The Science of Improving the EHR Experience 2023
2023 Update
Since the Arch Collaborative was created in 2017, KLAS has had the opportunity to partner with almost 300 healthcare organizations to measure clinician perceptions of the EHR experience. These measurements represent over 340,000 clinician responses and have revealed key insights about common areas of satisfaction and frustration. Perhaps more importantly, by evaluating the lessons learned from organizations that have completed multiple measurements over time, we have identified a continuous improvement process that any organization can implement to help their clinicians better succeed with the EHR. Outlined below, this process relies significantly on the hard work of IT and informatics personnel, clinical leaders, and clinicians. Additionally, KLAS and the Arch Collaborative are there to help every step of the way.
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Steps to Improving Clinician Satisfaction with the EHR
- Measure your clinicians’ current EHR experience
- Understand the impact of a poor EHR experience
- Identify groups in need of targeted intervention
- Evaluate and select improvement initiative(s) for deployment
- Deploy selected initiative(s)
- Remeasure and repeat
Key Findings from Repeat Measurements
To date, 95 Arch Collaborative members have completed at least two organization-wide measurements of clinician satisfaction with the EHR
40% of organizations that have remeasured have seen significant improvements (8.0+ point increase in Net EHR Experience Score) since their first measurement (see chart on next page)
On average, organizations with repeat measurements achieve Net EHR Experience Scores (NEES) 10.6 points higher than organizations that have measured only once
Of all measured clinician groups, nurses have seen the largest improvements in EHR satisfaction since 2017; nurse satisfaction has increased by 12.4 points (n=22,744 respondents)
Physicians have also seen improvement, achieving an 8.0 point increase in NEES (n=20,114 respondents)
Step #1: Measure Your Clinicians’ Current EHR Experience
Historically, conclusions about clinician satisfaction with the EHR were often based on anecdotal data and feedback rather than formal measurement. Depending on the volume of this feedback (in terms of quantity or decibels), one could draw a variety of conclusions about the clinician EHR experience, some perhaps less accurate than others. To correctly identify—and then improve—the real issues your clinicians are experiencing with the EHR, the first step is standardized, organization-wide measurement. The data collected by the Arch Collaborative over the past five years serves as a benchmark to this measurement and can help organizations understand the markers of high satisfaction and the most effective ways to create a better EHR experience for clinicians.
Step #2: Understand the Impact of a Poor EHR Experience
One potential cost of a poor EHR experience is clinician turnover. Nearly one-fifth of respondents to the Collaborative survey say it is likely or very likely they will leave their organization within the next two years, meaning Collaborative members could be facing a significant turnover expense. Based on existing literature outlining the cost of turnover, estimates show that the expense could be as high as $1.9–$3.4 million per organization to replace nurses and $6.4–$25.6 million per organization to replace physicians.† The combination of these estimates and KLAS models on the correlation between clinician EHR satisfaction, burnout, and turnover shows how much of this cost could be attributed to EHR dissatisfaction: $93,000–$170,000 per organization per year for nurses and $319,000–$1.3 million for physicians. These estimates illuminate the potential financial cost of not addressing clinician dissatisfaction with the EHR.
† Cost estimates are based on data from the following sources:
- 2022 NSI National Health Care Retention & RN Staffing Report, published by NSI Nursing Solutions, Inc.
- Shanafelt T, Goh J, Sinsky C. The Business Case for Investing in Physician Well-being. JAMA Intern Med. 2017; 177 (12): 1826–1832. doi:10.1001/jamainternmed.2017.4340
Step #3: Identify Groups in Need of Targeted Intervention
Organizations should first focus on departments, specialties, clinical roles, or other cohorts that have communicated a desire for improvements to their EHR experience or that report low satisfaction via the Collaborative survey. The best candidates for intervention will be groups with strong leadership willing to engage in a change initiative. Additionally, Collaborative data has identified several clinical backgrounds, specialties, and departments that generally haven’t seen much improvement over time and may therefore benefit from targeted intervention. For example, EHR satisfaction among allied health professionals has not improved over time and has in fact decreased slightly. Many provider specialties have also not seen improvement and may benefit from extra attention; among these specialties, those with the largest samples include pulmonology, radiology, and urology. While nurses on the whole report improved satisfaction, many nursing focus areas haven’t seen as much improvement. The largest groups include nurses that work in emergency care, inpatient care, and surgery. A case study from Sutter Health shares details on how that organization was able to move the needle for their perioperative nurses by focusing on workflows.
Step #4: Evaluate and Select Improvement Initiative(s) for Deployment
Organizations looking to implement an improvement initiative will naturally wonder which are most worth the investment. Organizations that have standardized to one EHR across their enterprise or have implemented a new EHR altogether have seen the highest increases in average NEES (more on that in the next paragraph). However, that approach may not be a feasible option for many organizations. Other improvement initiatives that have garnered noteworthy improvements include deploying third-party tools aimed at improving usability, investing in clinical-improvement initiatives (such as adopting new clinical EHR functionality), implementing at-the-elbow training, and improving online training options. Arch Collaborative resources can help member organizations seeking further guidance on selecting and successfully carrying out an EHR improvement initiative. One such option is peer guidance. These services connect organizations with external peer experts who can help evaluate and develop plans of improvements (see Intermountain case study on next page).
Case Study
Intermountain Healthcare Leverages Peer Guidance
Intermountain Healthcare’s first Arch Collaborative measurement in June 2019 showed room for improvement in satisfaction with the EHR. Seeking to improve the clinician experience, Intermountain Healthcare invited KLAS and four high-performing Arch Collaborative members (Kaiser Permanente Northwest, Memorial Health System, Sharp HealthCare, and UCLA Health) to an on-site peer guidance session. As a result of the insights gained, Intermountain Healthcare launched a series of new training efforts, including flexible, individualized EHR coaching for providers. By the end of 2020, providers across Intermountain Healthcare’s organization reported an average NEES 33 points higher than Intermountain Healthcare’s original measurement. Newly hired providers now receive a one-week follow-up session and four to six optimization sessions, and Intermountain Healthcare continues to expand access by developing various training modalities, including webinars and short videos. For more details, see Intermountain Healthcare’s full case study on the KLAS website.
The data from the Arch Collaborative continues to demonstrate that organizations can find success with any EHR vendor. That being said, some of the organizations that have seen the greatest improvements over time are those that have standardized to one EHR across their enterprise or have implemented a new EHR. Improved satisfaction following an EHR change can be attributed to multiple factors aside from the specific product chosen, including a renewed focus on EHR training and education and improved infrastructure (e.g., improved internal and external integration). Implementing a new EHR is obviously an enormous undertaking that requires significant investment in terms of time, resources, and change management. As a result, organizations that choose this route commonly see a decrease in clinician agreement that the EHR is easy to learn. The case study below from Ozarks Medical Center shares some best practice recommendations to making an EHR implementation successful.
Case Study
Ozarks Healthcare Implements a New EHR
Ozarks Healthcare has seen significant improvements since implementing a new EHR. Over 200 stakeholders from across the organization participated in the selection process, sitting in on demonstrations and submitting scorecards for each solution evaluated. After the selection, training became a high priority. To make the transition as smooth as possible, Ozarks required each user to complete a minimum of six hours of EHR education prior to the go-live. The training consisted of one-on-one education with an IT person, at-the-elbow support, and online, self-led learning modules. After completing the six-hour training, providers had additional training opportunities available if they wanted to learn more about the system. Providers also had the chance to play in the new system’s environment on their own time as much as they wanted. For more details, see Ozarks Healthcare’s full case study on the KLAS website.
Step #5: Deploy Selected Initiative(s)
After selecting an improvement initiative, organizations must then determine how to successfully implement the change. Effective change management is critical and if not planned and executed well can result in less-than-hoped-for improvement. Below are summaries of the deployment strategies of several Collaborative members who have seen significant improvement after implementing new EHR initiatives.
Case Study
Henry Ford Health System Boosts Nurse EHR Training
In preparation for a significant user interface enhancement, Henry Ford Health System brought together nursing leaders, educators, and informaticists to develop and implement a comprehensive EHR training program for nurses. Using their Arch Collaborative survey results as a reference, leaders vetted a new curriculum, explored the financial implications of such an undertaking, and painstakingly outlined the logistics of training over 4,000 nurses across a variety of care settings. The outcome of these efforts was a 52% improvement in NEES. Learnings from this successful but resource-intense experience led those involved to also develop guidelines for additional training. Henry Ford now requires at least a 30-day buffer for training prior to a major feature upgrade. This allows for timely and more regular education. In addition, virtual training was created to provide a more distributable and cost-effective training alternative. This relied heavily on training superusers through webinars and classroom training. Webinars prepared for superusers were also distributed to nursing staff to back up the trainers’ efforts. These efforts have led to a further 16% improvement in EHR satisfaction. For more details, see Henry Ford Health System’s full case study on the KLAS website.
Case Study
OrthoVirginia as a Model for Improvement
OrthoVirginia has been able to continually improve the EHR experience for their orthopedic physicians—a specialty that has historically felt the EHR does not meets their needs. Through internal efforts and direct partnership with their EHR vendor, OrthoVirginia saw a 31-point increase in NEES over three years. The first hurdle was that some providers did not fully understand how the EHR worked. To counteract this problem, OrthoVirginia created the Provider Support Specialist (PSS) program, in which PSS team members are strategically placed geographically to enable them to have one-on-one, at-the-elbow interactions with providers every one to two weeks. The PSS team is mostly made up of scribes who have a solid working knowledge of the EHR and the social skills to establish relationships with providers. To further improve satisfaction and understanding, OrthoVirginia modeled their governance structure after Kaiser Permanente Northwest’s “Pyramid of Change.” In collaboration with providers, analysts and PSS team members design, build, test, and implement changes at a rapid pace. This collaboration generates provider investment in their EHR success. For more details, please see OrthoVirginia’s full case study.
Case Study
Guthrie Clinic Decreases Turnover by Enhancing Training
Six years ago, The Guthrie Clinic was experiencing an above-average turnover rate, and the EHR was frequently mentioned as a factor in people’s decisions to leave. Guthrie conducted listening tours with providers and learned there was a perception that the IT department didn’t care about providers and that feedback from providers outside the main campus wasn’t heard. Guthrie took that feedback and realized their technology and training needed to be enhanced. Now, new providers receive EHR training within their first week. If providers have used the EHR at other organizations, they have the option to test out and receive abbreviated training to ensure new providers learn Guthrie-specific workflows. New providers can also import their smart phrases from their previous organization into Guthrie’s system. Guthrie has also implemented virtual trainings, and they make the EHR available to new providers while they are completing the trainings so that they can test on what they’re learning and create their own personalization as they go. Agreement that initial training for physicians is sufficient has increased 24%, and agreement that ongoing training is sufficient has increased 30%. For more details, read the Guthrie Clinic case study.
Case Study
Door County Medical Center Improves Satisfaction through One-on-One Onboarding
After making EHR training for new physicians a priority, Door County Medical Center saw a 38-point increase in NEES. New physicians at the organization get two to four hours of in-person EHR training with a registered nurse. During this training, physicians get a brief overview of the EHR functionality. In addition to the one-on-one overview, new physicians receive two to five days of at-the-elbow support in which a registered nurse shadows them while they are seeing patients and then helps with documentation or placing orders immediately after the patient visit is over. Though nurses are typically the ones to place orders, new physicians place orders themselves at the beginning to ensure they know the process if they ever need to complete it themselves. Ongoing training consists of emails, rounding, and teach-and-learn sessions. See Door County Medical Center’s full case study for more details.
Step #6: Remeasure and Repeat
Improving clinician satisfaction with the EHR is a continuous process that requires ongoing measurement. While surveying your entire organization multiple times a year may not be feasible, the Arch Collaborative offers several options for interim measurements, including pre- and post-initiative surveys, which measure a subset of users before and after an intervention, and pulse surveys, which can be used to increase understanding of a specific group’s EHR experience. On average, organizations see significant improvement in NEES when they measure clinician satisfaction both before and after implementing an initiative targeting a specific department or goal. In these measurements, the NEES of repeat respondents increases an average of 22 points (see chart below). In contrast, repeat respondents whose organizations have measured multiple times but not for a specific improvement initiative see an average NEES increase of about 7 points.
What Is the KLAS Arch Collaborative?
The Arch Collaborative is a group of healthcare organizations committed to improving the EHR experience through standardized surveys and benchmarking. To date, over 291 healthcare organizations have surveyed their end users and over 340,000 clinicians have responded. Impact reports such as this one seek to synthesize the feedback from these clinicians into actionable insights that organizations can use to revolutionize patient care by unlocking the potential of the EHR. To participate in the Arch Collaborative, go to klasresearch.com/arch-collaborative.
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This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2019 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.