.8% 69.4%
p = .368 p = .086 p = .737 p < .001** p = .002** p = .036* p = .005** p = .007** p = .585
Cost Effect on patient care Meaningful use incentives Efficiency Decision support Ability to access records off-site Patient portal Satisfying patient requests Othera a
For example, mandated by institution; *p < .05, **p < .01; ns may not match due to missing values.
Table 3. Percent with EHR Reporting the Most Important Motivation for Their Decision to Implement EHR EHR Group (n = 290)
Satisfied (n = 180)
Not Satisfied (n = 96)
29.7% 19.7% 19.3% 18.6% 9.3% 2.8% 0.3% 0.3%
36.7% 26.1% 15.6% 11.0% 6.1% 3.3% 0.6% 0.6%
16.7% 9.4% 28.1% 30.2% 13.5% 2.1% 0.0% 0.0%
Effect on patient care Efficiency Othera Meaningful use incentives Ability to access records off-site Cost Decision support Patient portal a
For example, mandated by institution; ns may not match due to missing values.
covered in the survey. As anticipated, the Satisfied Group reported more positive outcomes from implementation than did the Not Satisfied. The Not Satisfied Group was more likely to say that EHR “disrupts the way I interact with my patients” and “increases time spent on records/documentation” (see Table 5).
Among the No EHR Group, 33.3% were not interested in implementing EHR, and 20.2% were unsure. This group anticipated more major barriers to implementation than the EHR Group reported experiencing (see Table 6). The No EHR Group reported anticipating more negative outcomes resulting from
Table 4. Reported Major Barriers to EHR Implementation and Satisfaction with EHR in Physicians with an EHR System Satisfied (n = 211)
Not Satisfied (n = 103)
Significance
11.6% 30.6% 30.1% 52.3% 36.9% 38.1% 33.5%
19.6% 54.4% 34.8% 59.8% 75.0% 67.4% 41.8%
p = .077 p = .001** p = .431 p = .243 p < .001** p < .001** p = .185
Consensus on selecting an EHR system Finding a system that meets needs Effort to select system Cost Loss of productivity System reliability and tech support Resistance to changing work habits *p < .05, **p < .01; ns may not match due to missing values.
Vol. 00 No. 0 xxx 2014
Table 5. Reported Changes following EHR Implementation and Physician Satisfaction (Percent Who “Agree” or “Strongly Agree”)
Produces financial benefits for my practice Produces clinical benefits for my practice Allows me to deliver better patient care Makes records more readily available Disrupts the way I interact with my patients Is an asset when recruiting new physicians Enhances patient data confidentiality Increases time spent on records/documentation Provides more comprehensive access to records
Satisfied (n = 211)
Not Satisfied (n = 103)
Significance
40.7% 85.0% 71.0% 95.7% 42.3% 38.9% 35.9% 63.3% 90.3%
11.0% 30.0% 11.0% 66.0% 82.0% 12.0% 14.0% 93.0% 61.0%
p < .001** p < .001** p < .001** p < .001** p < .001** p < .001** p < .001** p < .001** p < .001**
*p < .05, **p < .01; ns may not match due to missing values.
Table 6. Anticipated Major Barriers to Implementation Compared to Actual Reported Major Barriers to Implementation following EHR Implementation EHR (actual; n = 334)
No EHR (anticipated; n = 135)
Significance
14.6% 39.1% 31.7% 55.7% 50.7% 48.6% 36.7%
34.6% 57.0% 51.2% 80.3% 70.8% 60.0% 39.2%
p < .001** p = .001** p < .001** p < .001** p < .001** p = .031* p = .629
Consensus on selecting an EHR system Finding a system that meets needs Effort to select system Cost Loss of productivity System reliability and tech support Resistance to changing work habits *p < .05, **p < .01; ns may not match due to missing values.
implementing an EHR system (e.g., “disruption of patient interactions”) and fewer positive outcomes (e.g., “clinical benefits for my practice”) as compared to the outcomes reported by the EHR Group (see Table 7). A higher proportion of the No EHR Group reported anticipating disruptions to patient interactions (67.4%) and the majority (55.8%) of the EHR Group reported this change as well (see Table 6). Interestingly, a significantly higher proportion of the EHR Group, versus the No EHR Group, reported that the EHR would deliver financial benefits, though this proportion (29.6%) was modest, at best, in absolute terms. A substantial proportion of the EHR Group reported improvements to patient care (i.e., “allows me to deliver better patient care”) and other benefits in the clinical setting (i.e., “produces clinical benefits for my practice”; see Table 6). Improved access to data was
overwhelmingly identified as a change experienced following the implementation of an EHR (81.0%).
Discussion The majority of ob-gyns surveyed use an EHR system, and most EHR users were satisfied with their systems. Common benefits reported included better access to records and clinical improvements in practice. Concerns about cost, reduction in efficiency, and increased time commitment were common even for those obgyns who were satisfied with their EHR system. Disruption of patient care was also a commonly cited result of EHR implementation. These concerns were reflected in physicians’ qualitative responses to questions about barriers and benefits to EHR implementation (Raglan et al., in press).
5
6
Journal for Healthcare Quality
Table 7. Anticipated Changes to Practice Compared to Actual Reported Changes following EHR Implementation (Percent Who “Agree” or “Strongly Agree”)
Produces financial benefits for my practice Produces clinical benefits for my practice Allows me to deliver better patient care Makes records more readily available Disrupts the way I interact with my patients Is an asset when recruiting new physicians Enhances patient data confidentiality Increases time spent on records/documentation Provides more comprehensive access to records
EHR (actual; n = 334)
No EHR (anticipated; n = 135)
Significance
29.6% 65.7% 49.8% 85.6% 55.8% 29.2% 28.2% 73.1% 81.0%
21.5% 38.5% 21.5% 61.5% 67.4% 36.2% 20.8% 71.5% 57.7%
p = .008** p < .001** p < .001** p < .001** p = .001** p = .172 p = .056 p = .108 p < .001**
*p < .05, **p < .01; ns may not match due to missing values.
Based on this study, over three-quarters of practicing ob-gyns have, or are planning to implement, an EHR system in their practice. This signifies an important shift in the ob-gyn care pattern after previous studies showing ob-gyns were slower to adopt EHRs than other medical subspecialties (Menechemi et al., 2006). This may represent success from programs like the HITECH Act, and positive financial and other effects reported in this study. Additionally, the majority of those physicians using an EHR reported satisfaction with their EHR systems. Those dissatisfied with their EHR were more likely to be critical of technical support and loss of productivity resulting from implementation, and were more likely to report difficulty in finding the right system for their practice. Many respondents reported that an EHR system provided benefits such as record availability and improved clinical outcomes. Nearly equal numbers of physicians said that an EHR increased and decreased efficiency, and the majority reported that it increased the time spent on documentation. Most ob-gyns also reported that EHR interfered with their interactions with patients. These findings indicate that greater work is needed to make EHR systems fully compatible with the particular needs of ob-gyn practices (McCoy et al., 2010). In particular, integrating EHR systems into newer, more portable hardware to reduce interference with patient interactions may be particularly important for ob-gyn practices. Measures to minimize interference with patient encounters are likely of
greater salience to ob-gyns than most other clinicians because of the vulnerability many patients experience in typical ob-gyn clinical encounters. Further work on honing or customizing templates and flow sheets to allow for easier and more efficient data entry and retrieval would be helpful in reducing the time burden associated with EHR usage. From faster and more efficient operation of an EHR, less disruption of the clinical encounter follows. Additional, and well-tailored, training may be a portal for increasing adoption of EHR among physicians who do not have a system, or satisfaction among those who do. Focus on familiarizing practitioners with timesaving features of their EHR in both training modules and outreach messages may increase awareness of the potential benefits of EHR. Consistent with previous studies, physicians without an EHR were likely to be older and to have a solo practice (Decker, Jamoom, & Sisk, 2012). Physicians without an EHR anticipated more barriers, more negative outcomes, and fewer positive outcomes to implementing an EHR than were reported by individuals who actually had an EHR system. Nevertheless, among ob-gyns who had not yet implemented an EHR, many reported being interested in doing so. Based on these findings, it is apparent that in spite of increased EHR adoption, targeted outreach to ob-gyns is necessary, particularly enhanced efforts to meet the needs of physicians in solo practices. Due to common concerns about costs, which could be a particular burden for those in solo practice, advances need to be made in terms of making
Vol. 00 No. 0 xxx 2014
EHR implementation and the technical support and upgrades needed postimplementation affordable, even for small practices. Lowering the initial amount of time (e.g., training) and expense necessary to become proficient EHR users would be a key consideration for these practitioners. In addition, more work needs to be done to provide outreach and accessibility to older physicians (Decker et al., 2012). A possible explanation for the lower prevalence of EHR implementation among older physicians could be that the perceived value of financial investment in purchasing an EHR, and investing time into learning the technology, is poor. A limitation of this study is that we did not examine computer literacy and comfort with technology in our survey. We also did not assess which EHR systems respondents were using or the degree to which their EHRs were implemented. Future studies are needed to assess whether specific EHR systems are ranked as more satisfactory by ob-gyns and why. Additionally, this study relies on respondent selfreports and recall, rather than more precise measures. Because this study is descriptive in nature, it is not possible to draw conclusions about causal differences between groups. Given that this study has a large sample size, we were able to detect relatively small effect sizes; however, results were examined for both statistical and practical significance. Future studies may look to The Technology Acceptance Model or other theoretical models to better understand the likelihood that a system is embraced by users (Holden & Karsh, 2010). It is clear that more efforts are needed to improve current systems in order to make them more relevant for ob-gyns and to increase understanding of the benefits of EHR systems (George & Bernstein, 2009). This could help encourage individuals to implement an EHR, as well as more fully utilize the systems that they already have. The nearly universal concerns regarding disruptions to clinical interactions should be seen by vendors and developers of EHR systems as an impetus to invest in new technologies that would enable ob-gyns to better focus on their patients and establishing rapport. Intuitive interfaces, for example, would reduce the time required for training, uptake, and development of proficiency with a specific system, thereby easing the transition to an EHR for the practitioner. Additionally, future work addressing workflow changes that com-
plement the transition to EHR systems could help address practical obstacles to EHR implementation. Clearly, continued work by multiple stakeholders is necessary to ensure EHR systems seamlessly function within the unique medical atmosphere of an ob-gyn practice.
Acknowledgments Financial Disclosure: This paper was supported by grant no. UA6MC19010 from the Maternal and Child Health Bureau (Title V, Social Security Act, Health Resources and Services Administration, and Department of Health and Human Services [DHHS]). The findings and conclusions are those of the authors and do not necessarily represent the views of the Health Resources and Services Administration, or the Department of Health and Human Services.
References Bernstein, P. S., Farinelli, C., & Merkatz, I. R. (2005). Using an electronic medical record to improve communication within a prenatal care network. American College of Obstetricians and Gynecologists, 105, 607–612. Burack, R. C., Gimotty, P. A., Simon, M., Moncrease, A., & Dews, P. (2003). The effect of adding Pap smear information to a mammography reminder system in an HMO: Results of randomized controlled trial. Preventive Medicine, 36, 547–554. Burt, C. W., & Sisk, J. E. (2005). Which physicians and practices are using electronic medical records? Health Affairs, 24, 1334–1343. Campbell, E. M., Li, H., Mori, T., Osterweil, P., & Guise, J. M. (2008). The impact of health information technology on work process and patient care in labor and delivery. Advances in patient safety: New directions and alternative approaches (Vol. 4, pp. 1–14). Rockville, MD: Agency for Healthcare Research and Quality (US). Decker, S. L., Jamoom, E. W., & Sisk, J. E. (2012). Physicians in nonprimary care and small practices and those age 55 and older lag in adopting electronic health record systems. Health Affairs, 31, 1108–1114. Deering, S. H., Tobler, K., & Cypher, R. (2010). Improvement in documentation using electronic checklist for shoulder dystocia deliveries. Obstetrics & Gynecology, 116, 63–66. Eden, K. B., Messina, R., Li, H., Osterweil, P., Henderson, C. R., & Guise, J. M. (2008). Examining the value of electronic health records on labor and delivery. American Journal of Obstetrics and Gynecology, 199, 307.e1–307.e9. George, J., & Bernstein, P. S. (2009). Using electronic medical records to reduce errors and risks in a prenatal record. Current Opinion in Obstetrics and Gynecology, 21, 527–531. Hahn, K. A., Ohman-Strickland, P. A., Cohen, D. J., Piasecki, A. K., Crosson, J. C., Clark, E. C., et al. (2011). Electronic medical records are not associated with improved documentation in community primary care practices. American Journal of Medical Quality, 26, 272–277. Holden, R. J., & Karsh, B. (2010). The Technology Acceptance Model: Its past and its future in health care. Journal of Biomedical Informatics, 43, 159–172. Hsiao, C., & Hing, E. (2012). Use and characteristics of electronic health record systems among office-based
7
8
Journal for Healthcare Quality
physician practices: United States, 2001–2012. NCHS Data Brief, 111, 1–8. McCoy, M. J., Diamond, A. M., & Strunk A. L. (2010). Special requirements of electronic medical record systems in obstetrics and gynecology. Obstetrics & Gynecology, 116, 140–143. Menechemi, N., Lee, S. C., Shepherd, J. E., & Brooks, R. G. (2006). Proliferation of electronic health records among obstetrician-gynecologists. Quality Management in Health Care, 15, 150–156. Miller, R. H., & Sim, I. (2004). Physicians’ use of electronic medical records: Barriers and solutions. Health Affairs, 23, 116–126. Nielsen, P. E., Thomson, B. A., Jackson, R. B., Kosman, K., & Kiley, K. C. (2000). Standard obstetric record charting system: Evaluation of a new electronic medical record. Obstetrics & Gynecology, 96(6), 1003-1008. Raglan, G. B., Margolis, B., Paulus, R. A., & Schulkin, J. (in press). Obstetrician/gynecologists’ experiences with electronic health record systems: A narrative study. Journal of Reproductive Medicine. The Physicians Foundation (2012). A survey of America’s physicians: Practice patterns and perspectives. Boston, MA: Physicians Foundation. Tundia, N. L., Kelton, C. M., Cavanaugh, T. M., Guo, J. J., Hanseman, D. J., & Heaton, P. C. (2013). The effect of electronic medical record system sophistication on preventive healthcare for women. Journal of the American Medical Informatics Association, 20, 268– 276. Zwaanswijk, M., Ploem, M. C., Wiesma, F. J., Verheij, R. A., & Gevers, J. K. (2013). Understanding health care
provider’s reluctance to adopt a national electronic patient record: An empirical and legal analysis. Medical Law Review, 32, 13–31.
Authors’ Biographies Greta B. Raglan, MA, is a research assistant at the American College of Obstetricians and Gynecologists, as well as a doctoral student in Clinical Psychology at American University, in Washington, DC. Benyamin Margolis, PhD, MPH, is a Health Scientist at the Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services in Rockville, MD. Ronald Paulus, MD, is President and CEO of Mission Health, an integrated health system serving Western North Carolina. Before joining Mission Health, Dr. Paulus was Executive Vice President, Clinical Operations and Chief Innovation Officer at Geisinger Health System. Jay Schulkin, PhD, is the Director of Research at the American College of Obstetricians and Gynecologists, as well as a research professor in the Department of Neuroscience at Georgetown University School of Medicine in Washington, DC. For more information on this article, contact Greta B. Raglan at [email protected].
1
Electronic Health Record Adoption among Obstetrician/Gynecologists in the United States: Physician Practices and Satisfaction Greta B. Raglan, Benyamin Margolis, Ronald A. Paulus, Jay Schulkin Electronic health record (EHR) systems, although in use for the last few decades, have been increasingly adopted by health professionals in recent years (Hsiao & Hing, 2012). The factors thought to influence the adoption of EHRs include improved system quality, increased patient interest, and the Heath Information Technology for Economic and Clinical Health (HITECH) Act that incentivized implementation of EHR systems. Few studies have directly tracked the prevalence or patterns of EHR adoption by obstetrician-gynecologists (ob-gyns). The studies that have examined this found that use of EHR systems among obgyns lagged behind many other subspecialties such as internists and primary care physicians (Burt & Sisk, 2005; Menechemi, Lee, Shepherd, & Brooks, 2006), and that ob-gyns often did not use all of the features of their EHR systems (Tundia et al., 2013). Estimates of ob-gyns utilization from 2001 to 2003 reported that only 15–20% of ob-gyns use an EHR system in the United States (Burt & Sisk, 2005; Menechemi et al., 2006). General studies of EHR adoption found that many physicians were reluctant to use an EHR system because of concerns it would increase time spent on documentation (e.g., Miller & Sim, 2004) and possibly lead to errors in documentation (Zwaanswijk, Ploem, Wiesma, Verheij, & Gevers, 2013). Additionally, concerns have been raised that EHR would decrease patient confidentiality (The Physicians Foundation, 2012; Zwaanswijk et al., 2013), and there is skepticism that EHR systems would increase effectiveness of care (Hahn et al., 2011). Existing studies on adoption and implementation have neither directly analyzed the experiences with, nor the opinions and perceptions of, EHR systems by ob-gyns. This information is particularly important to understanding why ob-gyns appear to trail other medical professionals in the adoption of EHR systems. There are unique qualities of ob-gyn practice (e.g., focus on both mother and child, officeand hospital-based, medical and surgical) relative to other subspecialties, which suggest
Abstract: Implementation of electronic health records (EHRs) has historically been lower among obstetrician-gynecologists (obgyns) than many physician groups. This study described ob-gyns’ adoption and use of EHR systems in practice, as well as barriers and benefits to implementation. Surveys asking about the physicians’ use of EHR, satisfaction with systems, and what features they found most or least helpful were mailed to 1,200 ob-gyns. An overall response rate of 57.4% was achieved, with 559 returning completed surveys. Over three-quarters of responders reported that they used an EHR system or planned to implement one. Physicians without EHR tended to be older, were more likely to be male, have a solo practice, and describe themselves as Asian/Pacific Islander. Over 63% of those physicians who use EHR reported being satisfied with their system, while 30.8% were not satisfied. Ob-gyns who reported satisfaction had a younger mean age (M = 52.98, SD = 8.87) than those not satisfied (M = 56.30, SD = 8.59; p = .002). Use of EHR systems among ob-gyns has increased in recent years and overall satisfaction with these systems is high. In spite of this, barriers to implementation are still present and increased outreach to certain groups of ob-gyns, including older practitioners and those in solo practices, is needed.
ob-gyns would have different requirements and considerations for an EHR system. Similarly, EHRs could have different impacts on ob-gyns in practice when compared to other subspecialties (McCoy, Diamond, & Strunk, 2010). Several studies have, however, demonstrated that the implementation of EHRs produces clinical benefits specific to ob-gyn practices (Campbell, Li, Mori, Osterweil, & Guise, 2008). Electronic records have been found to be more complete than paper records (Bernstein et al., 2005; Eden et al., 2008; George & Bernstein, 2009; Nielsen et al., 2000). Electronic reminders included in many EHR systems have improved rates of regular testing among patients and documentation of these services (Burack, Gimotty, Simon, Moncrease, & Dews, 2003). Checklists have been linked to improved clinical outcomes in certain procedures such as shoulder dystocia (Deering, Tobler, & Cypher, 2010). Improvements appear to increase with time since adoption, particularly as systems become more fully integrated into a practice (Tundia et al., 2013).
Keywords documentation efficiency/cost reduction research quantitative
Journal for Healthcare Quality Vol. 00, No. 0, pp. 1–8 C 2014 National Association for Healthcare Quality
2
Journal for Healthcare Quality
The current study was descriptive in nature and aimed at giving a more complete view of ob-gyns’ adoption and use of EHR systems in practice. In addition, we asked ob-gyns with and without EHR experience to comment on aspects of EHRs that may help or hinder daily practice in an effort to better understand barriers to implementation unique to ob-gyn practices. The aim of this study was to answer approximately how many ob-gyns currently use an EHR system, and how demographic and practice areas differ between that group and those who do not use an EHR system. Additionally, it addresses questions of what qualities of EHR systems were perceived as benefits versus barriers in EHR users and how EHR implementation affected practice. Among ob-gyns without EHR systems, the study focused on whether they wished to adopt EHR, and their beliefs about the effects of implementation.
Study Design and Methods A survey regarding practices, opinions, and patient characteristics was developed at the American College of Obstetricians and Gynecologists (ACOG) in consultation with practicing ob-gyns. Questions were pilot-tested on a sample of practicing ob-gyns with adjustments made based on feedback. IRB approval was obtained from ACOG. Paper mailings included a cover letter, a questionnaire, and a stamped return envelope. The survey was sent to 1,200 ACOG fellows. Six hundred were members of the Collaborative Ambulatory Research Network (CARN). CARN members are ACOG fellows and junior fellows in practice who have volunteered to participate in survey studies without compensation; they are typically recruited through advertising or random selection from ACOG’s membership rolls. CARN was established to improve the response rate on ACOG survey studies while maintaining a participant pool representative of practicing ACOG members. The remaining 600 participants consisted of a computer-generated random sample of ACOG fellows and junior fellows in practice who had not received a survey from ACOG during the previous 2 years. Fifteen participants were unreachable due to change of address or retirement from practice. Surveys asked a series of demographics questions and whether physicians currently use an EHR system. Likert-type questions asked physicians about EHR systems, barriers to imple-
mentation, reasons for implementation, and changes in practice since implementation. Physicians were also asked specific yes/no or fill-in-the-blank questions about their EHR system such as whether it communicates with their local hospital, and about utilization at their practice. Ob-gyns were also asked whether or not they were satisfied with their current EHR system. Respondents who reported not using an EHR system were asked to complete Likerttype questions about barriers to implementation, changes they anticipated if they were to implement an EHR system, and whether they would be interested in implementing an EHR system at their practice. Qualitative items about ob-gyns’ experiences are reported elsewhere (Raglan, Margolis, Paulus, & Schulkin, in press). Those who did not respond to the initial mailing were sent three reminders. Those who had not responded were sent a brief follow-up letter containing an abbreviated questionnaire. The data were analyzed using a personal computer-based software package (IBM SPSS R 20.0, IBM Corp , Armonk, NY). DeStatistics scriptive statistics were computed for the measures used in the analyses and one-way ANOVA was used to compare group means of continuous measures. Differences on dichotomous variables were assessed using chi-squares. Analyses were tested for significance using alpha of 0.05. C
Results Six-hundred-eighty-nine surveys and letters were returned for a total response rate of 58.1%. Those who responded with a letter did not differ from survey responders in terms of gender or EHR use. Letter responders were older (M = 55.63, SD = 9.26) than survey responders (M = 53.62, SD = 9.14; p = .030). Fewer letter responders (51.4%) reported being satisfied with their EHR system than survey responders (67.2%; p = .011). Unless otherwise noted, the following results reflect the responses of survey responders only because of the abbreviated questions found in letters. Of 559 ob-gyns who returned a survey, 334 (59.7%) reported that they currently use an EHR system (EHR Group), 90 (16.1%) planned to implement one in the next year (Planned EHR Group), and 135 (24.2%) did not have an EHR system or plans to implement one in the next year (No EHR Group). The No EHR Group tended to be older, was more likely to be male, was more likely to be Asian/Pacific
Vol. 00 No. 0 xxx 2014
Table 1. Physician Demographics
Age (mean years, SD) Gender (% female) Race White/European American Black/African American Asian/Pacific Islander Other/more than one Clinical practice setting Solo/private practice Partnership/group practice Multispecialty group University full time Other Practice location Urban, inner city Urban, noninner city Suburban Town of 5,000–50,000 Rural/other Specialty General ob-gyn Gynecology only Other *
Total (n = 559)
EHR/Planned EHR (n = 424)
No EHR (n = 135)
55.6, 9.25 47.6
54.64, 9.01 50.9
58.77, 9.31 38.5
82.2% 4.3% 8.2% 5.3%
83.5% 4.5% 7.2% 4.8%
78.4% 3.7% 11.2% 6.6%
17.8% 45.8% 14.4% 10.4% 11.6%
10.2% 45.3% 18.5% 13.0% 13.1%
41.5% 47.4% 1.5% 2.2% 7.4%
16.2% 28.2% 37.9% 13.8% 4.0%
17.3% 26.5% 39.2% 13.5% 3.5%
12.7% 33.6% 33.6% 14.9% 5.2%
73.8% 17.5% 8.7%
74.2% 15.9% 9.9%
72.6% 22.2% 5.2%
Significance p < .001** p = .012* p = .042*
p < .001**
p = .372
p = .292
p < .05, ** p < .01
Islander, and was more likely to have a solo practice. They did not differ from the EHR and Planned EHR Groups in terms of practice location or specialty (see Table 1). In addition, the No EHR Group reported seeing more patients per year (4,186.30 ± 8,319.28) than those in the EHR or Planned EHR Groups (3,145.91 ± SD = 2,254.20, p = .032). Just over half of physicians in the EHR Group reported that EHR decreased the time spent on pharmacy calls (50.3%) and time to receive and review lab results (50.3%). About half also reported that it increased the efficiency and comprehensiveness of billing (49.7%) and decreased the costs of managing and storing results (47.9%). Forty-one percent of respondents, however, reported that EHRs decreased overall practice efficiency, compared to 38.0% who said that efficiency increased. Additionally, 66.8% of respondents said that EHRs increased the time spent to plan, review, order, and document care. In the EHR Group, 63.2% reported that overall, they were satisfied with their EHR system (Satisfied Group), while 30.8% reported that they were not satisfied (Not Satisfied Group).
The Satisfied Group had a younger mean age (52.98 ± 8.87) than the Not Satisfied Group (56.30 ± 8.59; p = .002). The Satisfied Group was more likely than Not Satisfied to report that efficiency, decision support, offsite record access, patient portal, and satisfying patient requests were “important” or “very important” to their decision to implement an EHR system (see Table 2). Among the Not Satisfied Group, meaningful use incentives were cited as the single most compelling reason that led practitioners to implement an EHR system, while patient care and efficiency were cited for the Satisfied Group (see Table 3). Overall, the Not Satisfied Group reported more major barriers to the implementation of an EHR system. In particular, they were more likely to say that finding a system that meets the needs of their practice, loss of productivity, and system reliability and postpurchase support posed major barriers to EHR use and implementation (see Table 4). Anticipated costs of implementing and maintaining an EHR system were not associated with a physician’s reported satisfaction with that system, and other possible factors (e.g., data security) were not fully
3
4
Journal for Healthcare Quality
Table 2. Percent with EHR Reporting the Reason for Implementing EHR Was Important/Very Important Satisfied (n = 211)
Not Satisfied (n = 103)
Significance
61.1% 79.7% 49.5% 84.2% 59.5% 80.0% 40.9% 36.4% 63.6%
66.7% 70.5% 51.6% 59.6% 39.6% 68.8% 24.0% 20.8% 69.4%
p = .368 p = .086 p = .737 p < .001** p = .002** p = .036* p = .005** p = .007** p = .585
Cost Effect on patient care Meaningful use incentives Efficiency Decision support Ability to access records off-site Patient portal Satisfying patient requests Othera a
For example, mandated by institution; *p < .05, **p < .01; ns may not match due to missing values.
Table 3. Percent with EHR Reporting the Most Important Motivation for Their Decision to Implement EHR EHR Group (n = 290)
Satisfied (n = 180)
Not Satisfied (n = 96)
29.7% 19.7% 19.3% 18.6% 9.3% 2.8% 0.3% 0.3%
36.7% 26.1% 15.6% 11.0% 6.1% 3.3% 0.6% 0.6%
16.7% 9.4% 28.1% 30.2% 13.5% 2.1% 0.0% 0.0%
Effect on patient care Efficiency Othera Meaningful use incentives Ability to access records off-site Cost Decision support Patient portal a
For example, mandated by institution; ns may not match due to missing values.
covered in the survey. As anticipated, the Satisfied Group reported more positive outcomes from implementation than did the Not Satisfied. The Not Satisfied Group was more likely to say that EHR “disrupts the way I interact with my patients” and “increases time spent on records/documentation” (see Table 5).
Among the No EHR Group, 33.3% were not interested in implementing EHR, and 20.2% were unsure. This group anticipated more major barriers to implementation than the EHR Group reported experiencing (see Table 6). The No EHR Group reported anticipating more negative outcomes resulting from
Table 4. Reported Major Barriers to EHR Implementation and Satisfaction with EHR in Physicians with an EHR System Satisfied (n = 211)
Not Satisfied (n = 103)
Significance
11.6% 30.6% 30.1% 52.3% 36.9% 38.1% 33.5%
19.6% 54.4% 34.8% 59.8% 75.0% 67.4% 41.8%
p = .077 p = .001** p = .431 p = .243 p < .001** p < .001** p = .185
Consensus on selecting an EHR system Finding a system that meets needs Effort to select system Cost Loss of productivity System reliability and tech support Resistance to changing work habits *p < .05, **p < .01; ns may not match due to missing values.
Vol. 00 No. 0 xxx 2014
Table 5. Reported Changes following EHR Implementation and Physician Satisfaction (Percent Who “Agree” or “Strongly Agree”)
Produces financial benefits for my practice Produces clinical benefits for my practice Allows me to deliver better patient care Makes records more readily available Disrupts the way I interact with my patients Is an asset when recruiting new physicians Enhances patient data confidentiality Increases time spent on records/documentation Provides more comprehensive access to records
Satisfied (n = 211)
Not Satisfied (n = 103)
Significance
40.7% 85.0% 71.0% 95.7% 42.3% 38.9% 35.9% 63.3% 90.3%
11.0% 30.0% 11.0% 66.0% 82.0% 12.0% 14.0% 93.0% 61.0%
p < .001** p < .001** p < .001** p < .001** p < .001** p < .001** p < .001** p < .001** p < .001**
*p < .05, **p < .01; ns may not match due to missing values.
Table 6. Anticipated Major Barriers to Implementation Compared to Actual Reported Major Barriers to Implementation following EHR Implementation EHR (actual; n = 334)
No EHR (anticipated; n = 135)
Significance
14.6% 39.1% 31.7% 55.7% 50.7% 48.6% 36.7%
34.6% 57.0% 51.2% 80.3% 70.8% 60.0% 39.2%
p < .001** p = .001** p < .001** p < .001** p < .001** p = .031* p = .629
Consensus on selecting an EHR system Finding a system that meets needs Effort to select system Cost Loss of productivity System reliability and tech support Resistance to changing work habits *p < .05, **p < .01; ns may not match due to missing values.
implementing an EHR system (e.g., “disruption of patient interactions”) and fewer positive outcomes (e.g., “clinical benefits for my practice”) as compared to the outcomes reported by the EHR Group (see Table 7). A higher proportion of the No EHR Group reported anticipating disruptions to patient interactions (67.4%) and the majority (55.8%) of the EHR Group reported this change as well (see Table 6). Interestingly, a significantly higher proportion of the EHR Group, versus the No EHR Group, reported that the EHR would deliver financial benefits, though this proportion (29.6%) was modest, at best, in absolute terms. A substantial proportion of the EHR Group reported improvements to patient care (i.e., “allows me to deliver better patient care”) and other benefits in the clinical setting (i.e., “produces clinical benefits for my practice”; see Table 6). Improved access to data was
overwhelmingly identified as a change experienced following the implementation of an EHR (81.0%).
Discussion The majority of ob-gyns surveyed use an EHR system, and most EHR users were satisfied with their systems. Common benefits reported included better access to records and clinical improvements in practice. Concerns about cost, reduction in efficiency, and increased time commitment were common even for those obgyns who were satisfied with their EHR system. Disruption of patient care was also a commonly cited result of EHR implementation. These concerns were reflected in physicians’ qualitative responses to questions about barriers and benefits to EHR implementation (Raglan et al., in press).
5
6
Journal for Healthcare Quality
Table 7. Anticipated Changes to Practice Compared to Actual Reported Changes following EHR Implementation (Percent Who “Agree” or “Strongly Agree”)
Produces financial benefits for my practice Produces clinical benefits for my practice Allows me to deliver better patient care Makes records more readily available Disrupts the way I interact with my patients Is an asset when recruiting new physicians Enhances patient data confidentiality Increases time spent on records/documentation Provides more comprehensive access to records
EHR (actual; n = 334)
No EHR (anticipated; n = 135)
Significance
29.6% 65.7% 49.8% 85.6% 55.8% 29.2% 28.2% 73.1% 81.0%
21.5% 38.5% 21.5% 61.5% 67.4% 36.2% 20.8% 71.5% 57.7%
p = .008** p < .001** p < .001** p < .001** p = .001** p = .172 p = .056 p = .108 p < .001**
*p < .05, **p < .01; ns may not match due to missing values.
Based on this study, over three-quarters of practicing ob-gyns have, or are planning to implement, an EHR system in their practice. This signifies an important shift in the ob-gyn care pattern after previous studies showing ob-gyns were slower to adopt EHRs than other medical subspecialties (Menechemi et al., 2006). This may represent success from programs like the HITECH Act, and positive financial and other effects reported in this study. Additionally, the majority of those physicians using an EHR reported satisfaction with their EHR systems. Those dissatisfied with their EHR were more likely to be critical of technical support and loss of productivity resulting from implementation, and were more likely to report difficulty in finding the right system for their practice. Many respondents reported that an EHR system provided benefits such as record availability and improved clinical outcomes. Nearly equal numbers of physicians said that an EHR increased and decreased efficiency, and the majority reported that it increased the time spent on documentation. Most ob-gyns also reported that EHR interfered with their interactions with patients. These findings indicate that greater work is needed to make EHR systems fully compatible with the particular needs of ob-gyn practices (McCoy et al., 2010). In particular, integrating EHR systems into newer, more portable hardware to reduce interference with patient interactions may be particularly important for ob-gyn practices. Measures to minimize interference with patient encounters are likely of
greater salience to ob-gyns than most other clinicians because of the vulnerability many patients experience in typical ob-gyn clinical encounters. Further work on honing or customizing templates and flow sheets to allow for easier and more efficient data entry and retrieval would be helpful in reducing the time burden associated with EHR usage. From faster and more efficient operation of an EHR, less disruption of the clinical encounter follows. Additional, and well-tailored, training may be a portal for increasing adoption of EHR among physicians who do not have a system, or satisfaction among those who do. Focus on familiarizing practitioners with timesaving features of their EHR in both training modules and outreach messages may increase awareness of the potential benefits of EHR. Consistent with previous studies, physicians without an EHR were likely to be older and to have a solo practice (Decker, Jamoom, & Sisk, 2012). Physicians without an EHR anticipated more barriers, more negative outcomes, and fewer positive outcomes to implementing an EHR than were reported by individuals who actually had an EHR system. Nevertheless, among ob-gyns who had not yet implemented an EHR, many reported being interested in doing so. Based on these findings, it is apparent that in spite of increased EHR adoption, targeted outreach to ob-gyns is necessary, particularly enhanced efforts to meet the needs of physicians in solo practices. Due to common concerns about costs, which could be a particular burden for those in solo practice, advances need to be made in terms of making
Vol. 00 No. 0 xxx 2014
EHR implementation and the technical support and upgrades needed postimplementation affordable, even for small practices. Lowering the initial amount of time (e.g., training) and expense necessary to become proficient EHR users would be a key consideration for these practitioners. In addition, more work needs to be done to provide outreach and accessibility to older physicians (Decker et al., 2012). A possible explanation for the lower prevalence of EHR implementation among older physicians could be that the perceived value of financial investment in purchasing an EHR, and investing time into learning the technology, is poor. A limitation of this study is that we did not examine computer literacy and comfort with technology in our survey. We also did not assess which EHR systems respondents were using or the degree to which their EHRs were implemented. Future studies are needed to assess whether specific EHR systems are ranked as more satisfactory by ob-gyns and why. Additionally, this study relies on respondent selfreports and recall, rather than more precise measures. Because this study is descriptive in nature, it is not possible to draw conclusions about causal differences between groups. Given that this study has a large sample size, we were able to detect relatively small effect sizes; however, results were examined for both statistical and practical significance. Future studies may look to The Technology Acceptance Model or other theoretical models to better understand the likelihood that a system is embraced by users (Holden & Karsh, 2010). It is clear that more efforts are needed to improve current systems in order to make them more relevant for ob-gyns and to increase understanding of the benefits of EHR systems (George & Bernstein, 2009). This could help encourage individuals to implement an EHR, as well as more fully utilize the systems that they already have. The nearly universal concerns regarding disruptions to clinical interactions should be seen by vendors and developers of EHR systems as an impetus to invest in new technologies that would enable ob-gyns to better focus on their patients and establishing rapport. Intuitive interfaces, for example, would reduce the time required for training, uptake, and development of proficiency with a specific system, thereby easing the transition to an EHR for the practitioner. Additionally, future work addressing workflow changes that com-
plement the transition to EHR systems could help address practical obstacles to EHR implementation. Clearly, continued work by multiple stakeholders is necessary to ensure EHR systems seamlessly function within the unique medical atmosphere of an ob-gyn practice.
Acknowledgments Financial Disclosure: This paper was supported by grant no. UA6MC19010 from the Maternal and Child Health Bureau (Title V, Social Security Act, Health Resources and Services Administration, and Department of Health and Human Services [DHHS]). The findings and conclusions are those of the authors and do not necessarily represent the views of the Health Resources and Services Administration, or the Department of Health and Human Services.
References Bernstein, P. S., Farinelli, C., & Merkatz, I. R. (2005). Using an electronic medical record to improve communication within a prenatal care network. American College of Obstetricians and Gynecologists, 105, 607–612. Burack, R. C., Gimotty, P. A., Simon, M., Moncrease, A., & Dews, P. (2003). The effect of adding Pap smear information to a mammography reminder system in an HMO: Results of randomized controlled trial. Preventive Medicine, 36, 547–554. Burt, C. W., & Sisk, J. E. (2005). Which physicians and practices are using electronic medical records? Health Affairs, 24, 1334–1343. Campbell, E. M., Li, H., Mori, T., Osterweil, P., & Guise, J. M. (2008). The impact of health information technology on work process and patient care in labor and delivery. Advances in patient safety: New directions and alternative approaches (Vol. 4, pp. 1–14). Rockville, MD: Agency for Healthcare Research and Quality (US). Decker, S. L., Jamoom, E. W., & Sisk, J. E. (2012). Physicians in nonprimary care and small practices and those age 55 and older lag in adopting electronic health record systems. Health Affairs, 31, 1108–1114. Deering, S. H., Tobler, K., & Cypher, R. (2010). Improvement in documentation using electronic checklist for shoulder dystocia deliveries. Obstetrics & Gynecology, 116, 63–66. Eden, K. B., Messina, R., Li, H., Osterweil, P., Henderson, C. R., & Guise, J. M. (2008). Examining the value of electronic health records on labor and delivery. American Journal of Obstetrics and Gynecology, 199, 307.e1–307.e9. George, J., & Bernstein, P. S. (2009). Using electronic medical records to reduce errors and risks in a prenatal record. Current Opinion in Obstetrics and Gynecology, 21, 527–531. Hahn, K. A., Ohman-Strickland, P. A., Cohen, D. J., Piasecki, A. K., Crosson, J. C., Clark, E. C., et al. (2011). Electronic medical records are not associated with improved documentation in community primary care practices. American Journal of Medical Quality, 26, 272–277. Holden, R. J., & Karsh, B. (2010). The Technology Acceptance Model: Its past and its future in health care. Journal of Biomedical Informatics, 43, 159–172. Hsiao, C., & Hing, E. (2012). Use and characteristics of electronic health record systems among office-based
7
8
Journal for Healthcare Quality
physician practices: United States, 2001–2012. NCHS Data Brief, 111, 1–8. McCoy, M. J., Diamond, A. M., & Strunk A. L. (2010). Special requirements of electronic medical record systems in obstetrics and gynecology. Obstetrics & Gynecology, 116, 140–143. Menechemi, N., Lee, S. C., Shepherd, J. E., & Brooks, R. G. (2006). Proliferation of electronic health records among obstetrician-gynecologists. Quality Management in Health Care, 15, 150–156. Miller, R. H., & Sim, I. (2004). Physicians’ use of electronic medical records: Barriers and solutions. Health Affairs, 23, 116–126. Nielsen, P. E., Thomson, B. A., Jackson, R. B., Kosman, K., & Kiley, K. C. (2000). Standard obstetric record charting system: Evaluation of a new electronic medical record. Obstetrics & Gynecology, 96(6), 1003-1008. Raglan, G. B., Margolis, B., Paulus, R. A., & Schulkin, J. (in press). Obstetrician/gynecologists’ experiences with electronic health record systems: A narrative study. Journal of Reproductive Medicine. The Physicians Foundation (2012). A survey of America’s physicians: Practice patterns and perspectives. Boston, MA: Physicians Foundation. Tundia, N. L., Kelton, C. M., Cavanaugh, T. M., Guo, J. J., Hanseman, D. J., & Heaton, P. C. (2013). The effect of electronic medical record system sophistication on preventive healthcare for women. Journal of the American Medical Informatics Association, 20, 268– 276. Zwaanswijk, M., Ploem, M. C., Wiesma, F. J., Verheij, R. A., & Gevers, J. K. (2013). Understanding health care
provider’s reluctance to adopt a national electronic patient record: An empirical and legal analysis. Medical Law Review, 32, 13–31.
Authors’ Biographies Greta B. Raglan, MA, is a research assistant at the American College of Obstetricians and Gynecologists, as well as a doctoral student in Clinical Psychology at American University, in Washington, DC. Benyamin Margolis, PhD, MPH, is a Health Scientist at the Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services in Rockville, MD. Ronald Paulus, MD, is President and CEO of Mission Health, an integrated health system serving Western North Carolina. Before joining Mission Health, Dr. Paulus was Executive Vice President, Clinical Operations and Chief Innovation Officer at Geisinger Health System. Jay Schulkin, PhD, is the Director of Research at the American College of Obstetricians and Gynecologists, as well as a research professor in the Department of Neuroscience at Georgetown University School of Medicine in Washington, DC. For more information on this article, contact Greta B. Raglan at [email protected].
