In the context of a cluster randomized trial of novel EHR-based functionality that improved tobacco treatment, 50% of clinicians in intervention practices interacted with the functionality in a significant way. Conventional wisdom holds that novel technology is more likely to be adopted by younger users who are more comfortable with technology and may have more time to explore novel functionality.13
However, contrary to conventional wisdom, on bivariate testing, we found that older, clinically busier staff physicians who saw patients with more documented problems, were more likely to use novel EHR functionality and use it more heavily. In multivariable modeling, clinically busier physicians seeing patients with more documented problems were more likely to use novel EHR functionality.
Far from clinically busier clinicians not having time to explore novel functionality, they may have greater opportunities to explore the EHR, be more comfortable with the EHR, and have greater incentive in exploring potentially time-saving functionality. It is particularly interesting that clinicians who saw patients with more documented problems used the novel functionality more. On the one hand, these results are counterintuitive: clinicians who see more complicated patients may have less time to engage with novel functionality. On the other hand, busier clinicians may reap greater, more immediate benefits from novel EHR functionality. If the number of patient problems is a reflection of clinicians' interaction with the EHR—that is, clinicians are the ones entering the problems—the observed relationship is expected.
Other investigators have found various clinician-level factors related to the use of novel functionality. Somewhat in contrast to our results, Dixon and colleagues found that the amount of non-clinical time, but not workload or clinician age, was related to self-reported information technology adoption.19
Weingart and colleagues found that house officers were more likely to honor medication prescribing alerts than staff physicians.9
Consistent with our findings, Sittig and colleagues found that clinicians say they are more likely to follow CDS for patients with five or more chronic conditions or patients on more than five medications, but not if they were behind schedule.20
Physician specialty has been a predictor of use, with general internists less likely than family medicine doctors or pediatricians to use novel functionality like e-prescribing.13
This analysis has limitations that should be considered. The practices participating in this randomized controlled trial were academically affiliated, used a home-grown EHR, had mainly general internal medicine clinicians, had a high number of trainees, and were members of a ‘benchmark leader’ system in health information technology.6
Our results may not be generalizable to other settings. Although clinician type was not an independent predictor of functionality use, trainees (overwhelmingly residents who have low ambulatory volume) may feel less engaged with ambulatory duties and the EHR than staff physicians. This might partly—but not completely, given our supplementary analyses—explain the relationship between volume and use of novel functionality. Second, the relatively small sample size may limit the ability to detect differences based on some characteristics and limits our ability to carry out additional, restricted analyses. Third, this study was during the 9-month introduction of novel functionality; results may have changed if there had been a longer introductory period. Fourth, there could be differences in uptake between wholesale adoption of an EHR, core EHR functions (eg, e-prescribing), and more specialized, problem-specific functionality like tobacco treatment.
In conclusion, we found that clinically busier physicians seeing patients with more documented problems were more likely to use novel EHR functionality. Thus, being busy should not be used as an excuse for failure to adopt new technology. In implementing novel functionality, EHR developers and health system leaders should ensure that implementation is accompanied by good design, usefulness, attention to workflow, and aligned incentives.19
The meaningful use incentives on their own should encourage greater EHR adoption and use of more sophisticated EHR functionality.12
In addition, better identification of clinician and practice characteristics associated with uptake and use of novel EHR functionality—avoiding assumptions about who will use new functionality—as well as monitoring of implementation will serve to increase the use of novel functionality and deliver on the quality gains promised by the use of EHRs.