PROVIDENCE – For many physicians and health care professionals, electronic health records are a disliked fact of life in practicing medicine, a technological tool that they find themselves increasingly tethered to, much like a 21st century stethoscope.

EHRs bring with them an increasing burden of documentation, a decreasing quality in the interaction between patient and physician, as well as an increase in the beneficial ways that medical information can be shared across health care delivery platforms.

Those were some of the key findings in a recently published qualitative analysis of narrative comments made as part of a statewide 2014 health information technology study, in which 3,761 licensed physicians in Rhode Island were asked: How does using an EHR affect your interaction with patients?

Some 68 percent of licensed physicians – 2,236 – responded to the survey; more than 87 percent of the responding doctors said that they used EHRs.

Of those who responded, some 30 percent – 744 – provided a narrative answer to the question posed about how EHRs affected their relationship with patients.

The analysis further divided the comments by responding physicians in how they self-reported the details of their practices: whether they saw patients in an outpatient setting, such as primary care physician or a family physician, or an inpatient setting in a hospital.

In late June, the Journal of Innovation in Health Care Informatics published the results of the first qualitative analysis from the narrative data captured in the 2014 HIT survey, with the provocative headline: ‘It is like texting at the dinner table’: a qualitative analysis of the impact of electronic health records on patient-physician interaction.

The study was authored by Kimberly D. Pellard of Healthcentric Advisors, Rosa R. Baier of the Center for Long-Term Care Quality and Innovation at the Brown University School of Public Health, and Dr. Rebekah L. Gardner, senior medical scientist at Healthcentric Advisors, an associate professor of Medicine at Brown University, and a internal medicine physician with University Medicine at Rhode Island Hospital.

On July 28, Reuters health reporter Ronnie Cohen published a story following up the study, entitled: “Doctors frustrated that electronic records steal time from patients,” interviewing Gardner.

“We’re either left fumbling through data entry with our patient in the exam room, missing out on an opportunity to truly connect, or we’re left with hours of documentation and computer work after a long day of seeing patients,” Gardner told Cohen in a phone interview.

Last week, ConvergenceRI sat down with Gardner to conduct an in-depth, in-person interview to get a better understanding of the results of the study – and how the questions asked of doctors in narrative form might be amended and changed in future surveys.

A little history
Since 2008, at the direction of the R.I. General Assembly, the R.I. Department of Health has conducted a statewide Health Information Technology Survey of all licensed physicians in the state. The contractor chosen to conduct and analyze the survey results has been Healthcentric Advisors.

The impetus for the survey, according to Gardner, was to be able to put a finger on the pulse on where health IT was intersecting with physicians, and how physicians were using technology. The initial design of the survey was quite narrow in scope, Gardner explained, but was expanded in later years through a stakeholder-driven process.

To capture what patients think about EHRs, Gardner continued, would require the R.I. General Assembly to change the language under girding the scope of the survey.

The most recent statewide HIT survey was conducted in the spring of 2017; the quantitative results from that survey will be published this fall, according to Healthcentric Advisors.

In turn, the rationale for conducting a qualitative analysis of the narrative comments made by physicians in a text box at the end of the survey, because of a very consistent stream of comments made in every survey period.

Here is the ConvergenceRI interview with Dr. Rebekah Gardner, who helped to design the qualitative analysis of how licensed physicians have responded to the way that EHRs have changed the nature of the relationship with their patients.

ConvergenceRI: What was the genesis of the study you conducted? What were you looking at? And what did you want to find out?
GARDNER: Those are good questions. We had been administering the survey for many years through the R.I. Department of Health, looking at how physicians in the state are adopting and using health information technology.

There was a space at the end of the survey, a free text box, where physicians, when asked for any additional comments, provided a lot of comments about their anguish in using EHRs, and how challenging it had been to use them in a way that preserved the patient-physician relationship.

We were inspired by [the fact that there was] a consistent stream of comments in every survey period. We wanted to look more closely at that, and really get at that in a much more scientific way, using qualitative analysis techniques.

ConvergenceRI: What do you mean by qualitative analysis techniques?
GARDNER: The survey can ask questions which can be analyzed quantitatively: numbers, statistics, comparisons between groups using percentages. And, then, a statistical test would be used to determine whether or not there were statistically significant differences between groups.

In a qualitative research approach, in a survey, if you have a block of text, for example, or when you do interviews with someone, or focus groups, those kinds of data cannot be analyzed quantitatively.

They have to be analyzed qualitatively; that’s an entirely different research approach, one that requires a different methodology.

ConvergenceRI: I have reported on the HIT survey results for a number of years. But I don’t remember ever seeing any such qualitative analysis ever published. Is the first study of its kind?
GARDNER: Yes. I believe the qualitative analysis was done working the 2014 survey results. The HIT survey was initially administered as a pilot in 2008; the data was first publicly reported in 2009. This particular question [about EHRs and how it impacted the physician-patient relationship] was embedded in the 2014 HIT study.

In the past, we typically would create a data book and do presentations to various stakeholder groups. A lot of the results would be publicly available on the Department of Health website.

The qualitative analysis was not publicly reported at that time, because it took us significantly longer [to complete], to go through our usual analytic process, as a separate side project.

ConvergenceRI: You seem to wear many hats. What are they?
GARDNER: That is the fun part of my job. I do not have a direct role at the R.I. Department of Health. Healthcentric Advisors is the contractor that administers and analyzes the HIT survey on behalf of the Department of Health.

Part of my job as [senior medical scientist] at Healthcentric Advisors is to provide clinical oversight and expertise on that survey. Along with other tasks, the other thing I work on here is with our efforts with Medicare providers in terms of improving care transitions. I provide clinical oversight.

I split my time, 50-50, between the work I do here and my work as a physician. I see patients, both in a hospital and in the outpatient setting at Rhode Island Hospital. I practice internal medicine.

I’m also on the faculty at Brown. I think most of us in academics do many different things, which is why our jobs are so great.

ConvergenceRI: And, just to be clear, the responses you analyzed qualitatively in your study were optional.
GARDNER: Yes, the text box was optional; many of the survey questions required an answer.

ConvergenceRI: Did you find the results surprising?
GARDNER: Yes and no. I think the results confirmed what other smaller studies [had found], that had been done with focus groups, mostly as it related to primary care physicians and family physicians, most of whom work in an outpatient setting.

It confirmed [the findings of] those studies, in that physicians often find EHRs frustrating. They are concerned that having an EHR in the exam room interferes with the quality of the interaction they are having with patients. And that it may degrade that relationship; it impairs making eye contact, providing complete attention [to the patient].

What was particularly interesting to us, and I think novel about this particular study, was that it included inpatient physicians as well.

That’s a group that hasn’t been studied with the same intensity as it related to EHR use as the outpatient setting.

ConvergenceRI: How did you define inpatient and outpatient settings in the survey?
GARDNER: Early on in the HIT survey, physicians are asked to identify where their main practice setting is locate; is it in an outpatient setting, or in an inpatient office space or hospital based.

Once they self-identify, then the survey incorporates “skip patterns” to tailor the questions to them.

What was novel [in our study] was including a very large sample of specialties of inpatient care as well.

While many of the same things were echoed by what outpatient physicians said, what was interesting was that inpatient physicians talked less about how it interfered with the actual interaction with patients, that face-to-face piece of it. Instead, they talked more about the clunkiness of using the EHRs and doing data entry, and how the fairly significant documentation burden chained them to their desk and prevented them from spending time at the bedside with patients.

Inpatient physicians were less likely to use the computer in the exam room with the patient present; they were much more likely to have an encounter, talk to the patient, do an exam, and then go outside the room to do their documentation.

But they felt the documentation burdens have become so excessive that it was drawing important time away from that face-to-face interaction with the patient.

ConvergenceRI: As you sorted the data, were you able to do any sorts by age or by demographics? My hunch would be that younger physicians may be much more adept at using technology and find it less of a burden, because they have been brought up using it. Whereas older physicians, not to disparage them in any way for being older, may probably be more resistant to the technology and find it more burdensome.
GARDNER: That is a great question. We’ve looked at that in terms of physicians who have chosen to answer the question vs. physicians who choose not to do so. Physicians who choose to answer the question tended to be older and tend to be more likely to practice general medicine, such as primary care.

We did not look at the difference in the prevalence by age or gender.

ConvergenceRI: Could you go back and resort the data to do that kind of analysis?
GARDNER: Probably not, at this point. The data have been separated out from identifying characteristics, so trying to link them back at this point would be challenging. One could imagine designing the study analysis differently in the future.

Some people who do a lot of qualitative research don’t like imposing that kind of quantitative approach onto the data, so that would somewhat controversial. One could certainly do it, and it would be hard not to imagine how some of those themes might play out.

ConvergenceRI: When was the most recent HIT survey completed?
GARDNER: It was just done this past spring [in 2017].

ConvergenceRI: Beyond issues of impacts of relationships with patients and the burden of documentation, has the survey explored issues around interoperability between the competing health IT systems?
GARDNER: There are many reasons why EHRs can cause frustration. We took a deep dive on the patient interaction piece of it. But certainly, one could spend a lot of time looking at interoperability.

ConvergenceRI: Of late, there have been some very divergent schools of thought around EHRs. Folks like Jim Purcell, the former CEO of Blue Cross & Blue Shield of Rhode Island, in a recent interview with Providence Business News, said, in effect, let’s get rid of electronic health records.
GARDNER: I don’t think we are going in that direction.

ConvergenceRI: Others, such as Christine Ferguson, have talked about the need to add a function of patient engagement to health IT software, which she said was developed more as a may to increase the accuracy of billing and transactions rather than to improve communications between physicians and patients.
GARDNER: That is not something I can comment on.

ConvergenceRI: Is there a way to address the tremendous growth in wearable devices and how to integrate and incorporate patient data? Could that be included as a question in the survey for physicians? It has the potential to upend the paradigm of electronic health records.
GARDNER: It has the potential to do that, but I wouldn’t say at the moment it is currently doing that. We haven’t asked doctors about this, but gosh, now you make me want to consider asking in next year’s survey, how do doctors incorporate patients’ data. Just because data is being generated doesn’t mean that it is being used for clinical decision-making.

ConvergenceRI: It raises the questions: who owns the data? And, would patients be willing to share the data?
GARDNER: Another question is: what are the clinicians going to do with the data? What I hear is that it’s information overload already. Would patient reported data, which has value, increase the feeling of being overwhelmed by the amount of data that is already coming at you every day? It’s a difficult balance.

ConvergenceRI: What kinds of additional questions are being considered to become part of future HIT surveys?
GARDNER: This year’s survey has incorporated how physicians document information about vulnerable populations. Which is particularly important, because we can’t do population health and outreach unless we ask and document that information.

ConvergenceRI: When will those results become available?
GARDNER: In the fall. Another question we’ve added this year is in regard to stress and burnout as a result of EHRs. We think that’s an important safety and quality of workforce issue.

Something else we’ve added this year is about physicians’ knowledge, acceptance and understanding of online resources to help patients choose doctors.

And, in our vulnerable population section of the survey, some of the questions are centered around whether physicians ask, or do not ask, patients questions about domestic violence, do they ask about substance use disorders, and do they ask about mental health.

And, if they do ask those questions, how do they record that information? Is it in a specific designated field, or do they choose not to record it, to protect patient privacy. Or, do they not ask at all.

ConvergenceRI: What questions haven’t I ask, that you would like to talk about?
GARDNER: I would be remiss if I didn’t mention that a lot of physicians see the positive side of EHRs. While they may add to frustration levels, they also bring great benefits.

Several physicians, especially in hospital based positions, where they may not know the patients they are going to see, saw having an electronic health record was more beneficial than harmful. They were able to access the information quickly, they felt the information was accurate, and they felt that they were able to have a more productive conversation with the patient. They also felt more prepared.

I want to make sure to give the other side, that EHRs do have a lot of benefits, and they are certainly not going away.

Even among outpatient physicians, who are likely to be more frustrated, they recommend the benefits as well.