We surveyed community-based primary care physicians transitioning from a paper record system to a commercially available electronic health record over a 12-month period and noted increased support for the system across a spectrum of health-care quality domains. Within 1 year of the implementation of the record, a vast majority of clinicians felt that it improved overall quality, patient safety, communication among clinicians, and access to clinical information. We also noted that improvements related to the availability of clinical information and test result follow-up were perceived by clinicians sooner than other measures of efficiency, quality, and communication. Our findings provide an important rationale for persevering through the initial difficulties of implementation related to clinician perceptions.
Increased access to clinical information represented the only measure where improvements in clinician perceptions were not noted. However, virtually all clinicians (92%) reported immediate improvement in this measure at study baseline, which has important implications for clinical efficiency, where lack of access to information often results in redundant test ordering and the resultant substantial cost implications.30
This very early benefit might be used as a lever to hasten the conversion of clinicians resistant to accepting the electronic health record in the early phases of the implementation.
The implementation was not free of challenges. Many clinicians felt that the electronic health record had an initial negative effect on their patient interactions and resulted in worsening efficiencies related to medical documentation and length of patient visits. Fortunately, there were improvements in clinician perceptions of all three of these metrics within the first year following implementation. However, roughly two thirds of clinicians still reported that more time was being spent on medical documentation outside of their clinical sessions at 12 months, a situation that will likely worsen the growing problem of increased time spent providing care outside of office visits.31
Solutions are needed to address problems in workflow efficiency, potentially through the use of customizable note templates, speech recognition software for dictation, and more user-friendly management of problem lists, medication lists, and test results.
Our study findings expand on the literature of electronic health record adoption by providing a longitudinal assessment of clinician perceptions. Prior surveys have relied on cross-sectional data to provide a snapshot of clinician perceptions, often combining the views of clinicians with varied lengths of exposure to an electronic health record or focusing only on either the initial implementation period or long-term follow-up.32–39
Interestingly, some cross-sectional studies of physicians have shown more positive perceptions of the impact of electronic health records among those who have already implemented such systems compared to those who have not.22,40
However, it is not clear whether these more positive perceptions were in fact the initial impetus for adopting the electronic health record or if they were a result of a positive experience with the new record system. By quantifying the time required for changes in clinicians’ perceptions of the electronic health record, our results provide a benchmark for electronic health record adoption patterns. Additional longitudinal data from other implementations would help determine which design, training, and support interventions lead to improvements in the adoption rates of new systems.
Our study is strengthened by its longitudinal design and high survey response rate. In addition, we evaluated the implementation of a common commercially available electronic health record within a community setting, which builds on prior work in this field that has largely focused on internally developed systems within academic hospitals.9
However, our findings should be considered in the context of some limitations. Our study sample consisted of primary care clinicians practicing within a single health network that devoted significant resources to the implementation process, and our results may not extend to other settings with different core infrastructures or those implementing different electronic health record systems. In particular, the health centers in this study were relatively large, and there are legitimate concerns regarding the feasibility of implementing such electronic systems in smaller physician practices.16
Implementations in settings that are unable to employ such a resource intensive training model may not achieve the same results.
In addition, the adoption of the electronic health record within our study clinics occurred in the context of a merger with a larger umbrella organization that had been using the commercial electronic health record for several years. The experience of the umbrella organization with the electronic health record may have facilitated a smoother transition for the new practices joining the network. The recent merger may also have created more positive clinician responses towards the electronic health record. However, the initial level of support for the new electronic health record in our clinician sample closely mirrors findings from a recent study of all ambulatory practices in Massachusetts, arguing against such a bias. In this prior study, 80% of physicians not currently using an electronic health record reported that computers have the potential to positively impact the quality of health care and 84% reported that computers can positively impact the problem of medication errors.22
Another potential limitation of our study is that we only surveyed clinicians for 1 year following the implementation, and there may be continued changes beyond this time frame. However, our results indicated consistent trends across all survey items, and it is unlikely that a longer study period would identify contrasting results. We measured clinician acceptance of the electronic health record using a confidential survey rather than alternative methods, such as direct observation or qualitative interviews.28
We also did not collect actual clinical outcomes or measures of efficiency to validate the perceptions of the clinicians. While these alternative methods provide valid information regarding physician acceptance, clinician self report provides important insights into the perceived limitations or benefits of an electronic health record, which will play a strong role in the eventual long-term uptake of such technology. Finally, it is possible that the longitudinal changes in clinician perceptions we identified were influenced not only by their personal experience with the new electronic record, but also by the increased national focus on the need for electronic health records to improve quality of care.
In conclusion, we found that while clinicians may perceive some initial problems with a new electronic health record, they become significantly more receptive to it within 1 year of implementation. There is some variation in how quickly improvements are perceived, with those related to increased access to information and test result follow-up coming sooner than measures of overall quality, communication, and efficiency. These findings should provide support for clinicians and health system leaders as they seek to implement this new technology with the goal of improving health-care delivery in the ambulatory setting.