Understanding How Physicians Use EHR Systems

Technology usage patterns differ from person to person. Any number of factors could account for the differences such as varying needs for specific features, lack of familiarity, or being unaware of available functions. Two recent studies that looked at physicians’ EHR use may offer a much more nuanced and interesting take on this topic.

Like anyone who has practiced in a setting that used paper charts, I noticed specific information management patterns among my colleagues.   Some kept meticulous notes that read like novels, while others created notes that were so sparse they were nearly unusable.   The same held true for things like preventive maintenance. Some charts had documentation that was clear and precise while in other charts the only way to tell if a mammogram had been done was by slogging through radiology reports.   Why such a wide variation? Do disparities in recordkeeping have anything to say about the quality of care rendered?

Ancker, Kern et al. (1) studied how use of EHR system features varied among physicians.   The study setting is described as follows:

The Institute for Family Health (IFH) is a network of federally qualified health centers (FQHCs) providing safety net care in New York City and less urbanized regions to the north of the city. IFH offers primary care services at 18 sites, with more than 100 physicians (almost all family practitioners) and a patient population of approximately 100 000. IFH has been using the EpicCare EHR since 2003 and is currently a level III patient- centered medical home. EHR customization has taken place at the institutional level and does not vary by clinic, but in some cases clinics may have staffing differences that affect EHR work- flow. About half of IFH’s family practitioners attested to MU stage I under the Medicaid program in 2012. During the period of the study, two new clinics joined the network, resulting in an increase in numbers of providers and patients.

In all, the data set covered 112 family physicians who had 430, 803 encounters with 99,649 unique patients. As expected, significant differences were noted in how EHR systems were used.

Also, as hypothesized, provider-level variability was also quite high in most of the metrics (table 2). Table 2 shows the IQR to represent the central half of the data, but the full ranges were much wider. For example, best-practice alert acceptance rates per provider ranged from 0% to 68%, the annual average pro- portion of encounters with the problem list updated ranged from 4.9% to 60.2% per provider, and the annual average proportion of drug–allergy alerts that prompted a drug discontinuation ranged from 0.0% to 62.5% per provider.

The value of this paper is not so much that it documents variability in EHR use, but how it does so.   This study uses data from the EHR, not interviews or observations, which means that more data are available. As a result, it is easier to spot individual use patterns.   However, knowing that variations exist does not explain why they do. For that, we turn to a second paper.

Lanham and Sittig et al. (2) used semi-structured interviews and direct observation to look for individual differences in EHR use patterns. The study population is described as follows:

We enrolled primary care physicians (n=9) and sub-specialists (n=19) to study differences in EHR use in a diversity of medical specialties. Sub-specialists were endocrinologists, gastroenterologists, rheumatologists, neurologists, and podiatrists.

Examples of the interview questions appear below.

Describe how you use the EHR in your work.
What features of the EHR do you use?
Do you find the EHR easy/difficult to use?
What kinds of things do you like about using the EHR?
What kinds of things do you dislike about using the EHR?
How often do you change the way you use the EHR? What types of events might precipitate a change in your EHR use?
Is there anything you think is unique about how you use the EHR?
Have you modified or tailored template(s) for your EHR use? If so, how?
Has using an EHR changed the way you practice medicine? If so, how?
Do you involve patients in your EHR use?

As related by the authors, a link between uncertainty and information management proved to be a novel and unexpected finding. Subsequent to their analyses, the authors created categories for uncertainty and provided examples of each in terms of EHR use.

Category Description
Uncertainty reduction Views patient information contained in the medical record as paramount to the practice of medicine

Seeks certainty and/or perpetually searches for ways to use information to reduce uncertainty

Gives priority to codified patient information over other types of patient information (patient body language, tone of patient–physician interaction, tacit and/or difficult-to-capture aspects of patient encounter, etc)

More information, particularly the kinds of information that can be captured in an EHR [electronic health record], always equals better patient care

Uncertainty absorption Views the co-creation and continual exchange of information between patients and physicians during patient encounters as paramount to the practice of medicine

Manages uncertainty by engineering rich interactions between themselves and others

Gives priority to information that was co-created, discovered, emphasized, and/or nearly missed during patient–physician encounters

More information, particularly the kinds of information that can be captured in an EHR, does not always equal better patient care

Hybrid Views patient information contained in the medical record as paramount to the practice of medicine

Views the creation and exchange of information between patients and physicians during patient encounters as paramount to their practice of medicine

Manages uncertainty through information contained in the medical record and through interactions with others

More information is necessary but not sufficient for better patient care


The authors categorized EHR use in groups of high, medium, or low based on three factors: how heavily features were used, the degree of EHR-based communication, and how often EHR use patterns changed.   The correlation between EHR use and uncertainty categories was fascinating. Everyone in the uncertainty reduction group was in the high-use group.  Most physicians in the hybrid group were medium users with two in the high-use group.   The uncertainty absorption group had three low users and one in each of the other groups.

On reading the results of the paper, I was not surprised that those who valued information kept better records and used EHR systems to a greater degree. I wonder how useful this information is for understanding clinical care issues such as diagnostic errors and results management.   Does uncertainty absorption coupled with low EHR use point to a lower level of vigilance and lower quality care?

These findings may also offer clues to clinical software designers.   The three uncertainty categories might well point to a way of stratifying potential users by their desire for software with advanced features and niche functions.   For example, access to clinical knowledge resources or the ability to customize results management features might appeal to one group while others might be less interested.   From a design standpoint, this would mean making features modular. For example, making it possible to sell an add-on to one member of a practice group without all members having to license it. Mobile clinical apps would seem to be the ideal platform for testing this notion.

These two papers give valuable insight into how physicians use EHR systems. Even better, they may have inadvertently provided clues that may help in understanding clinical practice patterns and how those patterns may be uncovered by analyzing data available in any EHR system.

  1. Ancker JS, Kern LM, Edwards A, Nosal S, Stein DM, Hauser D, Kaushal R; HITEC Investigators. How is the electronic health record being used? Use of EHR data to assess physician-level variability in technology use. J Am Med Inform Assoc. 2014 Nov-Dec;21(6):1001-8.
  2. Lanham HJ, Sittig DF, Leykum LK, Parchman ML, Pugh JA, McDaniel RR. Understanding differences in electronic health record (EHR) use: linking individual physicians’ perceptions of uncertainty and EHR use patterns in ambulatory care. J Am Med Inform Assoc. 2014 Jan-Feb;21(1):73-81.

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