EHRs, Red Tape Eroding Physician Job Satisfaction

Problems with electronic health records systems and the overall burden of rules and regulations imposed by payers and other entities are having a deleterious effect on the professional satisfaction of medical doctors, survey results find.

Physicians are most satisfied when they deliver high quality care to their patients, but problems with electronic medical records and red tape are hindering their practices, a multi-state survey shows.

The RAND Corp. report was commissioned by the American Medical Association and surveyed hundreds of physicians in six states to identify the factors that influence professional satisfaction. The survey found that only 20% of physicians said they want to return to paper medical records.

Most physicians, however, expressed deep frustration with costly and overly complicated EHRs that have fallen far short of their promise to improve practice efficiency.

"This is a vexing problem," Mark Friedberg, MD, the study's lead author at RAND, said Tuesday at an AMA teleconference.

"Physicians like some aspects of their EHR and the vast majority prefer EHR to paper. However, physicians also report that EHRs are not nearly as good as they can and should be. The priority, our study suggests, is to rapidly improve EHR usability and functionality."

Friedberg says the survey findings also suggest that dissatisfied physicians "could be seen as canaries in the coal mine for quality as an early indicator of potential problems with quality in the healthcare system."

"Most prior studies have conceptualized physician professional satisfaction as mattering because it may lead downstream to higher quality and better experiences for patients and patient care," he says. "Our findings at least suggest an alternative reason to really care about physician professional satisfaction by reversing the causal and thinking of professional satisfaction as actually an indicator of quality of care rather than something that is necessary for quality of care to occur."

AMA President Ardis Dee Hoven, MD, says the survey suggests that physician satisfaction is a "wind vane that shows us the factors out there that can be barriers to first-rate medical care."

"The measurement that we are using on satisfaction really reflects what is happening at the site of care and when you have satisfied doctors in working environments, you also have satisfied patients with good health outcomes," she says. 

Hoven says it is understandable why most physicians don't want to return to paper records even though they complain about EHR. "It gives me better data at my fingertips in a more timely fashion to manage that patient's care appropriately. That is why we like electronic medical records," she says.

"At the end of the day the electronic medical record is what we need. At the same time it has to be usable and more intuitive; it has to be interoperable; it has to make my work flow easier, not more complicated."

Friedberg rejected suggestions that physicians are simply experiencing "growing pains" as they adapt to EHRs. "I am not sure that fairly reflects the findings of our study and the period of pain both for physicians and for patients may actually be long and something that might deserve a much more serious look," he says. "Certainly it might require quite a bit of explicit effort to address rather than waiting for it to resolve itself on its own."

The survey asked if physician satisfaction improved in practices that had more experience with EHRs.

"We found no relationship there," Friedberg says. "That to us suggests that the opposite may be true, that these issues with EHR are not necessarily an issue of physician familiarity or practice familiarity with the EHR. It really is a fundamental potential issue of the interaction between the state of EHR technology currently and the state of medical practice."

Hoven agreed that "familiarity with EHR isn't really the issue."

"Clearly usability issues, interoperability issues, workflow issues, standards that aren't practice or specialty specific, limitations on what is actually available and in many situations practices have had to actually rip out and replace systems because they simply were not working," she said. "So we still have some huge hurdles to go here to get EHR to where it really works for the physician practice in providing the care that the patient."

Jay Crosson, MD, AMA's group vice president for professional satisfaction, care delivery and payment, says "‘growing pains' may be an apt analogy but not with respect to physicians."

"In fact what we may be dealing with here is growing pains for the vendors themselves and the nature of the software. I know in my own personal experience as a physician in a medical group with an EHR that as good as they are, they need continual improvement," Crosson says. "We need to help the industry itself get through its growing pains."

Other issues affecting physician satisfaction that were identified in the survey included:

• Excessive productivity quotas and limitations on the time spent with each patient. The cumulative pressures associated with workload were described as a "treadmill" and as being "relentless," sentiments especially common among primary care physicians.

• Perceptions of collegiality, fairness, and respect. Within the practices studied, frequent meetings with other doctors and other health professionals fostered greater collegiality and satisfaction.  

Red tape mandates by government and payers also played a role in chilling physician satisfaction, although no single source was blamed. "What physicians did express was the overall burden of rules and regulations from a large number of sources not limited to the government at all and including also those that were imposed by payers and other entities in the healthcare system," Friedberg said.

"It was more of a sense of overload than any one or two specific sources of these rules and regulations."