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Association of Perceived Electronic Health Record Usability With Patient Interactions and Work-Life Integration Among US Physicians

Association of Perceived Electronic Health Record Usability With Patient Interactions and... Research Letter | Health Informatics Association of Perceived Electronic Health Record Usability With Patient Interactions and Work-Life Integration Among US Physicians Edward R. Melnick, MD, MHS; Christine A. Sinsky, MD; Liselotte N. Dyrbye, MD, MHPE; Mickey Trockel, MD, PhD; Colin P. West, MD, PhD; Laurence Nedelec, PhD; Tait Shanafelt, MD Introduction Electronic health record (EHR) usability is unacceptable to most US physicians and has been reported Author affiliations and article information are 1-3 listed at the end of this article. to be inversely associated with professional burnout, yet to date, little is known about EHR usability in terms of patient interaction and work-life integration. In this article, we assess the associations of perceived EHR usability with patient interaction and work-life integration. Methods This cross-sectional survey sampled 870 US practicing physicians from all specialty disciplines represented in the American Medical Association Physician Masterfile between October 2017 and March 2018. Full sampling details and assessment for response bias have been previously reported. A random 25% of responders also received an EHR subsurvey. The Stanford University and Mayo Clinic institutional review boards approved the study protocol. Participation in the voluntary anonymous survey was considered implied consent. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies. The role of EHRs in physician-patient interactions and work-life integration was assessed with 4 items, 2 each for perceived benefit and perceived disadvantage (Figure and Table). Individuals who indicated often or very often to the EHR benefit items or never or rarely for the EHR disadvantage Figure. Distribution of Survey Responses on Electronic Health Record (EHR) Integration Into Home and Work Life A Computer in examination room to share results B Computer in examination room distracts 40 40 EHR benefits EHR disadvantages 30 30 20 20 10 10 0 0 Never Rarely Sometimes Often Very often Never Rarely Sometimes Often Very often C D EHR at home allows better care EHR at home has adverse effect on work-life integration 40 40 EHR benefits EHR disadvantages 30 30 20 20 10 10 0 0 Never Rarely Sometimes Often Very often Never Rarely Sometimes Often Very often Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2020;3(6):e207374. doi:10.1001/jamanetworkopen.2020.7374 (Reprinted) June 22, 2020 1/4 Computer in examination EHR at home, % room, % Computer in examination EHR at home, % room, % JAMA Network Open | Health Informatics Electronic Health Record Usability and Work-Life Integration Among US Physicians items were considered to be satisfied with their EHR’s integration in patient care and home and work life. Perceived EHR usability was measured using the system usability scale (SUS), a short, reliable usability industry standard (score range, 0-100; higher scores indicate greater satisfaction with usability). Multivariable logistic regression was performed to identify characteristics associated with satisfaction with the EHR with regard to patient care and work-life integration. A 2-tailed P < .05 was the level at which statistical significance was set. All analyses were completed using R statistical software, version 3.5.3 (R Project for Statistical Computing). Results The analysis included 870 respondents (353 female [40.6%]; median [interquartile range] age, 53 [42-61] years). Full demographic characteristics and results by specialty were previously reported. Approximately half of respondents (49.8%) indicated that having a computer in the examination room allowed them to share test results with patients often, whereas nearly half (43.9%) also indicated that having a computer in the examination room was often distracting (Figure). Although approximately half of respondents (50.1%) felt that EHR access when at home allowed better care, a large proportion (43.9%) also felt EHR access at home often had an adverse effect on work-life integration. On multivariable analysis adjusting for age, sex, hours worked per week, number of nights on call per week, practice setting, primary care, and marital status, every 1 point higher EHR SUS score was associated with a higher likelihood of satisfaction with (1) computer use in the examination room to share test results with patients (odds ratio [OR], 1.01; 95% CI,1.00-1.02; P < .001) (Table) and (2) access to the EHR at home to allow better care (OR, 1.03; 95% CI, 1.02-1.04; P < .001). In addition, each 1 point higher SUS score was associated with a higher likelihood of reporting that (1) the computer in the examination room rarely or never distracts from interacting with patients (OR 1.04; 95% CI, 1.03-1.05; P < .001) and (2) EHR access at home rarely or never has an adverse effect on work-life integration (OR 1.02; 95% CI, 1.02-1.03; P < .001). Discussion We found that physicians recognize both the value of the EHR to patient care and negative associations with patient interactions and work-life integration. Furthermore, higher physician perceived EHR usability was associated with higher levels of perceived positive outcomes (improved patient care) and lower levels of perceived negative outcomes (worse patient interactions and work-life integration). Limitations include that a cross-sectional study is unable to determine causation or the direction of effect. We believe our findings give cause for optimism. Usability can be Table. Factors Associated With EHRs and Patient Care and Work-Life Integration Outcomes Among Practicing Physicians in 2017 Survey item Response Factor OR (95% CI) P value EHR benefit “I use a computer in the exam room (or at the bedside) to share test results Often or very often SUS 1.01 (1.00-1.02) <.001 with my patients” Veterans hospital setting 4.96 (1.36-18.11) .02 Nonprimary care 0.42 (0.30-0.56) <.001 “Access to the EHR while at home allows me to provide better care to my Often or very often SUS 1.03 (1.02-1.04) <.001 patients” EHR disadvantages “Interacting with a computer in the exam room (or at the bedside) Never or rarely SUS 1.04 (1.03-1.05) <.001 distracts me from interacting with my patients” Nights on call per week 0.87 (0.79-0.96) .005 Nonprimary care 1.73 (1.13-2.64) .01 “Interacting with the EHR while at home has had an adverse effect on my Rarely or never SUS 1.02 (1.02-1.03) <.001 work-life integration” Nonprimary care 1.77 (1.19-2.62) .004 Abbreviations: EHR, electronic health record; OR, odds ratio; SUS, system usability scale (score range, 0-100; higher scores indicate greater satisfaction with usability). JAMA Network Open. 2020;3(6):e207374. doi:10.1001/jamanetworkopen.2020.7374 (Reprinted) June 22, 2020 2/4 JAMA Network Open | Health Informatics Electronic Health Record Usability and Work-Life Integration Among US Physicians improved if prioritized by those who design, implement, and regulate EHRs, and prioritizing usability may help improve patient care and physician well-being. We also believe clearer boundaries are needed to protect against the invasive nature of EHRs in creating work outside of the workday. Better usability and clearer boundaries will likely support therapeutic relationships between physicians and patients and the well-being of the physician workforce. ARTICLE INFORMATION Accepted for Publication: April 6, 2020. Published: June 22, 2020. doi:10.1001/jamanetworkopen.2020.7374 Correction: This article was corrected on July 23, 2020, to fix a spelling error in the Introduction. Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Melnick ER et al. JAMA Network Open. Corresponding Author: Edward R. Melnick, MD, Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave, Ste 260, New Haven, CT 06519 (edward.melnick@yale.edu). Author Affiliations: Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut (Melnick); American Medical Association, Chicago, Illinois (Sinsky); Department of Medicine, Mayo Clinic, Rochester, Minnesota (Dyrbye, West); Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California (Trockel); Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota (West, Shanafelt); Department of Medicine, Stanford University School of Medicine, Palo Alto, California (Nedelec). Author Contributions: Drs Nedelec and Shanafelt had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Melnick, Sinsky, Dyrbye, West, Shanafelt. Acquisition, analysis, or interpretation of data: Melnick, Dyrbye, Trockel, West, Nedelec, Shanafelt. Drafting of the manuscript: Melnick, Shanafelt. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Melnick, Nedelec. Obtained funding: Shanafelt. Administrative, technical, or material support: Sinsky, Dyrbye, Shanafelt. Supervision: Melnick, Shanafelt. Conflict of Interest Disclosures: Dr Sinsky reported serving as the Vice President of Professional Satisfaction for the American Medical Association. Dr Dyrbye reported other support from Med Ed Solutions outside the submitted work. Dr Shanafelt reported a patent to Well-being Index. No other disclosures were reported. Funding/Support: This work was supported by funding from the Stanford Medicine WellMD Center (Drs Trockel, Nedelec, and Shanafelt), the American Medical Association (all authors), the Mayo Clinic Department of Medicine Program on Physician Well-being (Drs Dyrbye and West), and in part by 2 American Medical Association Practice Transformation Initiatives (Dr Melnick) and the National Institute on Drug Abuse of the National Institutes of Health grant UH3DA047003 (Dr Melnick). Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the American Medical Association or the National Institutes of Health. REFERENCES 1. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Rand Health Q. 2014;3(4):1. 2. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91(7): 836-848. doi:10.1016/j.mayocp.2016.05.007 JAMA Network Open. 2020;3(6):e207374. doi:10.1001/jamanetworkopen.2020.7374 (Reprinted) June 22, 2020 3/4 JAMA Network Open | Health Informatics Electronic Health Record Usability and Work-Life Integration Among US Physicians 3. Melnick ER, Dyrbye LN, Sinsky CA, et al. The association between perceived electronic health record usability and professional burnout among US physicians. Mayo Clin Proc. 2020;95(3):476-487. doi:10.1016/j.mayocp.2019. 09.024 4. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014 [published correction appears in Mayo Clin Proc. 2016 Feb;91(2):276]. Mayo Clin Proc. 2015;90(12):1600-1613. doi:10.1016/j.mayocp.2015.08.023 5. Brooke J. SUS: a retrospective. J Usability Stud. 2013;8(2):29-40. https://uxpajournal.org/wp-content/uploads/ sites/8/pdf/JUS_Brooke_February_2013.pdf 6. Gellert G, Webster L, Gillean J, Melnick E, Kanzaria H. Should US doctors embrace electronic health records? BMJ. 2017;356:j242. JAMA Network Open. 2020;3(6):e207374. doi:10.1001/jamanetworkopen.2020.7374 (Reprinted) June 22, 2020 4/4 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Network Open American Medical Association

Association of Perceived Electronic Health Record Usability With Patient Interactions and Work-Life Integration Among US Physicians

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American Medical Association
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Copyright 2020 Melnick ER et al. JAMA Network Open.
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Abstract

Research Letter | Health Informatics Association of Perceived Electronic Health Record Usability With Patient Interactions and Work-Life Integration Among US Physicians Edward R. Melnick, MD, MHS; Christine A. Sinsky, MD; Liselotte N. Dyrbye, MD, MHPE; Mickey Trockel, MD, PhD; Colin P. West, MD, PhD; Laurence Nedelec, PhD; Tait Shanafelt, MD Introduction Electronic health record (EHR) usability is unacceptable to most US physicians and has been reported Author affiliations and article information are 1-3 listed at the end of this article. to be inversely associated with professional burnout, yet to date, little is known about EHR usability in terms of patient interaction and work-life integration. In this article, we assess the associations of perceived EHR usability with patient interaction and work-life integration. Methods This cross-sectional survey sampled 870 US practicing physicians from all specialty disciplines represented in the American Medical Association Physician Masterfile between October 2017 and March 2018. Full sampling details and assessment for response bias have been previously reported. A random 25% of responders also received an EHR subsurvey. The Stanford University and Mayo Clinic institutional review boards approved the study protocol. Participation in the voluntary anonymous survey was considered implied consent. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies. The role of EHRs in physician-patient interactions and work-life integration was assessed with 4 items, 2 each for perceived benefit and perceived disadvantage (Figure and Table). Individuals who indicated often or very often to the EHR benefit items or never or rarely for the EHR disadvantage Figure. Distribution of Survey Responses on Electronic Health Record (EHR) Integration Into Home and Work Life A Computer in examination room to share results B Computer in examination room distracts 40 40 EHR benefits EHR disadvantages 30 30 20 20 10 10 0 0 Never Rarely Sometimes Often Very often Never Rarely Sometimes Often Very often C D EHR at home allows better care EHR at home has adverse effect on work-life integration 40 40 EHR benefits EHR disadvantages 30 30 20 20 10 10 0 0 Never Rarely Sometimes Often Very often Never Rarely Sometimes Often Very often Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2020;3(6):e207374. doi:10.1001/jamanetworkopen.2020.7374 (Reprinted) June 22, 2020 1/4 Computer in examination EHR at home, % room, % Computer in examination EHR at home, % room, % JAMA Network Open | Health Informatics Electronic Health Record Usability and Work-Life Integration Among US Physicians items were considered to be satisfied with their EHR’s integration in patient care and home and work life. Perceived EHR usability was measured using the system usability scale (SUS), a short, reliable usability industry standard (score range, 0-100; higher scores indicate greater satisfaction with usability). Multivariable logistic regression was performed to identify characteristics associated with satisfaction with the EHR with regard to patient care and work-life integration. A 2-tailed P < .05 was the level at which statistical significance was set. All analyses were completed using R statistical software, version 3.5.3 (R Project for Statistical Computing). Results The analysis included 870 respondents (353 female [40.6%]; median [interquartile range] age, 53 [42-61] years). Full demographic characteristics and results by specialty were previously reported. Approximately half of respondents (49.8%) indicated that having a computer in the examination room allowed them to share test results with patients often, whereas nearly half (43.9%) also indicated that having a computer in the examination room was often distracting (Figure). Although approximately half of respondents (50.1%) felt that EHR access when at home allowed better care, a large proportion (43.9%) also felt EHR access at home often had an adverse effect on work-life integration. On multivariable analysis adjusting for age, sex, hours worked per week, number of nights on call per week, practice setting, primary care, and marital status, every 1 point higher EHR SUS score was associated with a higher likelihood of satisfaction with (1) computer use in the examination room to share test results with patients (odds ratio [OR], 1.01; 95% CI,1.00-1.02; P < .001) (Table) and (2) access to the EHR at home to allow better care (OR, 1.03; 95% CI, 1.02-1.04; P < .001). In addition, each 1 point higher SUS score was associated with a higher likelihood of reporting that (1) the computer in the examination room rarely or never distracts from interacting with patients (OR 1.04; 95% CI, 1.03-1.05; P < .001) and (2) EHR access at home rarely or never has an adverse effect on work-life integration (OR 1.02; 95% CI, 1.02-1.03; P < .001). Discussion We found that physicians recognize both the value of the EHR to patient care and negative associations with patient interactions and work-life integration. Furthermore, higher physician perceived EHR usability was associated with higher levels of perceived positive outcomes (improved patient care) and lower levels of perceived negative outcomes (worse patient interactions and work-life integration). Limitations include that a cross-sectional study is unable to determine causation or the direction of effect. We believe our findings give cause for optimism. Usability can be Table. Factors Associated With EHRs and Patient Care and Work-Life Integration Outcomes Among Practicing Physicians in 2017 Survey item Response Factor OR (95% CI) P value EHR benefit “I use a computer in the exam room (or at the bedside) to share test results Often or very often SUS 1.01 (1.00-1.02) <.001 with my patients” Veterans hospital setting 4.96 (1.36-18.11) .02 Nonprimary care 0.42 (0.30-0.56) <.001 “Access to the EHR while at home allows me to provide better care to my Often or very often SUS 1.03 (1.02-1.04) <.001 patients” EHR disadvantages “Interacting with a computer in the exam room (or at the bedside) Never or rarely SUS 1.04 (1.03-1.05) <.001 distracts me from interacting with my patients” Nights on call per week 0.87 (0.79-0.96) .005 Nonprimary care 1.73 (1.13-2.64) .01 “Interacting with the EHR while at home has had an adverse effect on my Rarely or never SUS 1.02 (1.02-1.03) <.001 work-life integration” Nonprimary care 1.77 (1.19-2.62) .004 Abbreviations: EHR, electronic health record; OR, odds ratio; SUS, system usability scale (score range, 0-100; higher scores indicate greater satisfaction with usability). JAMA Network Open. 2020;3(6):e207374. doi:10.1001/jamanetworkopen.2020.7374 (Reprinted) June 22, 2020 2/4 JAMA Network Open | Health Informatics Electronic Health Record Usability and Work-Life Integration Among US Physicians improved if prioritized by those who design, implement, and regulate EHRs, and prioritizing usability may help improve patient care and physician well-being. We also believe clearer boundaries are needed to protect against the invasive nature of EHRs in creating work outside of the workday. Better usability and clearer boundaries will likely support therapeutic relationships between physicians and patients and the well-being of the physician workforce. ARTICLE INFORMATION Accepted for Publication: April 6, 2020. Published: June 22, 2020. doi:10.1001/jamanetworkopen.2020.7374 Correction: This article was corrected on July 23, 2020, to fix a spelling error in the Introduction. Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Melnick ER et al. JAMA Network Open. Corresponding Author: Edward R. Melnick, MD, Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave, Ste 260, New Haven, CT 06519 (edward.melnick@yale.edu). Author Affiliations: Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut (Melnick); American Medical Association, Chicago, Illinois (Sinsky); Department of Medicine, Mayo Clinic, Rochester, Minnesota (Dyrbye, West); Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California (Trockel); Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota (West, Shanafelt); Department of Medicine, Stanford University School of Medicine, Palo Alto, California (Nedelec). Author Contributions: Drs Nedelec and Shanafelt had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Melnick, Sinsky, Dyrbye, West, Shanafelt. Acquisition, analysis, or interpretation of data: Melnick, Dyrbye, Trockel, West, Nedelec, Shanafelt. Drafting of the manuscript: Melnick, Shanafelt. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Melnick, Nedelec. Obtained funding: Shanafelt. Administrative, technical, or material support: Sinsky, Dyrbye, Shanafelt. Supervision: Melnick, Shanafelt. Conflict of Interest Disclosures: Dr Sinsky reported serving as the Vice President of Professional Satisfaction for the American Medical Association. Dr Dyrbye reported other support from Med Ed Solutions outside the submitted work. Dr Shanafelt reported a patent to Well-being Index. No other disclosures were reported. Funding/Support: This work was supported by funding from the Stanford Medicine WellMD Center (Drs Trockel, Nedelec, and Shanafelt), the American Medical Association (all authors), the Mayo Clinic Department of Medicine Program on Physician Well-being (Drs Dyrbye and West), and in part by 2 American Medical Association Practice Transformation Initiatives (Dr Melnick) and the National Institute on Drug Abuse of the National Institutes of Health grant UH3DA047003 (Dr Melnick). Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the American Medical Association or the National Institutes of Health. REFERENCES 1. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Rand Health Q. 2014;3(4):1. 2. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91(7): 836-848. doi:10.1016/j.mayocp.2016.05.007 JAMA Network Open. 2020;3(6):e207374. doi:10.1001/jamanetworkopen.2020.7374 (Reprinted) June 22, 2020 3/4 JAMA Network Open | Health Informatics Electronic Health Record Usability and Work-Life Integration Among US Physicians 3. Melnick ER, Dyrbye LN, Sinsky CA, et al. The association between perceived electronic health record usability and professional burnout among US physicians. Mayo Clin Proc. 2020;95(3):476-487. doi:10.1016/j.mayocp.2019. 09.024 4. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014 [published correction appears in Mayo Clin Proc. 2016 Feb;91(2):276]. Mayo Clin Proc. 2015;90(12):1600-1613. doi:10.1016/j.mayocp.2015.08.023 5. Brooke J. SUS: a retrospective. J Usability Stud. 2013;8(2):29-40. https://uxpajournal.org/wp-content/uploads/ sites/8/pdf/JUS_Brooke_February_2013.pdf 6. Gellert G, Webster L, Gillean J, Melnick E, Kanzaria H. Should US doctors embrace electronic health records? BMJ. 2017;356:j242. JAMA Network Open. 2020;3(6):e207374. doi:10.1001/jamanetworkopen.2020.7374 (Reprinted) June 22, 2020 4/4

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JAMA Network Open – American Medical Association

Published: Jun 22, 2020

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