Patient Perceptions of Electronic Medical Records - IEEE Computer ...

Proceedings of the 43rd Hawaii International Conference on System Sciences - 2010

Patient Perceptions of Electronic Medical Records Christopher Sibona University of Colorado Denver, The Business School christopher.sibona @email.cudenver.edu

Jon Brickey University of Colorado Denver, The Business School jonalan.brickey @email.cudenver.edu

Abstract Background: Physicians are adopting electronic medical records in much greater numbers today and are escalating the rate of adoption. The American Recovery and Reinvestment Act of 2009 provides incentives for physicians to adopt this technology. Objectives: Determine whether patient satisfaction is affected by computer use in the exam room and whether patients who have experienced computers in the exam room perceive differences in the utility of electronic medical records. Results: Physicians received higher overall satisfaction scores when a computer was used to retrieve patient information. Physicians received similar satisfaction scores when a computer was used to enter patient information. Patients who have experienced electronic medical records perceive benefits such as increased portability of the record but do not believe that physicians who use electronic medical records produce better health outcomes. Patients who have experienced electronic medical records do not desire more control over their record than those who have traditional medical records.

1. Introduction This study investigates patient perceptions of service quality under the adoption of electronic medical records (EMR) and patient perceptions of the utility of EMR. This research is important because physicians are concerned about how computer usage in the exam room may affect service quality as new technology is introduced to the medical care process. New technology can introduce both positive and negative consequences to the patient experience. Some physicians are concerned about the effect of less eye contact with the patient with the use of EMR[1]. On the positive side, some studies indicate improved quality of care delivered to patients through the use of EMR[1]. The Congressional Budget Offices states that health information technology has the potential to

Steven Walczak University of Colorado Denver, The Business School steven.walczak @ucdenver.edu

Madhavan Parthasarathy University of Colorado Denver, The Business School madhavan.parthasarathy @ucdenver.edu

significantly increase the efficiency of the health sector by helping providers manage information, improve the quality of health care and improve patient outcomes[29]. Recent research of electronic medical records indicates that approximately 17% of physicians use these records today and that adoption is expected to increase to 43% of physicians overall in the next two years[9]. Increased adoption of this technology may affect the way that health care is delivered. Patients’ perception of service quality under the adoption of EMR remains understudied. There are three major research questions that this study addresses. 1) Is patient satisfaction affected by the use of electronic medical records in the exam room? 2) Do patients who have experienced electronic medical records perceive differences in their utility? 3) Do patients who have experienced electronic medical records desire more control over their record? 1.1. Electronic Medical Records Electronic medical records have a variety of definitions. The United States Congress recently legislated in the American Recovery and Reinvestment Act of 2009 (ARRA) that qualified electronic [medical] record systems have the following capabilities [30]: 1) Include patient demographic and clinical health information, such as medical history and problem lists; and 2) Has the capacity: a) to provide clinical decision support; b) to support physician order entry; c) to capture and query information relevant to health care quality; and d) to exchange electronic health information with, and integrate such information from other sources. The New England Journal of Medicine divides EMR functions into four domains: recording patients’ clinical

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and demographic data, viewing and managing results of laboratory tests and imaging, managing order entry (including electronic prescriptions), and supporting clinical decisions (including warnings about drug interactions or contraindications)[9]. The U.S. Congress encourages the use of electronic medical records through legislation such as ARRA by providing incentives to physicians to adopt the technology. Research into the costs and benefits of health information technology is mixed. Adoption of health information technology may improve efficiency and quality of health care by eliminating duplicate diagnostic tests or diminishing the likelihood of adverse drug events[29]. Patients may be less concerned with the technical capabilities of individual electronic medical systems and may be more concerned about how electronic medical records aid or interfere with the process of medicine, increase or reduce costs, and aid or harm patient outcome measures. 1.2. Constructs The study examined patients’ perceptions with seven constructs. four of the constructs are related to the physician-patient relationship and three of the constructs are related to perceptions of electronic medical records. Demographic information was collected to determine if there were differences between various demographic groups such as gender, age, education level, etc. The four constructs measured for physician-patient relationship were: physician interactions (PI), professional competence (PC), courtesy (CO) and overall satisfaction (SAT) to determine how patients perceive their physician exam room visits. These constructs are about service quality[27] in the exam room and not outcome measures such as whether a patient’s high blood pressure was reduced, patients with high cholesterol is lowered or five-year cancer survival rates were improved. The physician-patient relationship constructs are based on a Brown and Swartz study[8]and General Practice Assessment Questionnaire (GPAQ)[26]. Physician interactions (PI) measures how well the service interaction went in the exam room; that is how patients perceive the dynamics in the exam room. Professional competence (PC) measures how capable and proficient a physician is perceived to be. Courtesy (CO) measures patient perceptions of whether enough time is spent with the physician. Satisfaction (SAT) is an overall measure of satisfaction a patient has for their physician. The utility of electronic medical records was measured with three constructs: portability, confidentiality and process improvements. Portability measures patients’ perceptions of whether electronic medical records allow more effective communication between health

professionals. Control measures how much oversight a patient wants to have over their medical record. Process improvements measures whether patients perceive a positive impact on health care outcomes through the use of electronic medical records. 1.3. Literature Review Past studies on patient satisfaction with electronic medical records have produced mixed results. Some studies indicate that there is no change in patient satisfaction for physicians who use electronic medical records in the exam room[25], [20], [14]; however, other studies show that overall satisfaction increases and specific satisfaction measures increase (for example physician familiarity with the patient and communication)[19]. Physicians have expressed concern that the use of electronic medical records may interfere with communication in the exam room such as reduced eye-to-eye contact[1], that patients feel the physician is distracted by the computer and that its use ultimately depersonalizes medicine[2]. Previous studies on patient satisfaction show that length of time in the exam room had a positive impact on patient satisfaction[18], [32]. In addition to time in the exam room, discussing topics outside of medical care (“chatting”) and diet advice was correlated with greater patient satisfaction[18]. Physicians experience both internal and external pressures in their practice of medicine. Physicians who see a higher number of patients per hour are considered to be more efficient than those who spend more time with the patient; however, there is a trade-off with lower patient satisfaction and a less positive physician-patient relationship[32]. Some physicians experience external pressure from working in managed care groups where they feel they are unable to spend sufficient time with their patients[4]. Physicians who spend more time with patients are also less likely to have malpractice claims filed against them and lower patient turnover[22]. Gender and age also effects patient satisfaction but to a lesser extent than time measures[31]. Patients generally have higher satisfaction levels as age increases except for those over 75 years of age. There are significant gender differences overall but when controlled for by age the differences are small. Several studies have looked at the impacts of electronic medical records on patient care. Physicians who use electronic medical records tend to have more comprehensive medical records than those who use paper records[1]. Automated patient systems can reduce medication errors and adverse drug events in hospital patients. There is evidence that electronic medical records can reduce duplicate or inappropriate diagnostic

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tests[5]. A more portable medical record can lead to fewer duplicate diagnostic tests, reduce medical errors (because providers would have more accurate and complete information about the patient and lower administrative costs)[29]. Electronic medical record systems that provide clinical decision support systems can improve the quality of health care that patients receive[13], [3]. Although the quality of health care improves, patient outcomes based on clinical decision support systems does not appear to improve[13]. Physicians have resisted adoption of some of these health information technologies because computer based recommendations are considered “cookbook medicine” or other factors such as fit to the workflow, speed of information, etc[29], [6]. The typical amount of time a physician spends in the exam room with a patient has been studied and has varying results. When patient-physician contact time has been measured in some studies the time is 10.7 minutes and has a standard deviation of about 3 minutes[17]. Some studies use a fifteen minute time dichotomy to measure patient satisfaction in statistical analysis[12]. Physicians who see more than three to four patients per hour are associated with decreased patient satisfaction, increased patient turnover and inappropriate prescribing[11]. Physicians self-report that they spend approximately 17.5 minutes in direct patient contact time[16]. Some researchers believe that the physician self-report measures are inaccurate and may include more than face-to-face contact time such as time spent reviewing the chart before entering the exam room[17].

2. Hypotheses •

•

•

H1: Physicians who spend more time in the exam room with the patient will receive higher satisfaction scores. Past studies on patient satisfaction show that increasing amounts of time in the exam room increases satisfaction. H2a: Physicians will receive similar or higher satisfaction scores when a computer is used to retrieve patient medical records. Retrieval of patient information may increase satisfaction because the information may be more accurate, provide an easier method for physician to navigate the information, reduce redundant questions, and physicians may appear to know more about the patient. H2b: Physicians will receive similar or higher satisfaction scores regardless of how patient information is recorded (electronic medical record or paper). Physicians who enter information will not appear to

•

•

•

be more distracted or less caring then those who use traditional forms of recording patient information. H3a: Patients who have experienced electronic medical records believe their record is more portable. Patients will believe that their medical record can be exchanged between health care providers more easily in electronic form than paper records. H3b: Patients who have experienced electronic medical records want more control over their medical record. Electronic medical records have some capabilities that paper records do not have, such as auditability and the ability to review the record outside the medical office - for example from the patient’s home. Since the record is not a physical entity patients may want to exert more control over their record. H3c: Patients who have experienced electronic medical records believe they receive better care. There are some studies that indicate that patients have more comprehensive medical records and that physicians follow a better processes with their patients[1].

3. Instrument Design The survey was conducted solely on the Internet using a commercially available survey tool. The survey questions are a combination of established questions from previous studies and new questions to measure patient perceptions of electronic medical records plus demographic questions. The survey opens with a cover letter to introduce the survey using the Total Design Method by Dillman[10]. Twenty questions about physicians and thirteen questions about electronic medical records were asked in the survey. The questions were presented to the survey respondent in a randomized order. Additional questions were asked about the information technology used in the exam room and patient perceptions of time spent with the physician in the exam room. Additional demographic questions were asked at the end of the survey. The last page of the survey allowed the survey taker to enter their email address if they wanted survey results and an optional comment section to provide feedback on the survey or the topic. Construct questions were 7point Likert-type questions. Questions about the exam room and demographic questions were multiple choice with radio buttons as the interface. The survey was designed to take less than fifteen minutes to complete; most respondents completed the survey in seven minutes. Questions about physicians were adapted from Brown and Swartz[8] and the General Practice Assessment Questionnaire[26]. The Brown and Swartz study

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measured differences in physician and patient perceptions about service quality and the service encounter. GPAQ is a patient questionnaire developed by the National Primary Care Research and Development Centre at the University of Manchester (England) to measure patients’ perceptions of care in terms of service measures and not patient outcomes. Three constructs were used to measure patient perceptions in the exam room - physician interactions, professional competence and courtesy. An overall satisfaction measure was created to measure overall satisfaction with the physician. Electronic medical record questions were based on patient and physician concerns in the literature. Survey takers were asked questions based on three constructs - portability of the record, control of the record and process improvements due to the record. Portability questions were developed to measure if patients perceive that the electronic medical record provide better communication between physicians. Control questions were asked to determine how patients want to control their medical record[24]. Process questions were asked to determine if patients perceived that they would receive better care compared to physicians who did not use electronic medical records[28], [29]. The use of electronic medical records may provide better care because integrated clinical decision support systems are part of many electronic medical record systems[9], [13]. Electronic medical records have been designed to address each of these constructs to some extent although the results have been mixed. Time measures were based on an 11 minute exam room visit with the physician and a standard deviation of 3 minutes. The amount of time in the exam room was measured with five increments. The measures are less than 8 minutes, 8-14 minutes, 15-21 minutes, 22 to 28 minutes and more than 28 minutes. This scale is similar to ones used in other physician satisfaction studies[12].

4. Data Collection The survey was posted on a variety of Internet based forums to attract a wide variety of opinions. The websites were selected based on interest in health or health care. The sample did not seek out expert opinions on health information technology forums because those responses might be biased. The sampling is not random; however, other than the educational attainment of the survey takers the respondents appear to not be part of a particular class and show no inherent bias. The sampling is through convenience due to time and budgetary constraints. The sites include Beginner Triathlete, Blackboard, Denver Post Health Forum, Democratic Underground, Denver Topix, Facebook, iVillage, Oracle-Denver, Runner’s World, U.S

Master Swimmers, WebMD. Many sites were chosen because of an existing personal relationship with the websites. Surveys were collected between March 22nd and May 5th, 2009. A total of 242 surveys were returned. 96% of the people who started the survey completed the survey. A cover letter and a link to the survey were posted to eleven Internet based forums.

5. Methodology The raw data was collected from a commercially available survey tool (Survey Monkey) and used by SPSS version 17 for statistical analysis. To test construct validity factor analysis and Cronbach’s alpha were calculated. Since the research questions and corresponding hypothesis in this exploratory research aim to analyze the difference or variance between two groups (those respondents stating that an EMR was used during a visit versus those who claim no EMR was used) ANOVA and related methods are the ideal analysis choice[7]. Hence the hypotheses are evaluated using the statistical tests of analysis of variance (ANOVA), analysis of covariance (ANCOVA), multivariate analysis of variance (MANOVA) and multiple regression. The constructs physician interaction, professional competence and courtesy were used to determine how well they predicted overall physician satisfaction through multiple regression. MANOVA was used to determine if time in the exam room and demographic factors are a statistically significant factor in determining patient satisfaction. ANOVA was used to determine if patients perceived differences in the physician satisfaction constructs based on computer usage. ANCOVA was used for hypotheses H2a and H2b to determine whether there is a statistically significant difference between the independent patient satisfaction constructs (PI, PC and CO) and experimental conditions (computer usage) and the dependent overall patient satisfaction construct (SAT), controlling for any covariates. ANOVA was used to determine if patients perceived differences in portability, control and process impacts of electronic medical records depended on exposure to electronic medical records. Statistical tool selection is based on the appropriateness to the model and unit of analysis. Multiple regressions is used to predict one dependent variable based on multiple independent variables[21]. MANOVA is used to analyze multiple dependent variables that are correlated with each other in a low to moderate level[21]. ANOVA is used to compare differences between two or more groups to determine if there is a statistically significant difference[21]. ANCOVA is used to adjust for difference between the groups based on another typically

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Table 2.

Table 1.

R ELIABILITY

FACTOR A NALYSIS

Question pi1 pi2 pi3 pi4 pi5 pc1 pc2 pc3 pc4 pc5 pc6 co1 co2 co3 co4 co5

Preliminary Model Fact Fact Fact Fact 1 2 3 4 .744 .373 .705 .374 .408 .542 .334 .533 .341 .434 .332 .536 .349 .599 .729 .320 .649 .306 .657 .356 .329 .577 .389 .331

.775 .493 .329

Final Model PI PC CO .730 .663 .629 .608 .574 .527 .495 .320 .509 .401

.418 .355 .502 .365 .351 .378 .772 .654 .578 .361

.638 .632 .402

.327

.482 .774 .459

Measure

Cronbach’s Alpha

Physician Interaction

.862

5

5

Professional Competence

.890

6

5

Courtesy

.768

5

3

Satisfaction

.917

3

3

Portability

.838

4

4

Control

.847

4

3

Process

.813

5

5

Table 3. C ONSTRUCT D ESCRIPTIVES

Construct interval-level variable called the covariate[21].

6. Results Factor Analysis: Factor analysis was performed to determine how the factors loaded on the constructs. A preliminary model based on the Brown and Swartz study was used to determine factor loadings[8]. The questions selected from Brown and Swartz were from the categories of physician interactions, professional competence, diagnostics and from the doctor rating section of the GPAQ[26]. When confirmatory factor analysis was performed the questions from the constructs loaded on the multiple constructs. A second exploratory model was developed based on constructs from SERVQUAL[27]. Questions were grouped into constructs reflecting PI, PC and CO. Factor analysis was conducted on the preliminary and final model; Table 1. shows factor loadings above a .3 threshold for the preliminary and final model. Factor loadings greater than .30 and less than .50 are considered to be typical[21]. Reliability Results: The Cronbach’s alpha measure of reliability of the physician interaction (PI), professional competence (PC), courtesy (CO), satisfaction (SAT) constructs used to measure patient satisfaction were above .7 and considered acceptable. The electronic medical records measures are portability (port), control (control), and process changes (proc). and had reliability results above .7 and are considered acceptable[15].

Questions Questions asked used

Mean

Std. Dev

N

Physician Satisfaction Constructs Physician Interaction

5.780

0.903

231

Professional Competence

5.408

1.035

233

Courtesy

4.035

1.261

232

Satisfaction

5.807

1.172

235

EMR Constructs Portability

5.700

0.992

228

Control

6.041

1.057

228

Process

4.359

0.936

229

Valid N (listwise)

213

Multiple Regression Results on Satisfaction: A multiple regression was executed on the satisfaction constructs to determine how well PI, PC and CO determine overall physician satisfaction. The model significance was .001, adjusted R Square is .738 and the F-measure is 210. The constructs PI, PC and CO provide a good statistical model for overall physician satisfaction. The PI and PC constructs were significant in the model at the .001 level. Courtesy was not a statistically significant factor. The constant has a statistically small impact on

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Category

Table 4.

Table 5.

F REQUENCIES

M ULTIPLE R EGRESSION R ESULTS

N

Valid %

Construct

Coefficient

Significance

PI

.476

.001

Age 18-29

20

8.7

PC

.538

.001

30-39

72

31.2

CO

.066

.111

40-49

83

35.9

Constant

-.110

.669

50-59

36

15.6

60-69

18

7.8

>70

2

.9

Gender M

83

35.9

F

148

64.1

Category

N

Valid %

Computer used in exam room Yes

117

49

No

116

49

Don’t know

6

2

the overall equation. Hypothesis results: : H1: Physicians who spend more time in the exam room with the patient will receive higher satisfaction scores.: Hypothesis H1 was supported by the study. Every satisfaction measure and overall satisfaction increased as exam room time increased. This finding supports existing patient satisfaction research. A MANOVA statistical procedure was used and the multivariate tests of significance is .001 with Hotellings and an approximate F-score of 3.21. Each component of satisfaction is significant at the .001 level with F scores >21.

Computer used to enter patient information in exam room Yes

110

46

No

97

41

Don’t know

32

13

Computer used to retrieve patient information Yes

110

46

No

110

41

Don’t Know

32

13

Patient never exposed to computer in exam room Yes

177

74.1

No

58

24.3

Don’t Know

4

1.7

Time in exam room

N

Valid%

28

19

8

Table 6. H1 R ESULTS

Minutes

PI

PC

CO

SAT

N

28

6.413

6.263

5.104

6.396

16

Entire Sample

5.783

5.429

4.028

5.826

193

H2a: Physicians will receive similar or higher satisfaction scores when a computer is used to retrieve patient medical records.: Physicians who used computers in the exam room to retrieve patient information received higher satisfaction scores to those who did not use computers to retrieve patient information. The hypothesis has partial support. ANOVA supports higher overall satisfaction scores with computer usage to retrieve patient information at the .075 significance level. Every other satisfaction measure (PI, PC, CO) had significance levels >.1. ANCOVA was used to determine the effect retrieving patient information between each of

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the three satisfaction measures and overall satisfaction adjusting for time in the exam room. The ANCOVA results showed that computer usage was not a statistically significant factor. Table 7. H2 A R ESULTS

ANOVA results Computer Usage

Construct Mean

Std.Dev

N

Table 8. H2 B R ESULTS

ANOVA Results Computer Usage

Construct Mean

Std.Dev

N

C1

SAT

5.889

1.169

108

C2

SAT

5.691

1.230

96

C1

PI

5.828

.906

108

C2

PI

5.728

.953

94

C1

SAT

5.954*

1.160

108

C1

PC

5.526

1.042

108

C2

SAT

5.652*

1.245

96

C2

PC

5.317

1.074

94

C1

PI

5.873

.903

107

C1

CO

4.196

1.274

107

C2

PI

5.692

.954

93

C2

CO

3.894

1.273

94

C1

PC

5.487

1.049

108

C2

PC

5.351

1.082

94

C1

CO

4.160

1.235

106

C2

CO

3.874

1.331

95

C1 - Computer used to retrieve patient information C2 - Computer not used to retrieve patient information * significant at the .1 level. H2b: Physicians will receive similar or higher satisfaction scores regardless of how patient information is recorded (electronic medical record or paper).: Physicians who used computers in the exam room to retrieve patient information received similar satisfaction scores to those who did not use computers in the exam room. The hypothesis is supported. An ANOVA statistical procedure was used and tests had a of significance greater than .1 meaning no significant differences in satisfaction levels is found when a computer is used to enter patient information. ANCOVA was used to determine the effect of recording patient information between each of the three satisfaction measures and overall satisfaction adjusting for time in the exam room. The ANCOVA results showed that computer usage was not a statistically significant factor. H3a: Patients who have experienced electronic medical records believe their record is more portable.: Patients who experienced electronic medical records believe that their record is more portable than those who have not experienced electronic medical records. The hypothesis is supported with ANOVA. The results are statistically significant at the .066 level and patients who have experienced EMR did perceive their medical record to be more portable.

C1 - Computer used to enter patient information C2 - Computer not used to enter patient information

Table 9. H3 A R ESULTS

ANOVA results

Mean

Std.Dev

N

Patients with EMR

5.776

.963

171

Patients with no EMR

5.491

1.056

53

H3b: Patients who have experienced electronic medical records want more control over their medical record.: Patients who experienced electronic medical records did not want statistically significantly more control over their medical record compared to patients who have not experienced electronic medical records. The hypothesis is not supported. An ANOVA statistical procedure was used to determine statistical significance. Table 10. H3 B R ESULTS

ANOVA results

Mean

Std.Dev

N

Patients with EMR

6.073

1.011

169


5.970

1.056

55

H3c: Patients who have experienced electronic medical records believe that they receive better care.: Patients who experienced electronic medical records did not believe the record provided statistically significantly

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better patient outcomes compared to patients who have not experienced electronic medical records. The hypothesis is not supported. An ANOVA statistical procedure was used to determine statistical significance.

the desire to control the medical record (significance .216) or process improvements from medical records (significance .802).

7. Discussion Table 11. H3 C R ESULTS

ANOVA results

Mean

Std.Dev

N

Patients with EMR

4.388

.937

171


4.257

.950

55

Table 12. H YPOTHESES S UMMARY

Hypothesis Supported

Summary

H1

Yes

Increases in exam room time increase patient satisfaction

H2a

Yes

Physician satisfaction is similar or higher with computerized retrieval of patient information

H2b

Yes

Physician satisfaction is similar or higher with entering information into a computer

H3a

Yes

EMR patients will believe their record is more portable

H3b

No

EMR patients will want more control over their medical record

H3c

No

EMR patients will believe EMR provides better patient outcomes

Time Dependent Findings: The amount of time the patient spent with the physician in the exam room was not correlated with patient perceptions that physicians who used EMR spend more time with the patient (significance .252). The amount of time in the exam room was not correlated with patient perceptions that physicians who used EMR spend more time with the patient (significance .590). The amount of time spent in the exam room was not correlated with patients’ perception of portability of the medical record (significance .851),

This study had three research questions: 1) Is patient satisfaction affected by the use of electronic medical records in the exam room? 2) Do patients who have experienced electronic medical records perceive differences in their utility? 3) Do patients who have experienced electronic medical records desire more control over their record? Overall patient satisfaction was positively affected by the use of electronic medical records to retrieve patient information and not affected when patient information was entered into an electronic medical record. It is a positive finding that patients do not perceive lower physician interactions when physicians enter information into a computer during the exam process. Many physicians are concerned about the effect of less eye-to-eye contact when a computer is in use. Physicians are also concerned that patients may be curious as to what is in front of the physician when they are entering information into a computer and may get distracted themselves. Patients did have higher overall satisfaction with their physician when a physician retrieved their electronic medical record. Physicians who retrieved patient information in the exam room with a computer did not have higher physician interaction, professional competence or courtesy scores. The ANOVA results show that patient satisfaction is increased by patient information retrieval at the .1 significance level. Patients who have experienced electronic medical records perceive some significant differences in their utility. Patients believe that the electronic documents are more portable than paper records (.1 significance level). Patients may find that their electronic medical record is more portable if a different physician has a compatible system to exchange those electronic documents. Despite some evidence that electronic medical records coupled with clinical decision support systems provide some better process outcomes patients do not perceive a benefit. Despite some evidence that physicians who use electronic medical records ask more comprehensive questions again patients do not perceive a benefit. It appears survey takers were less prone to speculation for the questions on process benefits of electronic medical records. The five questions on process outcomes all received a majority of responses as “Neither Agree or Disagree.” The results were mixed on whether patients with electronic medical records wanted more control over

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their record than those with paper records. Electronic medical records have different qualities than paper records (e.g. auditability); however, patients did not express any more desire to control access to or audits of their electronic medical record compared to patients who had paper records. The responses to the control questions had the strongest responses of the electronic medical record section where survey takers said they wanted to control access to their medical record and wanted to know who and when their medical record was reviewed. The time that physicians spend with their patients is a significant factor in patient satisfaction. Time affected all physician satisfaction measures: physician interactions, professional competence, courtesy and overall satisfaction. It can be expected that time in the exam room effects physician interaction and courtesy; however, more time also increases the patient’s perception that their physician is competent.

8. Limitations Sampling of this study is not random and therefore it would be difficult to say how the general population perceives electronic medical records based on this study alone. There is no particular reason to believe that the survey takers in this study have a different perspective on physicians and electronic medical records than the general population. The results were cross checked with existing research on patient satisfaction and age, gender and time in the exam room. The largest educational group in the survey were bachelor degreed respondents; however, the bachelor degreed respondents did not significantly differ from people with high school degrees on patient satisfaction measures. The surveys may be biased toward technology savvy users because the survey link was posted on Internet based forums. The study is about perceptions of electronic medical records but the study questions can not conclusively determine whether a person who visits a physician is experiencing an electronic medical record or not. The questions ask about computer usage in the exam room either to enter information into or retrieve patient information. It can not be conclusively determined whether the physician is actually using an EMR system or something else. For the purposes of this study conclusive use of electronic medical records is not necessary. This study is about patient perceptions so the use of a computer may have the biggest impact as opposed to any particular implementation of EMR. Some survey takers felt that they would provide different answers for the primary care physician and specialist physicians. The survey did not make any

distinction of which physician the survey taker was to rate. The preferences was to rate the physician the patient who used medical records in the last six months, if available. If the patient did not see a physician in the last six months who used electronic medical records the survey taker was instructed to use the most recent physician. Survey takers appeared to be reluctant to answer questions about the impact EMR on the process outcomes. The most common answer to questions about how EMR may affect the exam room process or outcomes was “Neither Agree or Disagree.” Some survey takers said that they would have preferred a “not applicable” or “don’t know” option to some questions in the survey. This option may have improved some of the statistical results. The survey did not make a distinction about whether a patient’s record was ever used as a communication interchange between physicians. Analyses on portability were based on whether a patient ever experienced EMR in the exam room. If a patient had a medical record that was actually used by a different physician the portability analysis may yield different results. The study does not attempt to make actual measurements like length of time in the exam room but relies on patients to accurately state amounts of time. Just as the physicians appear to overestimate the amount of faceto-face contact time with the patient, patients may be underestimating the amount of face-to-face time. There appear to be some significant differences between physician who have adopted EMR and those who do not[23]. Physicians who have adopted EMR are classified as early adopters of the technology. Physicians who use EMR are more likely to practice in urban settings, use computerized scheduling use handheld computers and maintain different beliefs about the benefits of EMR. These different psycho-social measures may have complex interactions that are not being measured in this survey.

9. Conclusions Electronic medical records are increasingly being adopted by physicians; approximately 43% of physicians believe they will be using EMR in the next two years and about 17% use EMR today[9]. The ARRA provides incentives to physicians to purchase these medical record systems. Some physicians are concerned about the cost of the systems and whether they will receive a return on their investment. Physicians are also concerned about the impact on patient satisfaction. It appears that the impact on patient satisfaction is mostly positive. The use of a computer in the exam room does not appear to

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negatively affect patient perceptions of their interaction with their physician. Patients whose records are retrieved by physicians appear to have higher overall satisfaction levels. However patients also do not appear to perceive benefits from electronic medical records. There is interest in EMR from the federal government because of the potential cost savings of EMR, improved physician efficiency and improved quality of care measures[29]. There may be network effects for some of the benefits of EMR to be realized. When only a small number of physicians use EMR the benefits may be uneven; as a critical mass of physicians use EMR a tipping point may be reached and the benefits may be more quantifiable.

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