A survey of chiropractic intern experiences learning and using an electronic health record system

Electronic health records (EHR) are used commonly in health care.¹  How an EHR is selected, which features should be included, and how it is introduced to first-time users are important issues to address. Several barriers must be overcome when learning to use a complex EHR.²  New users have been recorded as spending longer hours for an average of 1 month while becoming familiar with a system.³  McGinn et al.⁴  noted decreased productivity and poorer job performance during the transition to EHR as well as worker dissatisfaction with slow system speed and certain features. Experienced providers, such as physicians, have reported decreased work efficiency, need for more data, less time for patient interaction, and tedious standardized formats as problems with some EHRs.⁵ 

Other studies have shown that systems that can be learned quickly, require few clicks, and facilitate rapid completion of work are favorable and facilitate implementation of and satisfaction with EHRs.^6,7  Better productivity has been cited as being associated with EHRs, since patient information is readily available and organized.⁸  Satisfied EHR users like systems that help them to improve quality of clinical decisions, delivery of long-term and preventive care, and communication with other providers.⁹ 

As a clinical educator who supervised some of our 4th year chiropractic interns, it became apparent that some readily learned and adapted to the EHR, while others had considerable difficulty. Some interns found shortcuts and shared them with classmates. Others voiced frustration with system functions and features. Studies in other health care settings have shown such perceptions vary between novice and more experienced users.^3,10  Thus, chiropractic interns were surveyed regarding their preferences or dislikes in learning and using our EHR, so that analysis could possibly lead to improvements in intern education regarding the EHR. It was hoped that findings also would provide insight into clinical educators who advise interns considering an EHR for their own future practices. This study fills a gap in the literature, as to our knowledge no other studies have reported the preferences of chiropractic interns, about EHRs, reported in chiropractic in the literature. The hypothesis tested was that 8th semester interns would perceive some aspects of the system to be easier to use and be more satisfied with some of its features, since they had more experience and adapted to the system, compared to 7th semester interns.

The Alteer EHR system (CompuGroup Medical, Phoenix, AZ) was used at our clinic. Thus, the survey was designed to capture intern observations regarding its features and ease of use, and to compare the perceptions of 7th semester interns, who had 6 weeks of experience with the EHR, to those of 8th semester interns with 24 weeks of experience. The interns also were asked to reflect on their perceived proficiency, how they generally experienced using the EHR, and how well they felt the system worked. Survey statements were selected based on similar ones used in other EHR surveys regarding system features and learning preferences^9,11–14  as well as recurring issues the author faced while interacting with and helping interns learn the system. The survey was not piloted, but it was reviewed by the dean of the college who made suggestions regarding sequencing statements in domains.

Students were asked to rate their agreement to 42 statements that were grouped into nine domains. Each respondent indicated their relative agreement to each statement by choosing 1 of the following: strongly agree, agree, neutral, disagree, or strongly disagree. Participants also were provided free text space to type in what they liked best about the EHR, what they liked least, what they think could be improved, and other comments. An e-mail message was sent to all 4th year interns (24 in 7th and 23 in 8th semesters) containing information regarding the survey and a link to it. The survey was hosted by SurveyMonkey (SurveyMonkey, San Mateo, CA). All responses were anonymous and not tracked. The University of Bridgeport institutional review board approved this research.

Of 47 possible surveys, 24 were completed (51% response rate; 54% male/46% female respondents), with 13 of 24 (54%) and 11 of 23 (49%) completed by 7th and 8th semester interns, respectively. Table 1 provides the percentage relative agreement for statements in each domain. Free text comments, organized by theme regarding EHR likes, dislikes, recommendations, and other comments are presented in Table 2. Many comments about the system were centered on network issues.

When faced with learning an EHR system, interns found challenges, learned some solutions, and were left with wishes for certain system features. A summary of findings and discussion relating to each domain follows.

Most indicated they learned the EHR by trial and error and with help from observing their same semester peers and upper semester interns. A 2-hour training session was offered in a computer simulation laboratory before first use of the system. Respondents were divided on how helpful that was. One student wrote: “…I feel that organized training in use of the EHR should begin earlier, preferably in the student clinic environment, and focused on utilizing the face sheet to effectively communicate patient status in a meaningful and quick way…” Borycki et al.¹⁵  found research was lacking on EHR integration in health care professional education, and introduced an educational portal for health care students to familiarize themselves with differing EHR in a simulated environment with no real patient data used. Educators should consider various teaching and learning methods, including experienced user and peer-to-peer instruction and simulations. Ample practice time should be provided when introducing the EHR to students.

Most data were not entered during the encounter, possibly indicating difficulty with the system, the amount of time it took, or interns having difficulty doing so in front of the patient. In fact, 69.23% of 7th and 100% of 8th semester interns agreed or strongly agreed with the statement: “I enter most patient data after the encounter is over.” More experienced interns may have stopped trying to enter data during the encounter, possibly due to difficulties entering data while maintaining patient rapport or good clinical flow.

Ventres et al.¹⁶  observed practitioners' EHR use in the presence of patients. The physical location of the EHR affected interaction with patients. For example, flat screens on a mobile cart gave providers more options to maintain eye contact with patients. They noted that most providers alternated between talking to a patient and typing, and the ability to relate to a patient decreased as more time was spent typing during the encounter. The authors identified three types of providers with differing EHR use characteristics. Informationally-focused providers generally positioned themselves at the computer and used computer-guided questions to focus on the patient's problem. Interpersonally-focused providers generally sat or stood away from the computer and faced the patient, entering data later. Those practitioners having a managerial style, alternated interviewing patients with defined intervals for data entry. Resident physicians voiced concerns about developing a patient communication style while simultaneously trying to enter findings and recommendations in the EHR. Most found it difficult to do both. Since interpersonal skill development is so important for patient-centered care, the authors suggested EHR training should be part of general medical education. Fredericks et al.¹⁷  also discussed the importance of eye contact and how reducing it may diminish patient trust. They further suggested that educators should train future practitioners regarding communication styles while using the EHR and make sure screen and body positioning are optimized. The significance of establishing a style of interaction with patients while using EHR should be discussed with novice users.

Respondents indicated the system was not reliable but maintained an organized record overall. They generally disagreed that the system permitted easy access to precautions, contraindications, or alerts. In a user satisfaction survey,¹¹  respondents favored EHR with the ability to rapidly find information. Systems should be selected that facilitate easy access to significant information and training should emphasize how to find it.

There was strong consensus that the EHR allowed easy access to general patient information and managed daily notes well, but was not good for documenting and tracking patient compliance to treatment recommendations, rehabilitation, or wellness advice. Interns felt the EHR did not allow easy access to treatment plans and problem lists. Russ et al.¹⁸  reflected on interviews with EHR users in a Veterans Administration Medical Center. Some respondents stated they were frustrated trying to locate particular information imbedded in the EHR. The authors raised the question as to how EHR design could prioritize critical information and make it more easily accessed and sorted. Again, the ability to rapidly access key information should be emphasized when choosing a system and training users.

Interns agreed the EHR saved time and was easier and more thorough when compared to paper notes. In our college, paper note keeping is used during semester 6 when students examine and treat fellow students in the student clinic. It was not surprising that interns would favor EHR over paper, as was found in a survey of faculty and house physicians that found both groups preferred EHR over paper records.⁷  Perhaps our institution's student clinic should adopt the same EHR as used in outpatient clinics to facilitate easier and more consistent implementation by interns.

Respondents generally did not find the system helpful with clinical workflow, physical examinations, or history taking. However, one intern favored the templates, stating, “I like the boxes that we can check off in the physical exam section. It makes it easier and faster when the patient is in a good condition.” Another intern wrote, “It organizes the history and physical exam portions nicely. The text boxes on the bottom are very useful.” Bonner et al.¹²  found survey respondents were divided regarding their like or dislike of built-in clinical reminders designed to help clinicians ask screening questions. In addition, some respondents valued availability of structured consultation forms and decision support based on best practices.

Respondents were neutral about whether the EHR helped them improve patient care, prepare for quality assurance, or track patient outcomes. One intern wrote about a weakness in the system: “Not being able to easily access patient radiographs, meds, problem lists, future appointments, and other provider notes. Some of these are possible to find, but not with ease.” EHR selection and training should emphasize the availability and easy accessibility of these features.

Both 7th and 8th semester interns agreed that using the EHR in the outpatient clinic helped them to decide what features to seek if they were to purchase their own system. A future study could investigate preferred features and the systems that have them available.

As expected, the more experienced 8th semester interns noted improvements in accuracy and time taken to complete notes. Of 8th semester interns, 63% agreed that the accuracy of their documentation increased after using the EHR over the previous semester, and 54.55% also indicated they were able to reduce the time it took to complete the patient encounter documentation. It appears that novice user's learning could be enhanced if those experienced with the system were formally involved as trainers.

The survey was not piloted. There was an attempt to use neutral statements in seeking agreement or disagreement to limit potential biases in wording of questions. Since the EHR was unique to the clinic studied, the results were not generalizable outside of the institution, but do provide the institution with valuable data to use in making change in our program. Of possible respondents, 51% participated and many offered helpful comments in the free text fields. Since these responses were anonymous and untraceable, it was hoped that interns would freely provide insights. Perhaps those who chose not to write a comment could provide other valuable information.

There may be unintended consequences stemming from the introduction of an EHR, such as difficulties with patient interaction, learning to navigate its features, and entering or extracting data. The EHR requires specific skills and training.¹⁹  Training on our EHR should be improved with the use of simulations and earlier exposure. Interns found a combination of help from more experienced users and their peers as well as trial and error helped them learn the system. Educators should facilitate such peer-to-peer and senior interaction on the system before use. Different interactional styles, as well as provider and patient preferences should be considered in the context of teaching and learning to use an EHR. Strategies also should be sought to optimize good patient rapport while collecting and recording important patient data. Interns wanted easy access to alerts and key patient data, such as precautions and contraindications, problem lists, and management plans. These should be emphasized during training and considered key features when purchasing an EHR.

The author has no conflicts of interest to declare relevant to this work.