Measuring Clinicians’ Expectations Prior to EHR Implementation

Abstract

To measure user expectations and knowledge of the issues involved in the transition from a paper-based system to an EHR, we created an on-line questionnaire, and invited physicians from several specialties at Beth Israel Medical Center (BIMC) to respond to it. As expected, most participants had positive expectations for the EHR and its features, but respondents were more skeptical of electronic clinical decision support systems (CDSS) than we had expected. The responses of this “EHR-naïve” group of physicians underscore the importance of managing expectations with the implementation of the EHR and of the delicate balance involved in preserving physician independence when proposing a clinical decision support system.

Background

Several other groups have evaluated physician attitudes toward EHRs, but generally these studies have been in the setting of experienced users¹ or established systems². One study showed moderately positive expectations for an EHR pre-implementation³; unfortunately, many of these were unmet after the actual implementation.

Methods

We designed a web-based questionnaire to gauge clinicians’ attitudes toward and knowledge of EHR systems and CDSS. Invitations were emailed to the clinical staff at BIMC and its affiliated hospitals. Over a one month period, we received 43 responses on the website out of 163 invitations that were sent.

Results

EHR

56% of users had used some sort of EHR in the past. Most respondents appeared to have a positive outlook on employing an EHR, as 63% believed that an EHR would help their workflow, while only 5% thought it would have a negative impact (the remaining 32% responded “not sure”). An even larger majority (72%) believed that an EHR would save them time, though 21% thought that it would increase their clinical time investment. Respondents were also asked to rank six different features of the EHR (creating electronic progress notes; connecting inpatient and outpatient information; an “inbox” of patient alerts; having multiple patient lists; integrated results reporting; and integrated electronic decision support) in terms of importance; interestingly, although we expected certain features such as “the ability to create electronic progress notes”, or “integrated results reporting” (as opposed to the 4 different systems currently in use) to stand out, no single feature was singled out among the users.

CDSS

We used respondents’ frequency of consultation with outside information sources, as a proxy measurement for unmet information needs, i.e. situations where CDSS would be useful. Only 19% of respondents consulted clinical guidelines daily or more frequently, but 47% consulted other information sources at least as often. Approximately one third of respondents were familiar with CDSS. Respondents had mainly positive expectations for a CDSS: 60% responded that a CDSS would help their clinical workflow, and 53% believed that it would lead to improved patient outcomes. Only 7% had negative opinions on these two questions. 28% believed that they would have a reason to use the system at least daily. The free text comments we received underlined the well-known idea that improved access to information is seen very positively, but using the information to impose decisions on clinicians provokes a great deal of resentment.

Conclusions

We plan to use these results to tailor user training prior to adopting the new EHR system, under the premise that managing expectations will lead to a higher likelihood of a successful implementation.