Barriers
Study participants described barriers to their use of the EHR. Recent research documents that the average primary care visit takes 20.8 minutes, with additional time required for counseling and screening [
28]; other research has found that about five minutes are allocated to the longest topic during the visit, with each additional topic receiving slightly more than one minute [
29]. Time has been identified as a significant barrier to use of clinical reminders [
30]. Participants accordingly expressed concerns about time management:
'CPRS is great, but it takes time to use ... [Providers] have to see very complicated patients in 20 minutes, and so anything that's in addition to is going to be negatively perceived ... With every point and click on a computer it's less time they spend with a patient. They generally just want to take care of the patients.' (Primary Care Nurse)
'I'm the click counter. I think one time I sent [an administrator] an e-mail about how many clicks it took to take care of a diabetic patient, because I clicked through all the reminders and I mean it's hundreds.' (Primary Care Physician)
As converging evidence, barriers to the effective use of clinical reminders have been documented previously. These barriers include number of reminders and presentation of inapplicable reminders [
30].
Another barrier was apprehension that the EHR would lead to impersonal interactions between staff and patients, and perhaps even between staff members. Clinicians expressed concerns about the impersonal nature of reminder-driven interactions, which in their experience made filling out forms rather than listening to patients the priority:
'Well, you know, clinical reminders are fine, but less and less they bring in independent thought, a provider that asks the right questions and show interest in the patient.' (Psychiatrist)
'I just feel like that the personal ... I mean, what happened with talking face to face with someone.' (Primary Care Physician Assistant)
'All these blasted checklists, clerks should be doing that.... Doctors need to sit there and look someone in the eye ... What's really bothering you? How can I help you today?' (Psychiatrist)
As converging evidence, DeBlasio and Walker [
31] examined the perceived quality of care delivered in a simulated medical interview. Simulated interviews using a desktop computer were rated lower than those using less obtrusive technologies or no technology, suggesting that EHR use may be perceived as interfering in the clinical relationship.
Complex clinical discussions require interpersonal trust between professionals, and it is preferable to conduct sensitive discussions in person. In the words of one case manager, 'I'm asking physicians in [another VA facility] to know me and trust me simply by what they have read in my progress notes ... and most of them have not met me personally.'
A primary care RN observed, '[T]here are a lot of things you don't want to put it as a formal note in the patient chart.' Likewise, a case manager describes the problems that arise when clinicians use the chart for clinical conversations:
'There have been a couple of times where I've found that the providers will respond back to me as if they're forgetting that they're in a patient's medical record and will say what would you like me to do where that's not ... appropriate.'
Values
Study participants described the value added by specific functions of the EHR, including notes used for communication and structured consults used to increase efficiency and educate providers. Participants used the electronic medical chart itself, not a separate email function, to support an asynchronous, secure conversation about treatment decisions. Participants used the cosign function, which enables one clinician to generate a note, and then name another as a cosigner, as a useful way of bringing matters to the correct person's attention and asking for the recipient's feedback, which was easily provided as an addendum to the original note. A psychologist mentioned the value of such conversations in supporting interdisciplinary collaboration: '[O]ur computerized record system ... makes it awfully easy for the mental health, primary care to work with the other on what's going on.'
Some participating clinics had recently implemented a depression clinical reminder when we conducted this study. Clinical reminders about required screenings and other tasks initially appear in the EHR when a patient arrives in the clinic and a nurse administers an initial screening. When the primary care provider opens the patient's EHR, the results of the screening are available, and the provider follows up as clinically indicated. These structured screenings add value by opening up important provider-patient discussions:
'[S]eeing so many patients a day, [the clinical reminder] reminds us to talk with these people and ask these patients ... are you feeling depressed ... if we didn't have the reminders, we may not take the time to do that.' (Primary Care Nurse)
Clinical reminders support a structured conversation with patients about potentially sensitive topics, in this case depression. Some participants appreciated the role of the clinical reminders in facilitating personal interaction between professional and patient:
'I feel that we probably because we took the time to really spend with them ... asking them questions, I really feel that we got a lot of people to talk to us about their depression ...' (Primary Care Registered Nurse)
Based upon all of our data, it is not possible to determine whether a majority of respondents liked or disliked clinical reminders. It is more accurate to state that respondents saw both positives and negatives of reminders, likely due to many variables that we did not capture, such as respondent profession, differences in the number of reminders presented, and other factors.
Another form of decision support is a structured consult form that provides the referring clinician with specific guidance about which clinical variables to assess, which interventions to begin and what information to include in referrals. Several participants valued the ability of structured consults to educate providers about best practices:
'We make it an effort to try to educate our colleagues by essentially templating the consults so it requires them to answer those questions that we need....' (Psychiatrist)
'[Y]ou can have a consult form that asks questions or builds in information ... and has force fields so you say ... here are the diagnostic criteria, here are the screening criteria, has your patient met these?... Have you done this kind of assessment?... Do they have contraindications? Have you tried this initial intervention?' (Primary Care Physician Administrator)
Although, as discussed above, time management concerns constituted a barrier to informatics use, some participants valued the time efficiency of asynchronous communication and rapid referrals provided by the EHR. A physician administrator said, 'I thought [the clinical reminder] was really slick ... with the click of the button you could refer them.' Likewise, a nurse care manager stated, 'A lot of the time, you know, you can stand outside the door and wait, and then they're busy throughout the day, and CPRS, you know, they can get to it whenever they have time for it.'
Finally, participants discussed EHR implementation in the context of the larger healthcare system. It is important to design the system of care so that implementation of informatics promotes good clinical practice. The following statements express the importance of organizational context:
'We don't flunk in depression screening, in catching it, we flunk in follow up of the depression screening.' (Primary Care Physician)
'[I]f the providers are overwhelmed with clinical reminders, they become somewhat numb to them ... It's also a system issue.' (Psychologist)