9 Reasons Physicians Hate EMR - The 2013 RAND Study

Posted by Dike Drummond MD

emr fail electronic medical record physician burnout dike drummond optHot off the Presses.

The results of the Physician Satisfaction Study sponsored by the RAND corporation and the AMA became available this week and all 152 pages are a treasure trove of information on how to lower stress, prevent physician burnout and create more satisfaction in your organization.

In short ... this is the Physician's "Love It/Hate It" list for the Clinical Practice of Medicine here in 2013

[here is a link to a .pdf file of the full study report  it's free ]

One of the biggest items on the "Hate It" list was Electronic Medical Records 

The study takes enormous pains to not say anything definitive (they are researchers after all) and here is the final score.

=> Physicians found only 3 things they liked about their EMR

=> And 9 ways EMR interferes with quality patient care

=> A full 18% of the participants still want to go back to paper charts :-


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Then they went on to make the understatement of the decade here: 

"We found that EHR usability represents a relatively new, unique, and vexing challenge to physician professional satisfaction.

Few other service industries are exposed to universal and substantial incentives to adopt such a specific, highly regulated form of technology, which has, as our findings suggest, not yet matured."

Specific Study Findings
EMR vs. Physician Satisfaction

"We found that EHRs had important effects on physician professional satisfaction, both positive and negative. In the practices we studied, physicians approved of EHRs in concept, describing better ability to remotely access patient information and improvements in quality of care. However, for many physicians, the current state of EHR technology appeared to significantly worsen professional satisfaction in multiple ways."

Worsened Professional Satisfaction:

I am going to simply provide paragraphs directly from the report below. I am certain you will see your personal frustrations well represented.

1) Time-Consuming Data Entry
"The majority of physicians who interacted with EHRs directly (i.e., without using a scribe or other assistant) described cumbersome, time-consuming data entry."

2) User Interfaces That Do Not Match Clinical Workflow
"Beyond data entry, physicians and their colleagues described EHR user interfaces that, in important ways, hampered rather than facilitated their clinical workflow. Non Intuitive order entry was particularly problematic."

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3) Interference with Face-to-Face Care
Multiple physicians who entered their notes via keyboard described their EHRs as interfering with face-to-face patient care. Many of these physicians blamed themselves for lacking the ability to type without compromising the level of attention they could devote to patients. These physicians faced a difficult trade-off: divide attention between the patient and the computer, or defer data entry until after leaving the patient, lengthening overall work hours:

4) Insufficient Health Information Exchange
Physicians in multiple specialties and a range of practice settings described frustration when health information was not exchanged between EHRs. Even when practices invested in EHRs, faxes were a common mode of communicating patient information between care settings:

5) Information Overload
Some EHR products feature automatic email alerts to physicians. For primary care physicians in particular, this has created a sense of information overload—the unceasing volume of messages reaching them has expanded beyond the number that they believe they can handle diligently:

6) Mismatch Between Meaningful-Use Criteria and Clinical Practice
Both primary care and subspecialist physicians noted a mismatch between meaningful-use criteria and what they considered to be the most important elements of patient care.

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7) EHRs Threaten Practice Finances

Some physicians, especially those who owned or who were partners in their practices, reported that investing in EHRs exposed their practices to significant financial risks. In particular, the costs of switching EHRs—which could become necessary due to factors beyond a practice’s control—were of high concern:

8) EHRs Require Physicians to Perform Lower-Skilled Work
Physicians who did not use scribes reported that their EHRs required them to perform tasks below their level of training, decreasing their efficiency:

9) Template-Based Notes Degrade the Quality of Clinical Documentation
While some physicians described using templates (or “macros”) to ease the writing of clinical notes (i.e., to overcome data entry problems), many described misuse of template-based notes as a significant threat to both clinical quality and professional satisfaction. Such notes were described as complicating the task of retrieving useful clinical information. This problem was reported by physicians in all specialties and practice models included in the study:

The researchers go on to state two more findings I believe are significant:

1) Things don't get better with time:
"In our sample, there was no significant relationship between overall satisfaction and the length of time since EHR installation."

2) More is definitely Worse:
"In addition, physicians whose practices reported having greater numbers of EHR functions (with higher numbers indicating more advanced and possibly more complex EHRs) were less likely to have high overall professional satisfaction."

Improved Professional Satisfaction:

And here are the three areas where physicians felt that EMR provided some benefits.

1) Better Access to Patient Data
"Physicians in multiple specialties and practice models noted that their EHRs improved their abilities to access patient data, both in health care settings and at home."

2) Improved Tracking of Guideline Compliance and Disease Markers
"Physicians and administrators in some practices described how EHRs improved their ability to provide guideline-based care and track patients’ markers of disease control over time. These advantages were predominantly noted in primary care practices."

3) Better Communication with Patients and Between Providers.
"Interviewees described enhanced communication through the medical record itself (e.g., by facilitating access to other providers’ notes and eliminating illegible handwriting) and through EHR-based messaging applications (e.g., patient portals). Improvements in between-provider communication were most commonly noted in larger practices, where all providers were on the same EHR."


There you have it ... with a score of 9 to 3, the "Nay's" have it (at least here in 2013). 

Despite this damning report, the majority of physicians these days are dealing with one or more EMR systems to document their clinical activities these days. If you deal with more than one ... for instance one in the office and another in the Hospital ... the odds are they don't communicate with each other.

Until the actual technology improves and there is a smaller number of standardized documentation programs - the only option that makes sense is to become a power user in your current system(s) and hope they stay constant in the years ahead.


What is your biggest challenge with your EMR ?
Has using an EMR improved the quality and efficiency of your practice ?
Has using an EMR made your work day more or less stressful ? 


-- About the RAND/AMA 2013 Physician Satisfaction Study:

"Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy"

Mark W. Friedberg et al

AMA and RAND Corporation performed the study in alignment with the core strategic objective "the advancement of health care delivery and payment models that enable high-quality, affordable care and restore and preserve physician satisfaction"

Began on October 22, 2012, and was completed on September 30, 2013. Sought to identify "high-priority determinants of professional satisfaction".

The study gathered data from 30 physician practices in six states: (CO, MA, NC, TX, WA and WI) Practices were selected to achieve diversity on practice size, specialty, and ownership model.

They conducted semistructured interviews with a total of 220 informants (108 with practicing physicians and 112 with practice leaders and other clinical staff)

Finally, they fielded a survey to 656 physicians in the 30 practices, receiving 447 responses (68-percent response rate).

[here is a link to a .pdf file of the full study report it's free ]


Tags: Physician Burnout, physician stress, EMR