The truth about declining clinician satisfaction with EPRs

As electronic patient records (EPRs)* become commonplace, there’s more we can learn from clinician feedback. It’s important to know what they think, because staff perception shapes satisfaction, adoption rates and ultimate success and impact with EPRs clinically and organizationally.

It was a privilege to contribute to the recent article in HSS Journal about clinician satisfaction and its variability over time.  Working with an orthopedic teaching hospital moving from a paper-based system to an EPR, we found that clinicians were initially elated with the change. Then their satisfaction dropped. What a curious pattern, since anecdotally their satisfaction and adoption continued to rise.

At first, this change in satisfaction sounded like a bad thing. No one wants to see EPR satisfaction decreasing, right? But after evaluating the results reported in this study, I’d argue it’s exactly what we should have anticipated we’d see. And it is good news.

Factors that affect clinician satisfaction with EPRs

A multidisciplinary team developed a 22-question survey to measure clinician satisfaction. We focused on patient demographics, orders, medications, laboratory and radiology data. We wanted to know if clinicians could:

  • Easily obtain data needed to take care of patients
  • Easily act upon the data
  • Receive clear and understandable data
  • Receive alerts about potential safety problems

We distributed this survey just before the EPR “go-live,” and at six and 12 months afterwards. There are a lot of results that the article covers in great detail, but here is a chart to help summarize:

 Truth about declining clinician satisfaction with EHRs

You can see from Figure 1 that clinicians’ satisfaction with orders improves significantly six months after implementation. But then across all categories, satisfaction drops a bit.

Why clinician satisfaction drops off

Six months after they started using an EPR, clinicians had a high level of satisfaction, as we hoped for and expected. It’s because they’ve become comfortable using the system, and they are seeing benefits over the previous ways of doing things.

However we see a curiously different story one year after implementation as satisfaction seems to decline. Interviews showed that as familiarity set in, clinicians realized what the system could do and wanted more.

This thirst for more capability among clinicians is a good thing. It indicates that physicians are engaged enough to want more, and through the EPR. We need to embrace this feedback and find ways to incorporate it.

For this exact reason, Allscripts long ago undertook the development of outcomes toolkits, which are proven, generalizable solution sets, harvested from the successes of client organizations. Using outcomes toolkits, many Allscripts clients have raised their levels of outcomes achievements by learning from their sister organizations.

All EPRs are not created equal

Most EPRs, as reflected in their satisfaction scores, are primarily about adoption and adaptation to the EPR. Basically, clinicians learn to use it with minimal changes possible and, “It is what it is.”

But in this instance, the EPR is adaptable to new and evolving wants and needs. Because it is locally programmable, organizations and clinicians can be innovative within the EPR. That creates a thirst for “what I want to do next.” And that appetite is what drives clinical excellence, continuous improvement, and innovation.

This EPR sparks interest in new capabilities in electronic documentation, patient-adaptive order sets and clinical decision support. So clinicians see all of the things they would like the system to do next. The slight decline in satisfaction materialized, because it signals higher adoption and higher desire to adopt.

Made possible by a locally programmable, adaptable EPR, higher adoption helps spark collaboration and innovation to improve care delivery.


“A Computerized Order Entry System Was Adopted with High User Satisfaction at an Orthopedic Teaching Hospital” HSS Journal Volume 10, Issue 1. February 2014.

Editor’s Note: Electronic Patient Record (EPR) is another term for Electronic Medical Record (EMR) or Electronic Health Record (EHR).

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About the author

Steven H. Shaha, Ph.D., DBA, is a Professor at the Center for Policy & Public Administration, and the Principal Outcomes Consultant for Allscripts. Dr. Shaha received his first doctorate in Research Methods and Applied Statistics from UCLA and has taught and lectured at universities including Harvard, University of Utah, UCLA, Princeton, Cambridge and others. An internationally recognized thought leader, lecturer, consultant and outcomes researcher, Dr. Shaha has provided advisory and consulting work to healthcare organizations including the National Institutes for Health (NIH), and to over 50 non-healthcare corporations including RAND Corp, AT&T, Coca-Cola, Disney, IBM, Johnson & Johnson, Kodak, and Time Warner. Dr. Shaha has presented over 200 professional papers, has over 100 peer-reviewed publications in print, over 35 technical notes and two books. He served on the 15-member team that authored and piloted the Malcolm Baldrige National Quality Award for Health Care, and he contributed to the Baldrige for Education.

5 COMMENTS on The truth about declining clinician satisfaction with EPRs


Joshua Davidson says:

06/11/2014 at 4:50 pm

Is it the physician “wanting more,” or is it the challenge of an ever-changing EPR that physicians have to cope with over a year’s time? As a physician who works with Allscripts on a daily basis, I completely understand the phenomenon presented here. Over the first 6 months or so, increased familiarity and enhanced work flow can lead to high satisfaction rates. Then the system is updated. Work flow routes change. New demands are placed on the physicians. The cycle starts anew, but the original honeymoon EPR period of euphoria is not repeated. Rather, frustration sets in as an ever-evolving learning curve presents itself. To me, this is the reason for decreased satisfaction rates over time. We’re not dealing with a static EPR entity that can be evaluated over time. Rather, this is a system that morphs over time, leading to physician frustration and decreased satisfaction rates.


David MIT says:

06/12/2014 at 6:49 am

I have been using one version or another of Touchworks for 12 years.

Clinicians would be happier if EMRs were designed for their workflows and not for billing or metric tracking or other administrative priorities. WAY too many clicks for most common tasks, inefficient user interfaces, wrong information on screen when processing information, etc. Example, in TW if I call a patient and simply want to document call, a task I do many times a day, there is no one click to text field solution, best I found is 8 clicks and scroll. Or if I am in one chart and want to get to another patient, need to do 3 clicks and scroll to enter name, rather than a patient field search window in banner. I have a dozen other examples, I have sent these ideas along for over 10 years but version after version does not adopt nor address my suggestions. If the development team would just sit next to me for 2 hours and “feel my pain” they could improve the product significantly. I am writing this publicly with hope it might get some attention, but given the long history here I would guess not.


health Care Provider says:

06/13/2014 at 2:37 pm

EHR are makeing the doctors and health care Providers become data gathers for the HHS.
This is capitalist system, make ing more money for the insurance companys and the infomatics PHD.
This system is Not Working..l
Primary Care Health Care Provider


Laura Duncan says:

06/13/2014 at 9:56 pm

I am a field clinician (physical therapist) for St. Joseph Home Health and would like to state my experience with the use of Allscripts. There are many positive aspects to EPR that allow for relevant up to date information needed to provide quality care to our patients. However, there are design flaws that are time consuming and often result in redundancy, ultimately compromising the quality of care. Two areas of interest (or rather disinterest) are the “visit” and “treatment” notes. The visit note simply confirms that the patient meets home health criteria and reminds patient/clinician of “face-to-face” MD visit. Do all insurance companies require that this be documented on each visit? If so a statement in the clinical note for example “patient meets home health criteria as stated at evaluation” would be more efficient than clicking all those boxes. Or add a (one) check box in the assessment section.
The design of the treatment note is not user friendly, I choose not to “click” each exercise, I spend the time with the patient. Listing the exercises in the clinical note is more efficient and I can state specifics of each exercise. For example a stretch or isometric contraction held for 10 sec, is not an option in this program, I am limited to “sets” and “reps.” Physical therapist are experts on the treatment that they provide and how to accurately document their treatment as well as the rationalization for that treatment. Thank you for taking the time to read these concerns, I am hopeful that changes will be implemented to improve efficiency and better use of our time with our patients.
Thank You
Laura Duncan, MPT


Geoff Caplea, MD, MBA says:

06/17/2014 at 1:08 pm

Thank you for your feedback. As you’ve illustrated from your experience, TouchWorks has an opportunity to improve usability across the application. Even with the regulatory requirements around Meaningful Use and EPCS, there is an opportunity with each release to deliver incremental usability enhancements for each module within TouchWorks.

In an attempt to better facilitate these improvements, TouchWorks development has reorganized into functional teams with each team “owning” specific areas of the application (e.g., Medication Management or Allscripts Clinical Notes [ACN]). This realignment impresses upon these teams greater accountability for both the usability and functionality.

Although these changes are relatively new, we’ve already realized progress with this approach in upcoming releases (e.g., 11.5). While TouchWorks won’t rewrite the UI overnight, the team is excited about the progress thus far and the progress to come. Thanks, again, for your feedback.

Geoff Caplea, MD
Solutions Management – TouchWorks EHR


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