One of the big concerns about implementing an electronic health record (EHR) into a medical practice is the fear that it will slow you down. In fact, after cost, usability (and its effect on productivity) is the second-biggest perceived barrier to EHR adoption.

Numerous studies have shown that EHR implementation actually ends up saving cost in a group practice, mainly because of reducing or eliminating the need for paper-based medical records-handling personnel. This might be true for larger groups, but may not be as compelling for solo or smaller-group practices.

Historic experience

The question about what kind of impact EHRs have on physician productivity has been largely anecdotal, or based on older technologies that have subsequently been improved. A recent anecdote presented at the ONC’s HIT Standards Committee Implementation Workgroup, based on the experience of a Family Medicine physician early-adopter using a NextGen product, described a 50% loss in productivity that lasted about 6 months and only slowly re-approximated pre-EHR levels after a year. Is this typical?

Recently (December, 2010), UC Davis published a study on the impact of adoption of their EHR on physician productivity. The study looked at internal medicine, family medicine and pediatric doctors in ambulatory clinics sponsored by the UC Davis health system. They all used PracticeConnect, which is UC Davis’ EHR based on Epic, and is thus a multi-million dollar system hosted and maintained by the university.

Their findings were that internal medicine specialties (which include more procedure-oriented practices) adjusted to the new technology and experienced slight increases in productivity. However, family medicine and pediatrics (which is more evaluation-and-management intensive) experienced a 25-30% drop in productivity, which lasted about a month before slowly rising to near pre-EHR levels by 6 months.

Their conclusions were that different tools work better in different settings and that one-size-fits-all is not a valid approach to EHR implementation. Another way of looking at it is that EHRs (like the Epic-based system used in the study) help documentation of more procedure-oriented specialties, but more interactive-intensive, cognitive specialties that “live and die on E&M codes” – family medicine and pediatrics – need tools that are differently designed. Such tools have not yet fully matured, even in very-expensive installations of “mature” EHR products.

Our own experience

At Practice Fusion, we have focused intensely on usability and have tried building an EHR that is particularly useful for small-practice ambulatory settings using a web-based approach. Based on continuous user feedback, we continue to refine the usability of our product with each successive release, in order to learn and improve the offering to match the workflows found in ambulatory practice. Have our users experienced the impact on productivity any differently from others that have been published before?

We recently conducted an email and web-based survey aimed at several thousand of our super-users, and asked them whether their productivity increased, stayed the same, or decreased as a result of implementing our EHR. We did not specify how to gauge “productivity,” so it could be anything from a general impression to a change in visit-count in the office to a change in revenues. If they experienced a decrease, we asked them how deep it was, and how long it lasted. If they experienced an increase, we asked how much of an increase, and how long it took to get there.

Survey results

The results of the survey are worth noting. The kinds of practices that are represented by the “super user” cohort surveyed are smaller-sized ambulatory practices, heavily concentrated in primary care specialties (internal medicine, family medicine and pediatrics). Based on a preliminary result of 168 respondents, only 32% had experienced a decrease in productivity. Surprisingly, 34.5% of respondents reported no change in productivity as the result of switching to the Practice Fusion EHR; and another 32.7% reported an increase in productivity.

We will continue to gather this data, and do a more in-depth analysis of how deep the decreases were (and how long they lasted), and how high the increases were (and how long it took to get there). We will report on this analysis at a later time.

Conclusions

Some physicians, even using our very-friendly web-based EHR, still struggle to implement their system in a way that recaptures their pre-EHR productivities. This has been seen in the literature, and is seen in our own survey – however such decreases were only experienced by 32% of users. Some of this may be training (given small office settings and self-service, self-learning, and web- and chat-based support), and some of this represents challenges to continued improvement in product design and performance.

Significantly, unlike what is reported in much of the literature, two-thirds of physicians adopting our web-based EHR experienced either unchanged or actually improved productivity. This is a dramatic new finding, especially given that such physicians – ambulatory primary care physicians in small-practice independent settings – are the kinds who have consistently experienced decreases using other systems that have been studied.

However, we are not ones to rest on our laurels. The fact that we have been able to deliver tools that result in productivity improvement precisely to the sector of the physician community that has struggled the most with EHR adoption historically – though a great stride forward, is not enough. There are still physicians who struggle, and we look to continually develop yet-better products as well as improved methods of training and support in order that these challenges can be overcome.

Robert Rowley is a family physician and CMO of Practice Fusion.  He blogs at EHR Bloggers.

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