Keywords
electronic patient records and systems - patient records - specific software - clinical
IT systems - usability - workflows
Background and Significance
Background and Significance
Electronic patient records (EPR) have become one of the central tools in physicians'
daily work. EPRs are expected to improve the quality and continuity of care, but they
have also changed physicians' workflows, documentation time, and documentation practices.[1]
[2]
[3]
[4]
In a study conducted by the American Medical Association (AMA), the introduction of
EPR systems impaired physicians' professional satisfaction.[5] This is ascribed to several factors such as poor usability, tedious data entry,
interference with direct patient care, inept and less meaningful work content, and
an inability to exchange health information.[5] In Finland, EPR usage is associated with an increase in mental strain as well as
poor well-being and work ability among physicians in both a longitudinal questionnaire
study and a cross-sectional investigations[6]
[7]
[8]: physicians consider poorly functioning EPRs as the major factor increasing their
work load and physicians working in public sector experience more stress due to EPR
usage than their colleagues in the private sector. The work-related well-being of
nurses seems less affected by EPR usage than that of physicians.[9]
In our own studies, Finnish physicians are dissatisfied with the usability of their
EPR systems.[10]
[11]
[12]
[13]
[14]
[15] Moreover, the experienced usability does not improve during the 4 year study period
(2010–2014)[10]
[13] and physicians link faulty functions in EPR systems with an endangering of patient
safety. The earlier studies from our data have focused on usability of EPR and HIE
(health information exchange) systems. The questionnaire measures for work-related
well-being and analysis of their predictors have not been previously reported. In
international studies, physicians report that the time taken for documentation has
increased and the information systems divert concentration from patient care.[16]
[17] Physicians experience that the patient–doctor relationship is negatively affected
by the usage of these systems.[18]
Health Information Technology in Finland
In Finland, health care is publicly funded for the most part and thus private sector
is relatively small. Public health care consists of primary care—health care centers
employing general practitioners and nurses—and secondary care—hospitals with specialized
inpatient and outpatient care. Private sector comprises mostly of specialist clinics
and only few hospitals. Practically, all critically ill patients are treated in public
hospitals; there are no private intensive care units (ICUs). In Finland, all public
health care organizations, both in primary care and hospitals, as well as the vast
majority of private care providers use EPRs.[19] At the time of this survey, the national e-prescription functionality was fully
implemented in all public sector and part of the private sector EPR systems. By contrast,
the national electronic data repository only functioned in one small hospital district.
Nevertheless, the new requirements for the implementation of these functionalities
had already generated changes and new features in the EPR systems. After the categorization
of EPRs as medical devices in 2010, the numbers of EPR-related patient safety incidents
reported to the National Supervisory Authority for Welfare and Health (Valvira) increased
rapidly.[20]
[21]
Work-Related Well-Being of Finnish Physicians
Time pressure, job control, and organizational justice are recognized as important
factors for the well-being and health of physicians.[22]
[23]
[24]
[25] Studies suggest that experience of being hurried and patient-related stress are
the main reasons for the mental pressure experienced by Finnish physicians.[26]
[27] In Finland, physicians and nurses tend to have more mental strain and psychological
problems than other personnel[25]: a cohort study from 2007 found physicians to have double the overall mortality
risk and a 3.9 times higher risk of suicide mortality than other health care personnel.
High levels of psychological stress and sleeping problems also increase the tendency
of physicians to change profession. There is no significant change in overall experienced
workload during study years 2006, 2010, and 2015.[7] Physicians working in primary care report more time pressure and more load factors
than their peers in secondary care and the private sector. Patient-related stress
seems to be more common among younger physicians working in the primary care sector.
One-fifth of Finnish physicians report having experienced a serious threat of burnout
and half of the physicians have thought about burnout from time to time.
Research Related to EPRs' Implementation and Work Well-Being
EPR usage is associated with physicians' mental strain and work-related well-being.[5]
[6]
[7]
[28] While most studies focus on factors related to the implementation and deployment
phases of health information technology (IT), only a few studies report the impact
on physician work well-being of the usage of the established EPR systems.
EPR implementation has been shown to increase the time taken for the documentation
of patient information and affect physician workflow. The study of Mamykina et al
revealed a high level of fragmentation of documentation activities and frequent task
transitions in EPR usage.[16] They argued that electronic documentation adversely affects the quality of clinical
work, increases physicians' mental load, and results in more frequent interruptions,
thus presenting a risk to patient safety. Munyisia et al found that electronic nursing
documentation system did not reduce time taken for documentation because paper documentation
was used alongside EPR.[29] A time motion study of otolaryngology residents found that the residents spent more
time in indirect patient care with EPR than directly caring for the patient. One of
the suggested reasons for this was the use of EPRs, which results in fragmentation
of clinical workflows.[17] In another study, EPR implementation had a major impact on the physician's time
usage for documentation in ICU, and also shifted the pattern of temporal tasks.[30]
Objective
Identification of EPR features that could ameliorate physicians' work-related well-being
has become necessary. The primary aim of the present study is to analyze the relationship
between EPR-related factors and the time pressure and job control perceived by physicians.
Methods
Data Collection
In February 2014, an electronic questionnaire on the usability of EPRs was sent to
all Finnish practicing physicians younger than 65 years (n = 18,257). The full questionnaire is available in English.[31] The survey was first performed in 2010 and repeated in 2014. The usability-focused
questionnaire comprised 18 background questions and 38 core statements with a five-point
Likert scale; in addition, there were groups of questions addressing issues of management,
patient safety, work well-being, information systems development, and EPR features
that are working well or are considered as the most important development targets.
The questionnaire was designed to focus on physicians work and their use on EPRs,
not on a specific software or system or user interface without the context of physicians
work. Compared with the standardized usability questionnaires (such as SUMI, QUIS,
or SUS), the strength of our questionnaire is that it is designed to focus on easiness,
efficiency, and quality of physicians' key tasks performed with the help of the clinical
IT systems as tools. Standardized usability questionnaires cannot capture this task-
and context-specific variation. The method has been described in detail in our previous
articles.[32]
[33] The questionnaire 2014 was piloted with eight physicians. National and international
articles[10]
[11]
[12]
[13]
[14]
[15]
[33] about the usability of different EPR brands have been published. This article is
the first to address work well-being.
Respondents
The 3,781 responses represent approximately one quarter (23.1%) of Finnish physicians
working in patient care. The representativeness was assessed by comparing sample to
the register of the Finnish Medical Association (FMA) and to Finnish physician labor
market survey of 2014.[34] Methodologically, the survey sample can be regarded as a representative random sample
of the population[13]: the proportion of respondents representing specialized care (46.4%) and primary
care (24.4%) were similar to the FMA register; however, the proportion of women had
increased and the proportion of younger age groups were slightly smaller than that
in the FMA population.
Measures
Time Pressure and Job Control
Time pressure and job control were measured by scales, which have been frequently
used in studies on psychosocial working conditions of physicians.[6]
[8]
[28] Due to the long questionnaire, shortened versions of the scales were used in the
current study. Time pressure was measured by two items derived from the Harris' stress
index.[35]
[36] The respondents were asked how often they had been disturbed by (1) a constant rush
and pressure due to uncompleted work and (2) not enough time to perform work properly.
The items were responded on a 5-point scale: 1 = quite often or constantly, 2 = rather
often, 3 = sometimes, 4 = rather seldom, 5 = very seldom or never. For computing a
composite score (a mean of responses), the scale was reversed so that higher score
indicated higher time pressure. The Cronbach's α coefficient for the scale was 0.91.
Job control was measured by two items: (1) “I am allowed to take independent decisions in my work” and (2) “I have a great deal to say in my own work,” derived from the three-item decision authority subscale from Karasek's job content
questionnaire.[37] The items were responded on a 5-point scale: 1 = completely agree, 2 = somewhat
agree, 3 = not agree nor disagree, 4 = somewhat disagree, 5 = completely disagree.
For computing a composite score (a mean of responses), the scale was reversed so that
higher score indicated higher job control. The α coefficient was 0.72.
Respondent Characteristics
Age (in years), gender, specialization (nonspecialized, specialization on going, and
specialized), health care sector (public/private), and employer (health center/hospital/private
practice or hospital) were selected as background factors.
Respondents' EPR Usage
The respondents were asked to select the principal brand of EPR system they use in
patient care and give an assessment of the system. In addition, the questionnaire
included questions about the length of use of the principal EPR system (response alternatives:
less than a year/1–3 years/3–6 years/over 6 years), the number of clinical systems
that need to be logged into on a daily basis when working with patients (response
alternatives: maximum 1/2/3/4 or more), and participation in the development work
on electronic information systems (no/somewhat/ actively).
EPR Usability
Usability of the (main) EPR system was assessed by a set of 36 items, which were grouped
in seven dimensions based on explorative factor analysis (see [Appendix]). The seven factors with eigenvalues (eigenvalue measures the variance in all variables
which the factor accounts) above 1 explained 55% of the variation in items. For interpretation
of the content of the factors, Varimax rotation (orthogonal rotation) of the factor
axes was used to maximize the variance of the squared loadings of a factor (column)
on all the variables (rows) in a factor matrix, which has the effect of differentiating
the original variables by extracted factor. In the Varimax-rotated solution, nine
items reflecting the usability of the system received strong loadings in the first
factor (loadings 0.40–0.75 explained the variance of 13%, which was the strongest
loading for the first factor, the item “The arrangement of fields and functions is logical on the computer screen”). The Cronbach's α of the total scale composed of all nine items (User friendliness) was 0.88.
Appendix
Factor analyses of the usability items. Varimax rotated 7 factor solution
|
|
For the second factor, seven items reflecting the perceived benefits of the electronic
information system received the strong loadings (−0.39, 0.64–0.79, explained a variance
of 11%), the strongest loading for the item “Information systems help to improve the quality of care”). The Cronbach's α of the total scale composed of these seven items (Perceived benefits) was 0.84 (in items where the negative loading coding was reversed).
The third factor comprised six items reflecting technical problems or technical stability
(loading −0.69 to −0.43, −0.64 to 0.72, explained a variance of 9%, the strongest
loading for the item “Information entered/documented occasionally disappears from the information system”). The Cronbach's α of the total scale composed of these six items (Technical problems) was 0.82 (in items where the negative loading coding was reversed).
The fourth factor was the four items reflecting the responsiveness of the system supplier
to the user feedback received (loadings 0.49–0.83 explained a variance of 7%, the
strongest loading for item “The system vendor implements corrections and change requests according to the suggestions
of end-users”). The Cronbach's α of the total scale composed of these four items (Feedback) was 0.81. Excluding one item (“I know to whom and how I can send feedback about the system if I wish to do so”) improved the α coefficient from 0.81 to 0.88, and this item was therefore excluded
from the final subscale.
The fifth factor comprised the strong loadings for five items reflecting external
cooperation (loading −0.72, 0.41–0.68, explained the variance of 6%, the strongest
loading for item “Obtaining patient information from another organization often takes too much time”) (negative loading). The α coefficient for the subscale (external cooperation) was 0.70.
Three items reflecting internal cooperation were loaded on the sixth factor (loadings
0.44—0.71 explained a variance of 5%, the strongest loading for item “How well do the information systems support collaboration and information exchange
between the physician and the nurses”). The α coefficient for the subscale (internal cooperation) was 0.63.
Finally, two items were loaded on the seventh factor: Diagnostic imaging results are easily available on a regional level (factor loading 0.79) and Laboratory results are easily available and are logically presented on a regional
level (loading 0.76). The last factor explained 4% of the variance between the items and
the α coefficient for the subscale (Test results) was 0.66.
In addition, the questionnaire included a statement on the additional features of
the EPR systems: “Documentation of patient information needed for statistical purposes (=billing, national
registries, reporting, etc.) takes too much time,” “The patient's current medication list is presented in a clear format,” “The information in the nursing record is easily readable.” These were assessed on a 6-point scale (1 = completely agree, 2 = agree somewhat,
3 = no opinion, 4 = disagree somewhat, 5 = disagree completely, 6 = the system does
not include the feature). For the analysis, the response scales were classified as
1 = agree somewhat or completely, 0 = disagree somewhat or completely/no opinion/the
feature not included in the system.
Statistical Analysis
The relationships between the dependent and independent variables were analyzed as
univariate associations by Pearson's correlation coefficients and by hierarchical
multivariable regression analyses. Multivariate regression analyses were chosen because
the dependent variables were continuous composite variables. In the regression analyses,
the independent variables were entered in the equation in four steps: (1) background
factors, (2) the principal brand of the EPR system, (3) experience in the use of electronic
systems, and (4) usability factors and additional features of the system.
Results
Results of the Univariate Analysis
In the univariate analysis, specialized physicians reported somewhat less time pressure
compared with those nonspecialized or in specialist training (F = 4.3, p < 0.05), while those in training reported less job control compared with those specialized
or nonspecialized (F = 62.38, p < 0.001). Time pressure was more common in health centers compared with public hospitals
and private practices (F = 222.22, p < 0.001), while highest job control was reported by those working in private practices
and the lowest job control by those working in public hospitals (F = 116.02, p < 0.001).
Those using several patient record systems on a daily basis reported more time pressure
and less job control. Longer experience in the use of EPRs was related to higher job
control. Those who had participated actively in the development of patient record
systems reported somewhat more time pressure and more job control ([Table 1]).
Table 1
Time pressure and job control according to physician's experience in the use of EPR
systems (univariate analysis)
|
Time pressure
|
Job control
|
|
Mean
|
SD
|
F-Value
|
p-Value
|
Mean
|
SD
|
F-Value
|
p-Value
|
|
Used the main system for
|
|
|
1.5
|
<0.214
|
|
|
19.15
|
<0.0001
|
|
>6 y
|
3.45
|
0.06
|
|
|
4.10
|
0.02
|
|
|
|
3–6 y
|
3.41
|
0.05
|
|
|
3.99
|
0.03
|
|
|
|
1–3 y
|
3.52
|
0.04
|
|
|
3.86
|
0.04
|
|
|
|
<1 y
|
3.51
|
0.03
|
|
|
3.78
|
0.05
|
|
|
|
Number of clinical systems logged into daily
|
|
|
24.3
|
<0.0001
|
|
|
30.35
|
<0.0001
|
|
Maximum 1
|
3.28
|
0.03
|
|
|
4.15
|
0.03
|
|
|
|
2
|
3.52
|
0.03
|
|
|
4.04
|
0.03
|
|
|
|
3
|
3.70
|
0.04
|
|
|
3.92
|
0.03
|
|
|
|
4 or more
|
3.58
|
0.04
|
|
|
3.77
|
0.03
|
|
|
|
Participated in the development of patient record system
|
4.03
|
<0.018
|
|
|
29.83
|
<0.0001
|
|
Actively
|
3.63
|
0.07
|
|
|
4.30
|
0.05
|
|
|
|
Somewhat
|
3.51
|
0.03
|
|
|
4.07
|
0.02
|
|
|
|
Not participated
|
3.44
|
0.03
|
|
|
3.91
|
0.02
|
|
|
Abbreviations: EPR, electronic patient record; SD, standard deviation.
[Table 2] shows the Pearson correlations between usability factors, time pressure, and job
control. Strong time pressure and job control were both particularly associated with
lower user friendliness and higher technical problems.
Table 2
Pairwise Pearson's correlation coefficients between time pressure, job control, and
EPR system usability factors
|
Time pressure
|
Job control
|
User friendly
|
Perceived benefits
|
Technical problems
|
Feedback
|
External cooperation
|
Internal cooperation
|
|
Time pressure
|
1.00
|
|
|
|
|
|
|
|
|
Job control
|
−0.23
|
1.00
|
|
|
|
|
|
|
|
User friendly
|
−0.19
|
0.20
|
1.00
|
|
|
|
|
|
|
Perceived benefits
|
−0.11
|
0.12
|
0.54
|
1.00
|
|
|
|
|
|
Technical problems
|
0.23
|
−0.22
|
−0.67
|
−0.43
|
1.00
|
|
|
|
|
Feedback
|
0.10
|
−0.10
|
−0.49
|
−0.43
|
0.42
|
1.00
|
|
|
|
External cooperation
|
−0.06
|
0.12
|
0.49
|
0.43
|
−0.39
|
−0.35
|
1.00
|
|
|
Internal cooperation
|
−0.06
|
0.14
|
0.49
|
0.47
|
−0.37
|
−0.32
|
0.41
|
1.00
|
|
Test results
|
0ns
|
0.03ns
|
0.27
|
0.25
|
−0.15
|
−0.17
|
0.39
|
0.27
|
Abbreviations: EPR, electronic patient record; ns, nonsignificant.
Note: All correlation coefficients significant (p < − 0.001) except those with “ns.”
Those who agreed with the statement that documentation of patient information for
statistical purposes was time consuming reported more time pressure (mean = 3.69,
standard deviation [SD] = 1.03 vs. mean = 3.20, SD = 1.09 among those not agreeing,
F = 173.12, p < 0.001) and lower job control (mean = 3.94, SD = 0.85 vs. mean = 4.09, SD = 0.86
among those not agreeing, F = 24.79, p < 0.0.001). Those agreeing with the statement that nursing records were easily readable
reported lower time pressure (mean = 3.29, SD = 1.10 vs. mean = 3.58, SD = 1.06 among
those who did not agree, F = 52.75, p < 0.001) and higher job control (mean = 4.20, SD = 0.77 vs. mean = 3.91, SD = 0.88
among those who did not agree, F = 52.75, p < 0.001).
Results of the Multivariate Analysis
[Table 3] presents the results of the hierarchic multivariate regression analysis with time
pressure and job control as independent variables.
Table 3
Factors associated with time pressure and job control (hierarchical regression analysis)
|
Explanatory variables, their distribution (%)[a]/means and (SD)[b]
|
Summary of the results of hierarchical regression analyses
|
|
|
Time pressure
|
Job control
|
|
%
|
β
|
|
∆R
2
|
β
|
|
∆R
2
|
|
Age
|
48.5 (10.9)
|
−0.031
|
|
|
−0.024
|
|
|
|
Gender
|
|
|
|
|
|
|
|
|
Men
|
38
|
ref
|
|
|
ref
|
|
|
|
Women
|
62
|
0.095
|
[g]
|
|
−0.088
|
[g]
|
|
|
Specialization
|
|
|
|
|
|
|
|
|
Nonspecialized
|
11
|
ref
|
|
|
ref
|
|
|
|
Specialization on going
|
22
|
−0.052
|
|
|
−0.045
|
|
|
|
Specialized
|
67
|
−0.033
|
|
|
0.108
|
[g]
|
|
|
Health care sector
|
|
|
|
|
|
|
|
|
Public
|
77
|
ref
|
|
|
ref
|
|
|
|
Private
|
|
−0.081
|
|
|
0.044
|
|
|
|
Employer
|
|
|
|
|
|
|
|
|
Public health center
|
28
|
ref
|
|
|
ref
|
|
|
|
Public hospital
|
54
|
−0.137
|
[g]
|
|
−0.094
|
[f]
|
|
|
Private sector
|
18
|
−0.264
|
[g]
|
0.13[g]
|
0.093
|
|
0.11[g]
|
|
Principal electronic patient information system
|
|
|
|
|
|
|
|
|
D
|
4
|
ref
|
|
|
ref
|
|
|
|
A
|
25
|
−0.108
|
[e]
|
|
0.086
|
[e]
|
|
|
B
|
14
|
−0.092
|
[e]
|
|
0.021
|
|
|
|
C
|
24
|
−0.121
|
[f]
|
|
0.004
|
|
|
|
Used the main system for
|
|
|
|
|
|
|
|
|
>6 y
|
49
|
ref
|
|
|
ref
|
|
|
|
3–6 y
|
25
|
0.009
|
|
|
−0.016
|
|
|
|
1–3 y
|
17
|
−0.032
|
|
|
−0.063
|
[f]
|
|
|
< 1 y
|
9
|
−0.023
|
|
|
−0.042
|
[e]
|
|
|
Number of clinical systems in daily use
|
|
|
|
|
|
|
|
|
Maximum 1
|
33
|
ref
|
|
|
ref
|
|
|
|
2
|
29
|
0.023
|
|
|
0.013
|
|
|
|
3
|
19
|
0.068
|
[g]
|
|
0.010
|
|
|
|
4 or more
|
19
|
0.027
|
|
|
−0.031
|
|
|
|
Participated in development of patient record system
|
|
|
|
|
|
|
|
|
No
|
52
|
ref
|
|
|
ref
|
|
|
|
Somewhat
|
41
|
0.022
|
|
|
0.077
|
[g]
|
|
|
Actively
|
7
|
0.055
|
[f]
|
0.01[g]
|
0.079
|
[g]
|
0.02[g]
|
|
Usability factors[c]
|
|
|
|
|
|
|
|
|
User friendliness
|
2.79 (0.84)
|
0.013
|
|
|
0.029
|
|
|
|
Perceived benefits
|
2.74 (0.80)
|
−0.030
|
|
|
0.020
|
|
|
|
Technical problems
|
2.82 (0.87)
|
0.126
|
[g]
|
|
−0.073
|
[f]
|
|
|
Feedback
|
3.88 (0.96)
|
−0.022
|
|
|
0.014
|
|
|
|
External cooperation
|
2.13 (0.73)
|
−0.019
|
|
|
0.013
|
|
|
|
Internal cooperation
|
3.40 (0.89)
|
0.005
|
|
|
0.033
|
|
|
|
Test results
|
3.16 (1.12)
|
−0.029
|
|
|
0.017
|
|
|
|
Additional features of the system[d]
|
|
Compiling patient statistics time consuming
|
58
|
0.096
|
[g]
|
|
−.012
|
|
|
|
Patient's medication list in a clear format
|
32
|
0.006
|
|
|
0.034
|
|
|
|
Nursing record is in easily readable
|
32
|
−0.035
|
|
0.03[g]
|
0.075
|
[g]
|
0.03[g]
|
Abbreviation: SD, standard deviation.
a In categorized variables.
b In continuous variables.
c In continuous variables, scales 1–5.
d Cathegorical variable: 1 = agree completely or somewhat, 0 = no opinion/disagree
somewhat/disagree completely.
e
p < 0.05.
f
p < 0.01.
g
p < 0.001.
Factors Associating with Time Pressure in the Final Multivariate Analysis
Background factors explained 13% of the variance in time pressure. Entering the main
patient record system into the model in step 2 did not explain the additional share
of variance, while entering the level of self-regarded experience of using EPR systems
in the third step and usability factors in the fourth step increased the explanation
for the share of variance by 1 and 3 percentage points, respectively. In the final,
fully adjusted model, women reported more time pressure than men; those working in
public hospitals or private practices or private hospitals reported less time pressure
compared with those working in health centers. Those using several clinical systems
daily and those who participated actively in the development of the systems often
reported more time pressure compared with their counterparts. Of the usability factors,
more frequent technical problems lead to higher time pressure. Those who felt that
compiling patient statistics in the electronic system was time consuming reported
more time pressure. Even if the EPR brand did not increase the share of variance in
step 2, when brand D was chosen as a reference system with background factors constant,
the EPR system brands A, B, and C were associated with less of a feeling of the need
to hurry.
Factors Associating with Job Control in the Final Multivariate Analysis
Background factors explained 11% of the variance in job control. Entering the main
patient record system into the model in step 2 explained an additional 1% of the variance
in job control, an additional 2% experience of the use of electronic systems in the
third step, and an additional 3% usability factors in the fourth step. In the final,
fully adjusted model, women reported lower job control than men; those working in
public hospitals reported less job control compared with those working in health centers.
Those using several clinical systems daily reported lower job control, while those
who had participated actively in the development of the systems reported higher job
control. More common technical problems were related to lower job control while the
experience that nursing records were easy to read was related to higher job control.
When brand D was chosen as a reference system with background factors constant, brand
A of the EPR systems was associated with better job control.
Discussion
Perceived time pressure and lessened job control were strongly associated with technical
problems and poor usability. Job control decreased and time pressure increased with
having to use several clinical systems on a daily basis. More time pressure was experienced
if the documentation of patient information needed for billing, national registries,
etc., was experienced to take too much time. The experience of easy readability of
electronic nursing records was associated with better job control. Physician participation
in EPR development increased the feeling of job control, though it also exerted more
time pressure.
Technical Properties
As expected, technical problems were associated with time pressure; they appeared
to pose an important threat to work-related well-being. We have reported earlier[10]
[13] that the physicians' experiences with the technical properties of EPR systems have
not improved in 4 years; in some EPR brands, the situation has even deteriorated.
The fact that the stability of IT systems affects the work-related well-being of health
care personnel should be acknowledged not only by EPR systems vendors but also by
the organizations that provide hardware and network connections. The stability of
an EPR system is heavily dependent on IT infrastructure: hardware and network communications
are usually provided by the organizations and are just as credible factors as the
instability of the EPR.
Using several clinical systems on a daily basis led to the experience of time pressure
and lessened job control. In addition to EPR, a physician may have to access different
appliances and softwares, for radiology, laboratory results, HIE, and so on. In Finland,
private sector tends to have fewer clinical systems in use than the public sector
and also fewer logins. They also grade their EPR systems better and have less load
factors than their peers in the public primary care.[7]
[14] Multiple logins is one of the factors in EPR usage affecting work well-being that
could be improved with system integrations and context management (i.e., the system
recognizes patient and health care professional when changing between systems).
We chose to analyze time pressure and job control of different EPR brands in reference
to EPR brand D, because in our previous studies[10]
[13] it has been rated by physicians as one of the most usable EPR systems and has been
graded better than average. The results show that systems A, B, and C were less associated
with the feeling of hurry and system A was more associated with experience of better
job control. In previous studies, A, B, and C brands have not been graded as very
usable systems, although all three systems are the most widely used systems in Finland;
they have also been in use since the 1990s. The EPR system brand D is a relatively
new system and has fewer users. The length of experience was controlled in the regression
analysis, but there may be additional factors that were not covered by the study,
which would explain the result, and thus further study is required.
Documentation of Patient Information for Statistical Reporting and Nursing Record
Documentation of patient information for statistical purposes (e.g., billing, national
registries, or other administrative authorities) was experienced as time consuming
and it appeared to exert time pressure on physicians. One-third of private physicians
and 50 to 80% of their public sector colleagues find this documentation work too time
consuming.[10]
[14] Statistical or administrative purposes can be experienced as unnecessary work that
is irrelevant for patient care, if it is done to compile national statistics (e.g.,
as it is in Finland for the Register of Primary Health Care Visits to analyze visits
on a national level). In an American study, the use of “physician partners” who could
perform the administrative components of visits resulted in a decrease in time pressure,
shortened visits, and also higher patient satisfaction.[38] The financial implications and training of physician partners were issues left open
in the study.
Finnish physicians have criticized the readability of the nursing record applications
of EPR systems.[10]
[11]
[12]
[13] According to our results, easy access and understandable nursing record provide
physicians with more job control. A good and usable nursing record can give the physician
a good oversight on the status of the patient during rounds or visits and lead to
a better base for the physician's decision making and hence to better job control.
Physician Participation in EPR Development
Physicians participating in IT development tended to experience more feelings of time
pressure, but these same physicians felt they have better job control. User participation
in development takes time away from clinical work, but could lead to better job control.
However, the physicians experiencing better job control may be the ones who wish to
participate in IT development. IT organizations and physicians' opinions about user
involvement in development work differ: the physicians feel that there should be more
involvement, but IT organization representatives perceive that there is enough participation.[39]
[40] These studies suggest that better results could be gained by developing users' work
practices at the same time as software development, that IT developers should visit
the working places of the users, and that physicians involved in IT development should
not be overlooked. Our results suggest that health care organizations should provide
a timeframe for their users to participate in development work to relieve the time
pressure experienced by the physicians.
The Impact of Background Factors on Work-Related Well-being
The physicians' background characteristics appeared to affect work well-being more
substantially than the properties of the EPR systems. Time pressure and job control
varied depending on gender, working sector, and the specialty of the physician. Those
who are specializing tended to have less job control, which correlates with previous
studies[41]
[42] and can be explained by the training phase as they are learning only their specialty.
Specialized physicians may also have less feelings of being rushed, due to having
more expertise. In the multivariate analysis, the EPR systems used in the private
health care sector associated less with the feeling of time pressure than the ones
used in the public sector. According to a study conducted in Finland, physicians working
in the private sector experienced better containment of work, job control, and work
satisfaction in general.[41] Moreover, they have given their EPRs more positive usability assessments.[14]
[15] The requirements of EPR systems in national private health care are less complex
than in the public sector, as the context of the work is mostly specialist consulting
in definite issues and more complex and critically ill patients are treated in public
sector.
Longer experience of the use of EPRs is associated with better job control. Familiarity
with the system may reinforce the experience of job control. In our previous study,[10] physicians found that they do not receive enough training in the use of the systems.
Moreover, knowing the workflows and remembering the pitfalls of the systems help individuals
to use the systems in a more controlled manner. Introduction and training of system
use should always be well and carefully planned, also for system upgrades including
changes in functionality.
Limitations and Weaknesses
The overall effect of work satisfaction on how physicians experience their EPRs is
hard to distinguish from EPR's impact on work satisfaction. Physicians with good job
control and time management may experience the use of EPRs easier and more usable
than their peers, who are coping with experience of being hurried and having less
job control. The methodology in the multivariate hierarchical regression analysis
should remove most of these differences, but this cannot be ruled out as a confounder
factor. Our study is a cross-sectional study, but considering the sample size, associations
can be made.
Less than one quarter of Finnish physicians replied to the web-based questionnaire.
However, we evaluate that our study sample was a representative sample of Finnish
physicians by comparing our sample to Finnish Medical Association's register of physicians.
The study questionnaire was piloted in 2010 and the reliability and validity of the
questionnaire have been discussed in a study based on two study rounds in 2010 and
2014.[31]
[32] As the questionnaire was targeted to the whole physician population, we cannot take
into account the daily workflows of some specialties (e.g., laboratory specialties,
radiologists) when formulating the statements. The questionnaire was distributed only
electronically, which may have excluded some potential respondents. However, we are
not aware of any studies assessing whether those physicians who do not reply to electronic
questionnaires would be more positive or negative with regard to the use of EPR systems.
As a secondary aim, we set to find differences between EPR software brands, but eventually
there were no significant differences or further study was needed, and this hypothesis
was not followed.
We did not use the full scale of Karasek's job content questionnaire[37]; only seven questions were used of which two measured time pressure, and two accordingly
job control. Due to the length of the original full questionnaire, which had altogether
34 questions, we carefully selected job content questions for those dimensions that
the study was particularly interested in. This does not measure one's work well-being
in depth, but gives a clear indication of time pressure and job control experienced.
Because the number of our questions on the questionnaire was high, we grouped our
usability questions into seven dimensions by explorative factor analysis instead of
using the original questions. This does not measure usability factors in depth, but
gives a clear indication of key HER-usability–related elements in physicians' daily
work.
Conclusion
Our study is consistent with previous findings that EPRs affect physicians' work well-being.
We were able to identify factors of EPR usage that influence the experience of time
pressure and job control of physicians. These factors should be used in EPR development
by vendors as well as legislators and health care organizations. As EPR systems have
become one of the major factors in the work-related well-being of physician, the EPR
software and hardware provided by the organization should be more stable, be better
integrated, and have better usability to relieve time pressure and increase the job
control of physicians. Improvements in login procedures, the ease of reading nursing
records, and a reduction in the separate statistical documentation required could
enhance better work well-being by relieving the mental strain experienced by physicians.
Physician participation in EPR development is important and increases the feeling
of job control; however, it also exerts more time pressure; thus, organizations should
arrange time for developmental work.
In the future, the cross-sectional study is to be renewed in Finland. It would be
interesting to find out if there are changes in the main EPR factors that affect work
well-being. A similar study directed to other health care personnel such as nurses
would also provide more feedback on which areas to concentrate on in the development
work.
Clinical Relevance Statement
Clinical Relevance Statement
The problems related to usability and technical stability of healthcare IT systems
pose a significant threat to the work-related well-being of physicians. Fewer login
procedures, easier readability of nursing records, and a decreased need for separate
documentation for reporting purposes could enhance better work well-being. Physician
participation in IT development would increase the feeling of job control, but at
the cost of adding time pressure.
Multiple Choice Question
Physician participation in EPR development
Correct Answer: The correct answer is B. It increases job control, and also increases the feeling
of hurry. Thus, health care organizations should allow time for development work for
their workers.
