Digital record-keeping is slowly but inevitably replacing paper records everywhere from the pilot's cockpit to the registry of motor vehicles. But if implemented without proper consideration of how work gets done, the results can make productivity worse, not better.
That's one of the lessons from a new study of physician offices transitioning to electronic health records (EHRs) used in managing patient care. In general, larger offices in the study that employed EHRs recorded productivity gains, but certain types of smaller practices lost productivity.
“You should be aware of the subtle way that you might be changing existing communication patterns among staff”
One likely reason for the decline: processing electronic records can change the way staff members communicate with one another, clogging up what had been a well-oiled machine.
"When you adopt EHRs, you should be aware of the subtle way that you might be changing existing communication patterns among staff," says Harvard Business School Professor Robert S. Huckman, who recently cowrote The Impact of Electronic Health Record Use on Physician Productivity with University of Michigan Assistant Professor Julia Adler-Milstein.
The Digital Doctor
In recent years, many physicians have put away pen-and-paper and taken up the keyboard or tablet to maintain patient health records. One motivation was the 2009 Health Information Technology for Economic and Clinical Health Act, which allows for $27 billion in incentives for health care providers who demonstrate "meaningful use" of digital records. The legislation came from the belief that EHRs used in certain ways—such as medication order entry that would alert a clinician about drug-to-drug interactions—could ultimately make patient care safer, more effective, and more efficient.
However, several studies indicated that when physicians spent extra time entering data themselves, it cut down time spent with patients and stretched out their workday—hardly what was intended. So many practices realized that it made sense for clinicians—mostly physicians, but also nurse practitioners and physician assistants—to delegate some EHR-related tasks to clinical support staff, including registered nurses, licensed practical nurses, and medical assistants.
Huckman, the Albert J. Weatherhead III Professor of Business Administration and faculty cochair of the HBS Healthcare Initiative, set out with Adler-Milstein to discover what happens to productivity when doctors delegated their data entry. Did it free up their time and increase office productivity? After all, delegating these tasks can cost physicians extra coordination time, plus doctors still need to review and authorize orders in an EHR before they are submitted.
The study examined the relationship between physician productivity, the degree of digital health records use, and the delegation of EHR tasks. And it explored whether these relationships differed by practice size.
Huckman and Adler-Milstein researched monthly EHR task-log data between 2006 and 2009 from more than 40 primary care and internal medicine practices throughout the United States. Practices had a range of one to 14 clinicians, with an average of four. All the practices had used digital records for a minimum of six months, with an average of 17 months. All practices in the sample employed at least one clinical support staff member, allowing clinicians to delegate EHR tasks.
Overall, the findings suggest that increased use of electronic health records and greater delegation were independently associated with higher levels of production. That is, practices that increased the number of tasks performed using EHR saw an increase in clinician productivity, and practices that increased the extent to which EHR tasks were performed by clinical support staff, as opposed to clinicians, saw an independent increase in productivity as well.
“We rely on physicians' penmanship in making some pretty important decisions”
But there was one important caveat: Increasing both EHR use and delegation gave large practices with four or more clinicians a productivity boost, while the same dual increase led to a productivity loss among small practices with high levels of delegation.
Bigger practices may benefit more from EHRs by allowing a larger group to communicate more effectively, Huckman hypothesizes. In smaller practices, where informal but highly effective relationships may exist, introducing an EHR system might generate formal processes that, at a certain level, become counterproductive.
"In large practices, where staff might be less likely to interact face to face, putting such a system in place might serve to make communication richer and bring people closer. But in a small practice, where face-to-face contact is more common and effective, introducing an EHR might make communication more sterile, leading to either a smaller gain—or even decline—in productivity."
There may be other explanations for the differences among practice sizes. For example, large practices may devote more time to training and workﬂow protocols that improve productivity.
The Wrong Lesson
The research results should not dissuade practices, large or small, from using EHRs, Huckman says. Electronic records have many benefits. In particular, patient data can be shared relatively easily between providers within a given practice, and some of the errors that result from illegible penmanship might be avoided.
"We rely on physicians' penmanship in making some pretty important decisions," Huckman says. "That has been a challenge at times. We could still get it wrong with an electronic health record, but the chances are lower."
And mistakes can be detected much more quickly. If a prescribing physician puts an extra zero on the end of a dosing order that puts it out of the normal range, an EHR system may instantly detect the error. With hand-written prescriptions, the error could easily make it all the way to the pharmacist, who would check on it with the physician. "That requires more time and resources to get to the right answer," Huckman says.
Though interoperability—the ability to transfer information across EHR systems—remains a long-run goal that most systems are still working to achieve, Huckman believes electronic records can still help reduce expensive redundant care.
"If a physician can go into an electronic record and find out if her patient has already had a lab test or X-ray in the recent past, and can access the results of that study, she may be less inclined to repeat it," he says. "This reduction in duplication can lead to lower costs without harming quality."
Productivity losses are not inevitable, and not every small practice will experience a detrimental effect. Rather, Huckman says small practices should simply be mindful of the potential for EHRs to interfere with work coordination and they should pay close attention to how they might affect existing communication within the office to avoid productivity losses.
For example, in a small practice without an EHR, the staff might be able to engage in regular, face-to-face meetings about challenging cases. Once an EHR is adopted, however, some might perceive such meetings to be less critical, as the information shared at those times could now be exchanged via summary reports from the EHR system.
"But it is possible that the exchange of information in those meetings is not replicated by even the most detailed summary report coming out of an EHR," Huckman says. "My guess is that the size of many larger organizations allows for fewer natural opportunities for this regular person-to-person contact. So when an EHR is introduced and allows for information exchange through summary reports, it's a great innovation because it allows them to share information they were not routinely sharing before."
Lessons For Business
Aside from the implications for physicians, the research should also be interesting to any business that adopts new information technology as a way of categorizing and accessing information in an attempt to streamline a process that already exists.
Adopting these systems can have significant implications for how individuals in firms interact with one another, and that has to be accounted for when analyzing productivity implications from increased information technology.
"We often look at systems on the basis of their technical capability, the fact that they can store this many records or process that many requests in this period of time. But when we ask how that technology can improve productivity, we have to consider that the true capability of the system depends on the context in which it is adopted."