Physicians are likely going to give a loud groan when you ask them about EHRs. Why, then, have they warmed up to the mobile experience?
Since the enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, the adoption rate of EHR systems has spiked among healthcare providers. Not just hospital-based physicians, but physicians in all settings.
For instance, research from the Office of the National Coordinator for Health IT found that the percentage of office-based physicians with any kind of EHR went from a rate of 48 percent adoption in 2009 to 83 percent in 2014. The percentage of those physicians with a basic EHR, as designated by CMS through its Meaningful Use initiative, went from 22 percent in 2009 to 51 percent in 2014.
But while an EHR system is becoming as commonplace as a stethoscope, it's important to not mistake an increase in adoption for rising popularity. At the same time EHRs have become more pervasive, they have also become one of the chief sources of physicians' frustrations. For instance, in the 2016 Physicians Practice Technology Survey, 74 percent of respondents said they have not received a return on their investment from their EHR. Moreover, it could be linked to another rising statistic in the healthcare industry - burnout.
"[The EHR] is probably a major source in the disturbing uptick of burnout rates among American physicians," says Robert Wachter, physician and professor and interim chairman of the Department of Medicine at the University of California, San Francisco (UCSF) as well as the author of "The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age." "The Mayo Clinic published a study that showed burnout rates are above 50 percent and have gone up 9 percent in the last few years. I don't think it's coincidental that it's happened at the same time as widespread EHR adoption," he notes.
Physicians dove into the EHR era with an undeniable lack of enthusiasm for the technology. There is, however, an outlier in this realm. It seems as if mobile health (mHealth) technologies are something physicians are actually interested in.
"When you talk to physicians about EHRs and they are unhappy about a situation, they'll say, 'It shows me too much stuff, it requires too many clicks, it has too many screens, it slows me down.' The smartphone apps on the other hand are designed to show them what you need. They give you just enough functionality," says Bradley Howard, a physician and the executive medical director at consulting firm, Clinovations, a division of the Advisory Board Company.
While the EHR desktop applications feel "forced," according to Howard, who was also former chief medical informatics officer at Presence Health, the mobile apps are less of a "ball and chain," he says. Perhaps this explains the uptick in physicians who access and use mobile-enable EHRs, from 50 percent in 2013 to 78 percent this past year according to the 2016 Physicians Practice Technology Survey.
"Physicians are mobile for two reasons. Number one, anybody hates to be tied to a PC for any reason - whether they are in healthcare or not," says David Lee Scher, a cardiologist and founder and director of DLS Healthcare Consulting, LLC. "Number two, I think mobile is more attractive based on the fact you don't have 50 tabs on top and 12 on the side."
Jan Oldenburg, a health IT consultant with Ernst & Young and the co-chair of the Healthcare Information Management and Systems Society's (HIMSS) Connected Health Community, agrees with Scher's first reason. She says that mobile EHRs are simply more convenient for physicians. "There isn't a lot convenience about being chained to an office EHR or even a home desktop with remote access," she says.
Howard sees the physician's love for mobile no different than anyone else. "We love our smartphones. When we forget our smartphones … we're thinking about it [while we're away from them]," he says, noting that physicians are no different. "Can I get the EHR on my tablet is never a question [that is asked during implementation]. It's what can I do with it? The expectation is that they will have it."
WORK FLOW IMPROVEMENTS
In this regard, utilizing mobile devices may be a better fit for the physician's work flow than the desktop EHR. Joshua Bock, a Mesa, Ariz.-based chiropractor and managing partner of a 24-physician practice, says he is certainly of the belief that mobile technology improves clinical work flow. He says doctors in his practice use iPads and a mobile EHR app frequently to allow roaming around the building from room to room and quickly accessing pertinent information. It also relieves clinicians of the pressure to capture everything at the time they are in front of the patient he says.
"You can capture after [the physician has] left the room. When you have time to put your thoughts together, you don't have to do this on-the-fly medicine. You can turn around and capture that information five minutes later, an hour later, two hours later, when you actually have downtime. It just manages your work flow easier. The mobility piece of this gives them the freedom to not have to do it in the room," says Bock.
Cory Annis, an internal medicine physician as well as the owner and founder of Unorthodoc, a direct primary care (DPC) practice in Carrboro, N.C., says that her mobile EHR app fits her practice better than one on a desktop. She says being in a DPC practice means high-service toward your patients and understanding what's most convenient for them. In other words, Annis says it wouldn't be convenient for her, or her patients, to have to go into the office every time they wanted to have a conversation.
This is why Annis uses a mobile EHR app integrated with a HIPAA-compliant texting platform. She says this allows her to have meaningful conversations with patients whenever it is convenient for both sides. Moreover, the conversations are integrated directly into the patient's chart.
"The stride toward mobility allows you to take your work home with you. Of course, the downside is that it's constantly present, but at least it's not chained to a specific place," Annis says. "It's not just providers though. If patients can visit through their technology, this helps them. If we can visit through their technology, it helps us."
IMPROVING THE EXPERIENCE
Naturally, the mobile EHR experience isn't without its own issues. If it were, the 78 percent adoption would be closer to 100 percent. One of the biggest reasons Bock says there hasn't been higher rates of adoption is data security. He says many physicians may have a fear that the mobile EHR app will compromise their patients' data, and a result, violate HIPAA rules. He also says he has issues with inputting data into an EHR mobile app. "If you speak into the system, it won't always spell it correctly. That part is lagging," he says.
Scher doesn't believe the issues are a matter of technology, but rather usability. This is one of the chief complaints of desktop EHR systems and he says it spills over to the mobile app. "I don't think clinicians have had any input, at least it doesn't seem that way, with regards what is on the mobile app," he says.
Howard and Oldenburg both concur that developers need to give end users more flexibility and control of configuring. "It's got to be really well designed and the work flow around it has to be designed," Oldenburg says. "Design, design, design. Really sitting with physicians, sitting with nurses and understanding what's frustrating about their current [user interface], what the context where they'd like to look something up, update something … It's got to incorporate components of user-centered design, rather than taking your garden variety EHR and slapping a mobile front-end on it."
For those physicians who have yet to use a mobile EHR app or those who have used one, but would like to optimize the user experience, experts recommend relying on the vendor to get started. Howard says practices should be "leaning" on the vendor for advancing functionality to their liking. Annis says working with the right vendor is vital.
"If you want to do this, work with a company that has a track record in responding to you. Work with people who have good customer service," says Annis. "Work with people whose folks demonstrate that they care about what the user experience is going to be. With technology, user experience is everything. … Find people that are going to be behind you when run into a problem, because you will run into one."
Bock says his fellow physicians who are interested in this area need to "jump in." They should pick the day where they are the least busy and "test drive" a mobile EHR application. Annis also subscribes to this philosophy, noting that most physicians who are hesitant to get going in this area are worried that it would open a can of worms where they'd be forever at the patient's beck and call. She has seen it a different way though.
"If patients know they can reach me, they tend to be respectful of when they try to reach me," says Annis. "When people know you on a personal level and feel you are really there for them, they don't want to exhaust that resource. My worst weekends are when I'm on call for doctors whose patients I don't know well. I have to start from the ground up. If they are my own patients, it's much easier to solve their problem [faster] than it is for someone I don't know. Patients I know well and who know me well treat this 24/7 access with great respect. What's wrong with that?"
Gabriel Pernais managing editor for Physicians Practice. He can be reached at firstname.lastname@example.org.