# Primary Care Physicians' Experience with Electronic Medical Records: Barriers to Implementation in a Fee-for-Service Environment

Authors: D. A. Ludwick; John Doucette
Journal: International Journal of Telemedicine and Applications
 (2009)

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## Abstract

Our aging population has exacerbated strong and divergent trends between health human resource supply and demand. One way to mitigate future inequities is through the adoption of health information technology (HIT). Our previous research showed a number of risks and mitigating factors which affected HIT implementation success. We confirmed these findings through semistructured interviews with nine Alberta clinics.  Sociotechnical factors significantly affected physicians' implementation success. Physicians reported that the time constraints limited their willingness to investigate, procure, and implement an EMR. The combination of antiquated exam room design, complex HIT user interfaces, insufficient physician computer skills, and the urgency in patient encounters precipitated by a fee-for-service remuneration model and long waitlists compromised the quantity, if not the quality, of the information exchange. Alternative remuneration and access to services plans might be considered to drive prudent behavior during physician office system implementation.


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## Body

## 1. Introduction

Aging  populations with complex health conditions such as obesity and
chronic disease  place an increasing burden  on primary care systems in many
countries [1–5]. While demand escalates, health human resource
supply is declining as Canada’s
health workforce retires earlier and the average age of the remaining working
population increases [6–8]. Higher training
requirements, tuition fees [9], certification requirements [8, 10] and a higher female to male enrolment ratio are
leading to a decline in the primary care physician workforce. The adoption of
health information technology (HIT) is seen as one way to address the widening
health care demand and supply gap [11–13]. It seems intuitive that HIT would improve patient
safety, improve physician office efficiency and mitigate shortages in health
human resources, but studies have shown that such systems can compromise short-term
physician office performance [14–16], intimidate physicians and their office staff [17], and have shown, on occasion, to increase medical
errors [18–20].Health information system adopters face several risks when implementing
health systems [21]. The purpose
of this project was to assess the relevance and impact of these risks in the context
of primary care in Sherwood Park,
Alberta. Due to an economic boom, the population of Sherwood Park grew 14% from 2001 to 2006 compared to a
population growth rate of 10% in Edmonton [22] (the nearest city) and 5.4% in Canada
[23] during the same period. The Sherwood
Park
circumstance offers a microcosm in which to study
the effects of HIT adoption in primary care.Primary care usually refers to family or general practice and is the
first point of contact a person has with the health system [24]. An electronic
medical record is a computerized health information system where providers
record detailed encounter information such as patient demographics, encounter
summaries, medical history, allergies, intolerances, and lab test histories.
Some EMRs support scheduling, billing, reporting, order entry, results
management, and decision support [25–27]. Such systems
are often referred to as physician office
systems or practice management
systems [25, 28].


## 2. Previous Research

In a previous comprehensive literature review [21], the implications of HIT were examined across a
number of care domains. Health information technology implementation success
depends on a number of factors. Implementers
need to be aware of sociotechnical system fit to achieve success [29–32]. However, implementers perceive privacy [33, 34], patient safety, provider/patient relations, staff
anxiety [31], time needed to implement [35–39], quality of care, financial [40–42], efficiency, and liability [43] factors as risks that can pressure or derail a project.
Users’ previous experiences with HIT affected their experience with a new
system, both positively and negatively [44–46]. Users applied their previous experience to new
systems and evaluated the usability and effectiveness of their new system
against that of the previous system. Exam room layouts and computer monitor
placement have been shown to affect, positively and negatively, the interaction
between provider and patient [47–49].Implementers can insulate the project from
such risks by establishing strong leadership [16, 37, 45, 50–54], using project management techniques [50, 51, 55–61], establishing standards, and training their staff [13, 16, 35–39, 46, 52, 54, 58, 62, 63, 64, 65] to ensure such risks do not compromise
implementation success.


## 3. Methodology

This research project used one hour semistructured interviews to
acquire information from primary care physicians’ experience of selecting,
implementing, and operating an EMR system.
Physician candidates were selected from our local primary care network,
in which 47 physicians are members. Inclusion criteria required physicians to be
practicing full time in the community, have significant EMR experience and be a
lead physician or influencer in clinic decision making. Physicians were paid a honorarium to
acknowledge their lost revenue generating opportunity. An interview guide consisting of closed-ended
statistical questions and several open-ended questions stimulated a qualitative
conversation regarding the experience. The researcher recorded detailed notes that
were later used for synthesis and analysis.After the interview, the researcher documented the layout of exam rooms.
Exam rooms were depicted in a floor plan conceptually locating the computer
keyboard and monitor with respect to the patient exam table or chair. The
researcher also asked physicians to recount the positioning of the patient with
respect to themselves and the computer. Exam room layouts were subsequently
analyzed and categorized into three general types for critical review. Figures1, 2,  and
3 depict the three exam room layouts which best illustrate the wide range
of layouts. The researcher recorded the quantity of rooms in the clinics for
statistical purposes.Figure 1
Exam room layout 1.Figure 2
Exam room layout 2.Figure 3
Exam room layout
3.


## 4. Results

Of the 47 physicians in the primary care network, 19 physicians are
clinic leads. Of the 19 clinic owners or
influencers, there are 11 clinics with practical EMR experience. Nine
interviewees were selected who represent a total of 26 physicians and were
interviewed during the months of  February and March 2008 using the interview
guide shown in Table1. Two interviewees were sole practitioners, 2
interviewees represented clinics with 2 physicians each in them, 3 interviewees
represented practices with of 3 physicians, one interviewee represented a
clinic of 5 physicians, and  one interviewee represented a clinic of 6
physicians. Table 2 summarizes the key findings from the interviews’ closed-ended
questions.Table 1
Interview guide.
Interview questions for physician
interviewsSherwood
Park - Strathcona County PCNInterviewee(s):Interviewer:Date:Interview
questionsNotes
of candidate’s answerInterviewer’s guide to answersHow long have you been in practice?[Years
or Months]How many physicians are currently practicing
in your office?[Number]How many non-physician clinicians do you
employ?[Number]How many staff/admin do you employ?[Number]Are you the practice owner/key decision
maker? If not, what is your role?[Yes/No]. [If no, partner, contracted, part time]How many patients do you typically see in a
day?[Number]What is your target interview duration?[Minutes]What sort of health records system do you
currently use?[paper;
electronic, but paper used to record notes first followed by transcription;
electronic, desktop in exam room; electronic, laptop carried into exam room]Can you describe the role your health information
system plays when you are interviewing a patient[take
paper based notes as I go, take e-based notes as I go, don’t take any notes
in interview]How long have you owned your EMR?[Years
or Months]On a scale of 1 to 5, where 1 is poor and 5 is
excellent, can you rate your computer skills (before and after the
implementation)?[1 to
5], [1 to 5]When/where do you make your encounter notes?[during
interview in exam room, immediately after interview outside exam room door,
at end of day either at the office or at home]Prior to your current practice, what did you
use for health information system to support your work?[paper;
electronic, but paper used to record notes first followed by transcription;
electronic, desktop in exam room; electronic, laptop carried into exam room]Can you describe the process you went through
to buy your EMR?
How did you gather market information?[market
scan, called vendors directly, talked to colleagues, talked to AMA/POSP/CPSA]How did you select your EMR? What purchasing
factors were most relevant to you?[price,
features, eligibility for financial support]How did you install the EMR into your
practice?[big-bang,
pilot, team-oriented integrative approach]What do you use your EMR system for?[Billing,
scheduling, encounter note taking, lab results, order entry, contraindication
management]Where do you get your technical support?[self,
colleague, 3rd party]What do you like/dislike about your current
system?—Did
you notice a change in your patient volumes after your implementation? If so, can you say what % age it dropped to
and for how long? Why?[%,
months]On a scale of 1 to 5, where 1 is completely
dissatisfied and 5 is extremely satisfied, what would you say your overall
satisfaction is with your system?[1 to
5]Knowing what you know now, would you still
have bought the EMR? Why do you say
that?[yes/no]Table 2
Closed-ended interview results: statistics describing the
number and experience of physicians, patient throughput, years of experience
using an EMR, computer skills, and clinic size.
Interview factorAverage(N=9)Range(N=9)Years in practice20 years10 to 33 yearsNumber of physicians
practicing in clinic31 to 6Number of nonphysician
clinicians in practice1.750 to 8Number of support staff in
clinic2.51 to 4Target number of patients
to be seen in a day32.520 to 40Target patient interview
duration8.4 minutes7.5 to 15 minutesNumber of years owned an
EMR4 years0 to 10 yearsPersonal rating of
computer skills (range: 1 to 5)3.252 to 4Overall EMR satisfaction
rating (range: 1 to 5)2.92 to 4.5All physicians have at least 10 years of practice experience. Two
physicians were female, both of which are operating in multiphysician
practices. All interviewees except one considered themselves owners or decision
makers in the practice but all reported that they had a hand in selecting and
implementing their EMR. Eight physicians are satisfied with their own computer
and data entry skills, rating themselves a 3 out of 5 or higher. Physicians
have 30 patient encounters per day but, often see as many as 40 patients at
roughly 10 minutes per encounter.Seven physicians routinely make encounter notes directly into their EMR
during the interview, although occasionally they complete note taking outside
the room after the encounter. The other 2 physicians make notes on paper. Six
physicians have permanently stationed desktop computers located in exam rooms
to make notes, while two use wireless laptop computers. One of the two
physicians using a paper system has computers stationed in his exam rooms but has
reverted back to record patient encounter data on paper. One clinic reported
that physicians wrote encounter notes on paper and scanned them into their EMR
as a way to kick start the implementation and develop their computer skills. Eight
clinics use paper record systems prior to their EMR, while one clinic is now
operating its second EMR.Eight physicians did not follow a prescribed procurement plan while the
other followed a procurement plan consisting of a market scan, price analysis,
vendor demonstrations, and visiting colleagues’ clinics. Four physicians
invited vendors to demonstrate their products to them at their clinics. Two
physicians completed a price comparison, while one called their professional
association for procurement advice, another acquired his EMR through personal
connections, and yet another could not remember how he had selected his EMR. Physicians did not have the time or
experience to follow a detailed procurement plan. All physicians reported
disorientation in the procurement process as they had not had any related
experiences in the past.Physicians did not report the breakpoint that McGrath had reported [47]. Even though physicians said patients rarely
commented, some physicians felt a need to apologize for taking notes on
computer, or at least to acknowledge it to patients. Those physicians who had
owned their system for a while were more comfortable since most patients had
rotated through and seen the system previously. Physicians felt compelled to
stop typing if patients became emotional during the interview, although they
did not always do so.Our physicians complained about their training and postsale experience
with their vendor. Instead of a training
regimen similar to that described in the literature [21], physicians reported that their vendor simply
offered one training session of one half to a full day in duration. Training was often too soon after
implementation. Physicians had not developed sufficient experience with their
new EMR to ask relevant questions or appreciate the answers.Physicians reported that they could not always access vendor technical
support. Even when they could get a person, they were not confident that the
technical support person “knew how a clinical practice functioned." Physicians
were concerned that the company did not appreciate the implications of a dysfunctional
EMR. Physicians often procured
supplementary local technical support at higher cost.Physicians pointed to opportunities for more efficient data entry. Two
physicians have made great use of the template features in their EMRs. They
have spent significant time building templates which allow them to enter data
or orders into their system for common ailments with a few key strokes. Two
other physicians reported that they have made use of voice recognition software
which emulates dictation, a familiar mode of data entry for physicians. Voice
recognition software requires training and is not functional for clinicians
with strong accents, but physicians who invested significant time training
their software had achieved a satisfactory level of efficiency.A total number of 19 examination rooms were viewed during the study
representing 51% of the total 37 rooms in these physicians’ offices.
Figures1 to
3 depict three exam room layouts
which were categorized based on the following observations:(i)
the presence of an office desk, or not,(ii)
the presence of a patient interview chair, or not,(iii)
the general size of the room,(iv)
the orientation of the computer monitor with respect to the physician,
the exam table, and the patient,Table 3 below summarizes the key characteristics of the observed exam
rooms. The layout-type column indicates the figure which best depicts the exam
room. Eight out of 9 physicians interview patients while they are seated in
chairs (one owns rooms numbered 13 and 14 which were too small for a chair and
therefore interviewed and examined the patient on bed). Note that two columns
in the table refer to an angle. Exam room observations note that an angle was
created between the lines of sight from physician to monitor and physician to
bed (Angle A) as well as between the lines of sight from physician to monitor
and physician to chair (Angle B), if the chair existed.Table 3
Exam room layout results.
Room no.Layout typeSystem configurationHas chairHas office deskRoom sizeAngle A (monitor to bed)Angle B (monitor to chair)12DesktopYesYesMedium1209022DesktopYesYesMedium1209032DesktopYesYesMedium1209043DesktopNoYesLarge120n/a52DesktopYesYesLarge12012061LaptopYesNoMedium0071LaptopYesNoMedium0081LaptopYesNoMedium0092DesktopYesYesSmall18090102DesktopYesYesSmall18090113DesktopYesYesLarge180180122DesktopYesYesLarge12090131DesktopNoYesSmall90n/a141DesktopNoYesSmall90n/a152DesktopYesYesMedium18090162DesktopYesYesMedium18090171LaptopYesNoMedium00181LaptopYesNoMedium00191LaptopYesNoMedium00Many brands of EMR are used in these clinics (Telin, Global Biometrics,
Med Access, Practice Solutions, EMIS, and Wolf). Clinics use most system features
including billing, scheduling, importing lab results, drug order entry, and
encounter note taking. Drug-to-drug and drug-to-allergy contraindication
management was used by many physicians when the data had been entered to
support it. Three physicians do not use
contraindication management because they leave this responsibility to the
pharmacy. One practice reported that this feature had to be purchased
separately so was not currently part of their system. Many physicians
automatically receive lab test results electronically through an electronic
mailbox system (ftp-based system) arranged by the RHA.


## 5. Discussion

The purpose of this project was to assess the relevance and impact of
risk and insulating factors for HIT adoption in the context of primary care in Sherwood Park, Alberta.
Our interviews showed that few physicians follow a complete procurement
approach. Exam room layouts require computer systems to be situated such that
physicians face away from their patients.
Physicians struggle to get appropriate training and technical support
for their systems. However, when
physicians invest the time, they realize benefits to using their EMR.Time constrains many physician offices when procuring and implementing
HIT. In Canada,
primary care physicians get paid on a fee-for-service basis. The more patients
they see, the more revenue they generate. Further, Canada
reports large wait times for
access to health services [66]. Physicians choose
not to invest the time in systems procurement because they are uncomfortable with
the process. Investigating systems during office hours reduces revenue
generating opportunity and increases patient wait times. Interestingly, other
reviews have shown that pay-for-performance models, as one strategy for
payment, have worked well in driving to long-term national HIT adoption success
[67]. More research on the effects of remuneration models
on adoption is warranted and will be the subject of future research.Interviews revealed that exam room layouts could compromise the quantity,
if not quality, of information transfer from patient to physician. Our figures
above attempt to simplify and categorize these into three types based on the
type and placement of furniture, the type and placement of the computer
monitor, as well as the positioning of the physician with respect to the
patient. If the amount of interpersonal
communication is a function of visual cues, as would be suggested by Mehrabian
[68], then the Angle A, created between the two lines of
sight from the physician to their computer monitor and the physician to the patient,
would be critical to the success of communications. Layout 1 has a relatively
small angle (estimated at 60 degrees).
Layouts 2 and 3 show Angle A to be greater than 90 degrees. This
situates  the patients somewhat behind the
physician as they face the monitor. Physicians operating in exam rooms similar to that of
layout 1 expressed the least concern over eroded interpersonal
communications. Furthermore, the two
physicians using laptops could position themselves to look over their laptop
monitor directly at the patient, effectively reducing Angle A to zero degrees.
We did not interview enough physicians to be conclusive, but we assert that
there could be a relationship between the quantity, and possibly quality, of
information transfer from patient to physician and the size of Angle A, as
would be supported by Robinson et al. [69]. The smaller Angle A is, the more direct patient eye
contact is and, therefore, the more complete the interpersonal communication,
possibly leading to higher quality of care. A few physicians appreciated this concept
as one had previously taken advantage of pending renovations to accommodate her
systems implementations and another was planning changes to his office
furniture to close Angle A to zero degrees.The above problem gets more aggravated when we consider our physicians’
computer skills in the context of the complex EMR user interfaces and the time
pressure of a patient encounter within the context of a fee-for-service
remuneration model. Our physicians self-reported their computer skills rated at
3, on a scale of 1 to 5. Similarly, a US
survey [70] reported that their physician survey respondents
felt quite confident about their computer skills. We did not observe physicians
using their EMR for note taking during patient encounters (exam room
observation would have required significant ethics approval); however,
extrapolating complaints they had about the usability of basic computer functions
make us hypothesize that physicians, vendors, and HIT advocates have
underestimated the level of computer skills required for this work (physicians reported
that they hunt for menus and buttons to the extent they sometimes stop using
the EMR in interviews because of the disruption). EMR user interfaces are
complex and busy (reminiscent of an airplane cockpit). The skills needed to listen to patients’
complaints, assess medical relevance, contemplate interventions as well as type
notes—all at the same time–would require a significant level of
concentration, typing skills, and familiarity with the application’s user
interface, not normally found in the most adept computer users. Therefore, we
were not surprised to learn that physicians often had to complete note taking
after the encounter or at the end of the business day. We hypothesize that HIT
can disrupt the flow of information from patient to provider when computer
monitors require the physician to face away from the patient. Physicians’ eyes are
focused on the computer system and not the patient which compromises
information transfer especially in clinics with high-patient volumes and
inexperienced physician computer users. We are concerned that this may compromise
the physicians’ implied and historic role as confidante. We are planning future
research to investigate this concept further.The study’s most
obvious weakness is its narrow field of interviewees. Sherwood Park PCN has
over 40 physicians; however, only nine met our inclusion criteria. The small
sample means that the discussion and conclusions outlined above can only be
considered directional. They are not conclusive or statistically significant.
Bias may result from interviewee selection. Ideally, interviewees would have
represented more clinics from a greater geographical area. We interviewed
physician leaders who influenced implementation decisions; yet, physician
leaders’ perceptions may not reflect those of their associates. Our physicians
are members of a PCN; consequently, findings may not be applicable to primary
care physicians who practice outside of an interdisciplinary team. We infer
that there is a relationship between information transfer and the angles
described above. Future research involving patients is required to confirm
this. This Alberta
study is influenced by provincial matters, such as health policy, remuneration
approaches, and physician office system funding models, which may prevent
results from applying in other jurisdictions.


## 6. Conclusions

Our interviews and previous research have shown time to be a precious
resource for physicians in several facets of their day-to-day operations.
Physicians do not take the time to properly become familiar with the available
products, select an EMR, implement it, and then train to use it even though colleagues
have invested time and realized great benefit. We wonder whether the current
fee-for-service payment model in Alberta
creates an urgency to maintain patient throughput. The opportunity to maximize
clinic revenue and waiting rooms full of patients may discourage physicians
from investing the time in EMR implementation activities. The Sherwood Park
experience might point to a need for a change in remuneration approach and
guidance for reducing wait times, at least for the purposes of selecting,
acquiring, and implementing the system prior to returning to steady-state
clinic operations.Computer skills, complexity in EMR interfaces, and exam room layouts
combine to affect physicians’ encounter experience. Despite their strong self
assessments, we are concerned that physicians do not have sufficient computer
skills to take notes and navigate an EMR while listening to a patient in an
encounter. Physicians might consider changing to laptop systems (even with
wired networks), using voice recognition software and/or developing templates
to permit more direct patient interaction and improve efficiency.


## 7. Relevance

Alberta, like other jurisdictions, is aggressively driving the adoption of
HIT. Despite well structured and financed programs, factors such as computer
aptitude in physicians and complexity in graphical user interfaces are not
being considered as hindrances to adoption.
Medical associations provide valuable coaching to physicians on system
procurement and physician office design, but time constrains physicians from
taking advantage. Vendor certification programs test and conform EMR
applications for interoperability but need to increase scrutiny on vendor
business and technical support qualifications.
Although jurisdictions continue to finance adoption, organized effort
needs to be applied to other points of friction. Training for physicians on computers,
establishing user interface design standards and guidance on exam room design
is also required.Canada’s fee-for-service payment model provides physicians with an
opportunity to maximize patient throughput. Yet, HIT projects take physicians
offline from their core activities as physicians. When physicians are
remunerated based on patient volume, they are discouraged from spending the
time needed to make their implementations a success. This paper does not
advocate one payment model over another, but simply points to a pattern of
behavior which seems to be caused by the current approach. Jurisdictions might
consider the implications of the current payment model with regard to adoption
and provide alternative vehicles which encourage physicians to invest the time
to maximize outcomes from  their investments.



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