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If you’re thinking of moving to electronic records,the results of this survey may help.User Satisfaction With EHRs:Report of a Survey of 422Family PhysiciansRobert L. Edsall and Kenneth G. Adler, MD, MMMWb o b da lyith more and more family physicianstrying to decide whether to move to anelectronic health records (EHR) systemand which system to choose, we thoughtit high time we repeated thesurvey of user satisfactionwith EHR systems thatFamily Practice Managementconducted in 2005.1We published a revisedand simplified version ofthe 2005 survey instrument in the April 2007issue.2 Over the next severalmonths, we collected 422usable responses from AAFPmembers who completedeither the print version ofthe survey or an online version posted on the FPMWeb site. As with the 2005survey, respondents were selfselected. Consequently, it isprobably most useful to consider this report as the kindof information you might getif you could ask a few hundred colleagues how they liketheir EHR systems.The 422 respondents reported on a total of 61 different EHR systems, the majority of which were reported bythree or fewer respondents; on the other hand, the 13 systems most commonly mentioned, each reported by 12 ormore respondents, accounted for 80 percent (336) of theresponses. In the analysis below, we report system-specificresults for these 13 commonly reported systems, usingpooled data from all 422 respondents as a point of reference against which to view the system-specific results. Wechose to focus on these 13 systems because we believedthat we had enough responses on each to represent a reasonable spread of opinions onthe system. The 13 systems inquestion are listed on page 26.The respondentsGiven the wide publicationof the survey instrument, weaccepted responses only fromAAFP members as a way ofavoiding frivolous responses,multiple responses per individual and other potentialsources of bias. Respondentscame from a range of practicesituations, with 36 percent(152) in solo or two-personpractices, 31 percent (132)in practices of three to 10physicians, 20 percent (83) inpractices of 11 to 50 physicians, and 13 percent (55) inlarger practices. Most of the respondents (70 percent, or295) were in single-specialty family medicine practices.As you might expect, certain EHR systems werereported more commonly by respondents in smallerpractices and other systems more commonly by those inlarger practices. The practice size distribution of the 13most commonly reported systems is shown on page 27.When choosing a system for your practice, you mightfind this chart a useful reference, since appropriateness toDownloaded from the Family Practice Management Web site at www.aafp.org/fpm. Copyright 2008 American Academy of Family Physicians. For the private, noncommercialuse of one individual user of the Web site. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
practice size is an important consideration.Respondents’ range of experience with EHRs wasquite wide, with a few reporting more than 10 years ofexperience with their current system. The bulk of respondents were less experienced, however, with 80 percent(336) reporting 0.5 to 5.0 years of experience with theircurrent systems. Respondents were generally pretty sanguine about their ability to use their EHR system, with72 percent rating their skill as above average or expert.Since the survey did not specify behaviors or capabilities corresponding to the levels of expertise, the reportedlevels should be taken as indications of the respondents’confidence in their own abilities rather than as measuresof actual abilities.Some 65 percent of respondents (275) said that theyhelped select the EHR system they use. Unsurprisingly,users of systems common in small practices were mostlikely to have helped. While all respondents for PraxisEMR and Amazing Charts said they had been involved inthe selection, only 14 percent of EpicCare respondents (3)and no respondents for Cerner PowerChart Office did.While the survey did collect this sort of limited information about the respondents, its focus, as the nameimplies, was on the users’ satisfaction with the EHRsystems they used. It assessed satisfaction in several areas: Functions facilitated or performed by the system(22 items), Ease of use and flexibility (4 items), Service and support (4 items), Cost (3 items), Interoperability (10 items), Security (3 items), Overall satisfaction (6 items).FunctionalityThe survey asked respondents to report their satisfactionwith the functionality of their EHR systems by indicatingtheir degree of satisfaction or dissatisfaction with how theirsystems allowed them to perform various functions such as“review chart information” or “update and review problemlists.” In each case, the respondent could choose Verysatisfied, Satisfied, Neutral, Dissatisfied, Very dissatisfied,Function not installed or Function installed but not used.“Functionality rankings for 13 EHR systems,” page29, shows how the 13 systems ranked on each of theThe 13 EHR systems most commonly reported by survey respondentsAmazing ricity** (formerly ucts/centricity practice/emr index.htmlCerner PowerChart Office**http://www.cerner.com/public/Cerner 3.asp?id 808816-201-0054eClinicalWorks features.html508-836-2700e-MDs tml888-344-9836 or 00HealthMatics -practice/solutions-ehr.asp800-654-0889Misys ct portfolio/misys emr/default.htm866-647-9787NextGen EMR*http://www.nextgen.com/pro emr.asp215-657-7010Practice PartnerPatient ecords.htm800-770-7674 or 206-441-2400Praxis ttp://www.docs.com800-455-7627 or 654-0889*CCHIT Certified 2006 and 2007.**CCHIT Certified 2006.See http://cchit.org/choose/index.asp for information about the significance of CCHIT certification.26 FAMILY PRACTICE MANAGEMENT www.aafp.org/fpm February 2008
EHR SurveyEHR DISTRIBUTION BY PRACTICE SIZE FOR 13 EHR SYSTEMSPraxis EMR (N 12)Amazing Charts (N 27)SOAPware (N 15)e-MDs Chart (N 28)eClinicalWorks EMR (N 30)Practice Partner EMR (N 38)HealthMatics EMR (N 24)All 422 respondentsMisys EMR (N 21)NextGen EMR (N 35)Centricity (formerly Logician) (N 53)TouchWorks (N 21)EpicCare (N 20)Cerner PowerChart Office (N 12)0%Number of physicians:10%120%2functions asked about, with rankings determined bypercentage of Satisfied and Very satisfied responsescombined. For each of the functions listed, the fourhighest ranks are tinted blue and the four lowest tintedred to help show overall satisfaction, and the 13 systemsare listed across the top of the table in order of overallaverage rank, with the ones getting the best evaluationsfrom their users at the left. The 22 areas of functionalityare ranked separately in case any should be of particularimportance to you.For a better picture of general satisfaction with these22 areas, see “Overall satisfaction with functionality of13 EHR systems” on page 30. This chart represents theaggregate of responses to the 22 items in the functionality section. Respondents who use e-MDs Chart seemmost satisfied with its functionality, with 80 percent oftheir ratings being Satisfied or Very satisfied. At the otherextreme is Misys EMR, with 44 percent Satisfied or Verysatisfied – and 34 percent Dissatisfied or Very dissatisfied.A word about the chart format used in this article:By displaying the four “satisfaction/dissatisfaction” barsin characteristic colors and arranging them around thecenter line, the chart gives you a way to compare thoseratings at a glance. And by including bars for otherresponses such as Function not installed, it gives you amore complete picture of the data collected. The totallength of each bar represents 100 percent of responses,with some slight variation because of rounding and a3-530%40%6-1050%11-2060%21-5070%80%90%100% 50handful of blank responses. Just remember that the lesscolorful bars for Neutral, Function not installed, etc. arenot necessarily measures of satisfaction or dissatisfaction;they could as easily be shown on the right as on the left ofthe satisfaction/dissatisfaction bars.Ease of useRespondents were asked to indicate the extent to whichthey agreed or disagreed with four statements concerningease of use and flexibility: This EHR allows individual user-specificcustomization. This EHR minimizes data input. This EHR offers multiple note creation options. This EHR is fast (minimal wait between screens,minimal boot-up time, etc.).Of the 13 systems, three received below-average ratings on all four of the above statements: Cerner PowerChart Office, Misys EMR and NextGen EMR. On theother hand, six systems received above-average ratings onall four: Amazing Charts, e-MDs Chart, EpicCare, Practice Partner Patient Records, Praxis EMR and SOAPware.Perhaps unsurprisingly, users were generally least satisfiedwith the amount of data input required by their systems.Only 48 percent of the 422 respondents indicated thatthey agreed or strongly agreed with the statement that“this EHR minimizes data input,” while 68 percent to 78February 2008 www.aafp.org/fpm FAMILY PRACTICE MANAGEMENT 27
percent agreed or strongly agreed with theother three statements regarding ease of useand flexibility. “Overall satisfaction with easeof use and flexibility of 13 EHR systems,”page 30, shows how the 13 systems did in theaggregate. Praxis EMR and e-MDs Chartcame out on top, with Cerner PowerChartOffice and NextGen EMR at the bottom.SupportOf 61 EHR systemsused by respondents, 13 were mentioned frequentlyenough to justifyreporting systemspecific results.The 13 systems arerated separately onfunctionality, easeof use, vendor support and other criteria of satisfaction.No system rankedwell consistently,but AmazingCharts, e-MDsChart, HealthMatics EMR, PracticePartner PatientRecords, and PraxisEMR appearedmost frequently inthe top ranks.The four survey items devoted to service andsupport were these: Our vendor provided excellent supportduring our implementation period. Our vendor provides excellent ongoingsupport and service. Our vendor issues at least one significantsystem upgrade per year. Our vendor assists with ongoing training.Overall, 72 percent of respondents (305)agreed or strongly agreed with the statementabout system upgrades, while 50 percent to57 percent of respondents agreed or stronglyagreed with the others. Four systems ratedbelow average in all four areas – Centricity,Cerner PowerChart Office, Misys EMRand TouchWorks – and six rated aboveaverage in all four: Amazing Charts, eClinicalWorks EMR, e-MDs Chart, HealthMatics EMR, Praxis EMR and SOAPware. See“Overall satisfaction with support and trainingfor 13 EHR systems,” page 31, for theaggregate results.System costAs in our 2005 survey, we asked respondentsfor an estimate of the per-physician cost oftheir system. We learned from the responsesthat the situation hasn’t really changed in thelast two years: Physicians generally have nomore than a vague sense of EHR cost. PerAbout the AuthorsDr. Adler is a family physician in full-time clinicalpractice in Tucson, Ariz. He has a Master of Medical Management degree from Tulane University anda Certificate in Healthcare Information Technologyfrom the University of Connecticut. Robert Edsallis editor-in-chief of Family Practice Management.Author disclosure: Dr. Adler discloses that he usesTouchWorks EHR.28 FAMILY PRACTICE MANAGEMENT www.aafp.org/fpm February 2008physician cost estimates ranged from 1,000to 350,000, with more than 150 respondentsnot responding or indicating that they didn’tknow the cost.Responses to two other cost-related items,nevertheless, seem to have some value. Oneasked respondents to indicate their level ofagreement with the statement, “This EHRcosts more than it’s worth.” This item calledmore for a value judgment than a financialassessment, and we’ll cover the responsesbelow, in the section on overall satisfaction.The other, which gauged agreement ordisagreement with the statement, “This EHRhas saved or will save my practice money overits first five years of use,” may not reflect reality, considering that many medical practicesdo not seem to have a good handle on theirfinances, but it did produce intriguing results.As you’ll see from the chart at the bottom ofpage 31, respondents for some systems weredecidedly in agreement with the statement;systems further down the chart show bothweaker agreement and larger percentages of“no opinion” responses. But if you comparethis chart with the one on practice sizes onpage 27, you’ll see that the systems used primarily by smaller practices are the ones thatrespondents believe most strongly are savingtheir practices money. Thus, the high levels ofagreement and the relatively small, or in twocases nonexistent, component of No opinionresponses suggest that physicians in smallerpractices may be both more in touch withtheir financial performance and more positivethat their EHRs are saving them money thanphysicians in larger groups.InteroperabilityThe more systems an EHR directly interfaceswith, the greater its usefulness. An EHRinterfaced with a lab system, for instance, canobtain patient lab results automatically andeasily flowchart the results. Similar benefitsaccrue from other interfaces. Hence, we askedrespondents whether their systems were interfaced with a practice management system, alab system, a radiology system, a pharmacysystem or a hospital system.The most commonly reported interfaceswere with lab systems and practice management systems. We ranked systems by percentage of respondents reporting three or more
EHR SurveyFunctions facilitatedor performed by the systeme-MDs Chart (N 28)Praxis EMR (N 12)Practice Partner EMR (N 38)Centricity (formerly Logician) (N 53)EpicCare (N 20)HealthMatics EMR (N 24)eClinicalWorks EMR (N 30)Amazing Charts (N 27)SOAPware (N 15)NextGen EMR (N 35)TouchWorks (N 21)Cerner PowerChart Office (N 12)Misys EMR (N 21)Functionalityrankings for13 EHR systemsReview chart information45372681912111013Create visit notes13485962711101312Create telephone messages23614857101311912Generate and use referral forms,work excuses, etc.93541810627121311Work without paper13985267410121113Update and review problem lists17382695412111013Update and review allergies24185697312101113Update and review immunizations11068392411512713Update and review medication lists16351148279101213Present graphic views of vital signs11148927310612513Enter and review test orders21764385109111213Manage and review test results61432781091112513Prescribe electronically74105136131282911Create and reviewscanned documents16341352712118109Manage referrals81532946127111310Manage and provide patienteducation materials43521791086121311Generate patient lists(e.g., all with diabetes)53421176189121310Generate diseasemanagement reports54628311110712139Assign tasks to otheroffice personnel42759318121061311EHR alerts you to problematicmedications when relevant13475261312910811EHR reminds you of healthmaintenance deficienciesduring visit42137116139510128EHR assists in coding visitsand capturing charges16810723495111312Blue tint identifies the top rankings (1 - 4); red tint identifies the lowest rankings (10 - 13). Systems are listed from left to right based on the sum of their rankings.February 2008 www.aafp.org/fpm FAMILY PRACTICE MANAGEMENT 29
interfaces. Overall, 58 percent of respondents reportedthat many interfaces. The six above-average systems, bythis measure, were Centricity, Cerner PowerChart Office,eClinicalWorks EMR, EpicCare, HealthMatics EMRand TouchWorks. Perhaps unsurprisingly, most of theseare systems used in larger practices. The main exceptionis eClinicalWorks EMR. Of respondents who reportedusing it, 63 percent say their installations have at leastthree interfaces, but 77 percent are in practices with nomore than five physicians.OVERALL SATISFACTION WITHFUNCTIONALITY OF 13 EHR SYSTEMSVery satisfiedSatisfiedDissatisfiedVery dissatisfiedFunction not installedFunction installed but not usedNeutrale-MDs Chart (N 28)Praxis EMR (N 12)Practice Partner EMR (N 38)Centricity (formerly Logician) (N 53)EpicCare (N 20)HealthMatics EMR (N 24)eClinicalWorks EMR (N 30)Amazing Charts (N 27)All 422 responsesNextGen EMR (N 35)SOAPware (N 15)TouchWorks (N 21)Cerner PowerChart Office (N 12)Misys EMR (N 21)60%40%20%OVERALL SATISFACTION WITH EASE OF USEAND FLEXIBILITY OF 13 EHR SYSTEMS0%20%Strongly agreeAgree40%60%DisagreeStrongly disagree80%No opinionPraxis EMR (N 12)e-MDs Chart (N 28)Amazing Charts (N 27)Practice Partner EMR (N 38)SOAPware (N 15)EpicCare (N 20)eClinicalWorks EMR (N 30)HealthMatics EMR (N 24)All 422 ResponsesCentricity (formerly Logician) (N 53)TouchWorks (N 21)Misys EMR (N 21)Cerner PowerChart Office (N 12)NextGen EMR (N 35)80%60%40%30 FAMILY PRACTICE MANAGEMENT www.aafp.org/fpm February 200820%0%20%40%60%80%100%
EHR SurveySecurityThe survey included three items designed to assess EHRsystem security – yes/no questions asking whether therespondent’s system required a password for access, couldallow different users different levels of access to recordsin the system, and kept an audit trail of informationabout who had accessed which charts. Password protection seems to be generally available, with 98 percentof users of the 13 most common systems reporting thattheir systems had it. Access restriction was also prettywidely implemented, with 90 percent of respondents forthe 13 systems reporting it. The audit trail feature wasreported by only 74 percent of users of the 13 systems.Audit trails were most commonly reported by users ofeClinicalWorks EMR, e-MDs Chart, EpicCare andHealthMatics EMR. OVERALL SATISFACTION WITH SUPPORTAND TRAINING FOR 13 EHR SYSTEMSStrongly agreeAgreeDisagreeStrongly disagreeNo opinionPraxis EMR (N 12)Amazing Charts (N 27)e-MDs Chart (N 28)HealthMatics EMR (N 24)eClinicalWorks EMR (N 30)SOAPware (N 15)EpicCare (N 20)Practice Partner EMR (N 38)All 422 ResponsesNextGen EMR (N 35)Centricity (formerly Logician) (N 53)Misys EMR (N 21)Cerner PowerChart Office (N 12)TouchWorks (N 21)80%60%40%20%Agreement with the statement, “This EHR has savedor will save my practice money over its first five yearsof use” for 13 EHR systems0%20%Strongly agreeAgree40%60%DisagreeStrongly disagree80%100%No opinionPraxis EMR (N 12)Amazing Charts (N 27)SOAPware (N 15)HealthMatics EMR (N 24)e-MDs Chart (N 28)eClinicalWorks EMR (N 30)Practice Partner EMR (N 38)All 422 ResponsesEpicCare (N 20)Centricity (formerly Logician) (N 53)Cerner PowerChart Office (N 12)NextGen EMR (N 35)Misys EMR (N 21)TouchWorks (N 21)100% 80%60%40%20%0%20%40%60%80%100%February 2008 www.aafp.org/fpm FAMILY PRACTICE MANAGEMENT 31
Overall satisfactionIn three measures ofoverall satisfaction,Amazing Charts,eClinicalWorks andPraxis EMR werehighest rated.Given the surveymethodology andrelatively small cellsizes, results shouldbe interpretedwith caution.Since a physician’s opinion of his or her EHRsystem is probably too nuanced to be capturedin a single question about overall satisfaction,the survey attempted to approach that issuefrom three separate directions, with items thatasked respondents to agree or disagree withthree statements, one of which invited expressions of satisfaction and two that invitedexpress
Misys EMR (N 21) All 422 respondents HealthMatics EMR (N 24) Practice Partner EMR (N 38) eClinicalWorks EMR (N 30) e-MDs Chart (N 28) SOAPware (N 15) Amazing Charts (N 27) Praxis EMR .
