Physicians, NPs, and PAs: Where's This All Going?

Leigh Page

Disclosures October 29, 2014

Where's It All Headed?

Many physicians depend heavily on nurse practitioners (NPs) and physician assistants (PAs) to provide care within their practice, yet many physicians' views of this rapidly growing group of healthcare professionals are exceedingly ambivalent.

Doctors highly value NP/PA skills, but they also believe that these skills have distinct limitations, and many physicians are concerned that more reliance on these professionals might create a two-tier system of caregivers with different competencies.

Sandeep Jauhar, MD, a cardiologist in New Hyde Park, New York, and author of a new book, Doctored: The Disillusionment of an American Physician, owned up to this ambivalence.

On the one hand, Dr Jauhar said there's hardly anyone he trusts more than the NP who works with him in his practice. "He's been my professional partner and colleague for over a decade, and he's excellent," he said. "We have a collaborative relationship, and I think it works very well. It's not just one-way. I bounce things off of him every day."

On the other hand, he made it clear that they're not clinical equals, noting that the NP "checks in with me." And he was very concerned this April, when the New York legislature decided to loosen physician oversight over NPs. Writing in the New York Times, Dr Jauhar argued that the new law gives NPs more independence than their training should allow. The effect of the law is to "underestimate the clinical importance of physicians' expertise and overestimate the cost-effectiveness of nurse practitioners," he wrote.[1]

Many physicians share Dr Jauhar's conflicted feelings about the value of NPs-and also of PAs. A 2013 study in the Journal of the American Board of Family Medicine[2] found that 60% of family physicians routinely work with NPs, PAs, or nurse midwives. But a survey published last year in the New England Journal of Medicine[3] showed that about one third of physicians thought NPs would decrease safety and reduce effectiveness.

PAs remain under physician supervision, but NPs have been slowly and steadily winning the right to practice independently in many states. Currently, 19 states grant full independence to NPs, according to the American Association of Nurse Practitioners (AANP).

Although only a small fraction of NPs practice independently, many physicians feel that the change could alter the entire healthcare system. For example, the drive toward autonomy might prompt NPs and PAs within practices to demand their own panels of patients. And notions of equal status could affect both sides' relationships in accountable care organizations and patient-centered medical homes.

With shorter training time, NPs and PAs are simply not equal to physicians, said Roy Stoller, DO, a New York City otolaryngologist who, as a writer of test questions for otolaryngologist exams, is interested in competency. Less education means that NPs/PAs are less equipped to make accurate differential diagnoses of patients. Nurses in particular "don't have as much schooling in the 'whys' of medicine," he said. "Learning the science of medicine taught me how to think. The science helps the doctor make a successful diagnosis."

But concerns about NP/PA competence haven't been borne out by the literature. Several major studies[4-6] measuring the outcomes for NPs/PAs have put them on par with physicians, and sometimes even above. Although some find fault with the studies' methodology,[7] this research has convinced a variety of influential groups, including the Institute of Medicine (IOM) in 2010,[8] to call for NPs/PAs to be licensed to "the full extent of their education and training."

Does a Team Approach Change the Dynamic?

NPs/PAs are an integral part of "team-based" care and work in concert with doctors and other staff members to improve quality and efficiency and to lower costs. Team-based care has been endorsed by a broad sweep of organizations, including the IOM.

David Kauff, MD, is in charge of team building at Group Health Cooperative, a healthcare system in Seattle with 1100 physicians. "We are moving toward systems of care," said Dr Kauff, who is medical director for practice and leadership at Group Health. "In a system of care, the role of an NP or PA becomes increasingly important. They're going to be indispensable in how care is delivered."

PAs in particular have become "an integral and essential part" of healthcare delivery at Group Health, he said. Dr Kauff, an internist who has worked in emergency departments (EDs), said EDs were early adopters of NPs/PAs working in teams with physicians. These NPs/PAs can help triage patients so that they can get care as soon as possible.

Although physicians are expected to lead the teams, members are taught to value each other's expertise. Group Health teams are instructed to get together in a "huddle" one or two times a day to share concerns about patients. "It's an egalitarian way for each member to have a say," Dr Kauff said.

"Each person on the team has their own expertise," Dr Kauff said. In the physician's office, "there are things that PAs do better than MDs, such as sewing of a laceration or making a cast," Dr Kauff said. "They may take care of certain procedures that are in high demand," such as placing a patient's IUD.

Patients have been generally receptive to NPs and PAs. A 2013 study in Health Affairs[9] found that although half of patients would prefer a physician, many in that group would accept an NP/PA if they had to wait for a physician. Another study, in Medical Care,[10] found that patients who saw NPs/PAs were significantly more likely to be satisfied with the visit than when visiting with physicians.

NPs and PAs are widely thought to make practices more efficient, but studies have been mixed on this point.[11] Some NPs take more time with each patient than physicians do.

Meanwhile, practices are developing ever more ways to employ NPs and PAs. A joint policy statement on team-based care by the American Academy of Family Physicians (AAFP) and the American Academy of Physician Assistants (AAPA)[12] identified several ways that PAs are working within practices. They may serve as designated clinicians in specific areas such as adolescent gynecology, wound care, or diabetic counseling. They may help reduce waiting times by spending part of the day seeing same-day patients. And they may treat patients at satellite offices in remote locations.

NPs in particular pride themselves on working closely with patients and teaching them self-care techniques and use of medications. "One thing NPs are particularly good at is advocating for and involving patients in their healthcare," said Deonne Benedict, an NP who owns a small clinic in Edmonds, Washington.

Some NPs or PAs work miles away from their supervising doctors in satellite offices or urgent care clinics. Robert Hollingsworth, a PA, runs a small hospital-owned clinic in Red Springs, North Carolina, that is 20 miles away from his supervising physician. He says not having a physician onsite has made him more self-reliant. "When you're working on your own, there's a huge difference from working with a physician down the hall," he said. "But you have to know what your limit is. You have to have the confidence to say, 'I can't do this.'"

The Push Toward More Autonomy

A growing shortage of physicians has increased the demand for NPs/PAs and prompted states to allow greater autonomy. These shortages are particularly pronounced in primary care, where NPs have a much higher participation rate than physicians. AANP reports that 87% of NPs are trained in primary care, more than twice the percentage of physicians practicing in primary care. PAs have a much lower rate, with about 27% in primary care, according to AAPA.

Practices, hospitals, retail clinics, and community health centers have been driving up demand for NPs and PAs. At Merritt Hawkins, the Texas-based physician recruiting firm, requests for both groups have increased 320% over the past three years.[13]

NP and PA training programs have been expanding to keep up with demand. According to the latest figures from AANP and AAPA, there are about 192,000 NPs and 95,000 PAs practicing in the United States. The combined total is about one third the number of practicing physicians, but the NP/PA population is growing much faster than physicians, even with the recent growth of medical school graduates. According to AANP, a staggering 14,000 new NPs completed their training in the 2011-2012 academic year, and AAPA reported that no fewer than 60 new PA programs were awaiting accreditation as of May 2013.

Faced with shortages in rural and inner-city areas, states have been much more willing than doctors to allow NPs to practice without supervision. Both the National Governors Association[14] and the National Conference of State Legislatures[15] have issued reports recommending looser supervision requirements.

And this year, the Federal Trade Commission (FTC), which oversees market competition, got into the act,[16] reporting that it had been advising legislators considering changes in NP scope of practice. The FTC observed that state limitations on scope often have "political" motivations rather than being based on hard evidence.

Almost all of the 19 states that allow NP independent practice have large rural areas where physicians are scarce, but the addition of Connecticut to the list this year has implications for more urbanized states joining the trend. Independent practice is barred in most large states, including California, Texas, Florida, and New York. (Although New York loosened restrictions this year, the AANP still does not consider it an independent-practice state.) In April, however, the Florida House of Representatives passed an independent-practice bill for NPs. Although the Senate rejected it, Paul J. Dorio, MD, an interventional radiologist in Naples, Florida, who opposes the trend, said it "could be only a matter for time" before Florida allows independent practice.

Because the large states continue to have restrictions, most NPs in the country still have to follow essentially the same restrictions that every PA has to follow. These restrictions involve signing written agreements with physicians, having periodic face-to-face meetings with them, submitting to mandated chart reviews, and restricting how far NPs can practice from the physician, according to Tay Kopanos, vice president for state government affairs at AANP.

Are the Requirements Pointless?

In Kopanos' view, these requirements are an unnecessary burden. "Linking the ability of a clinician to another professional limits transparency, accountability, and outcomes tracking of individual clinicians, and limits the capacity of the workforce to effectively meet healthcare needs," she said.

In fact, the need for supervision has been challenged by many payers and policymakers as an unnecessary burden. "Nurse practitioners don't want to have to walk down the hall and ask for permission each time they want to order an x-ray or write a prescription," said John W. Rowe, MD, professor of Health Policy and Management at Columbia's School of Public Health and former CEO of Aetna insurance company. He added that health insurers are "increasingly recognizing" NPs as independent practitioners for payment purposes.

Even PAs, who don't dispute physician supervision, have been calling for some degree of autonomy. Marc Katz, president-elect of the North Carolina Academy of Physician Assistants, said in 1993 that he personally helped rewrite North Carolina's PA regulations, in close cooperation with the North Carolina Medical Society. The new law, he said, removed a requirement that PAs submit to chart reviews by their supervising physician. He said this was a drain on physicians' time and was often done perfunctorily. Now, Katz said, PAs only need to periodically meet with their supervising physician for "quality improvement meetings," making North Carolina one of the most PA-friendly states in the nation.

In North Carolina, PAs can even own their own practices, but they are not considered independent because they still must report to a supervising physician. For example, Robert Hollingsworth owned his practice for six years before selling it to a hospital system. Handing operations over to the hospital system "was a tremendous relief," he said, citing the same reasons that small practices are challenging for physicians. "What kept me up at night was having to make payroll for four other people," he said.

NPs are far more likely than PAs to own their own practices, but only an estimated 6000 NPs, or about 3% of all NPs, actually do so, according to Lusine Poghosyan, PhD, a nurse who is assistant professor at Columbia School of Nursing in New York.

Dr Poghosyan has studied the barriers to independent NP practice, which she said include lack of recognition by some insurers, lack of privileges in some hospitals, and lower reimbursements. Medicare, for example, pays NPs 85% of what physicians get and won't pay for home services ordered by NPs unless a physician signs the order.

Despite the barriers, independent NPs are slowly being accepted into the mainstream. The National Committee for Quality Assurance (NCQA) has changed policy and now recognizes practices led by NPs or PAs as patient-centered medical homes.[17] In 2009, Life Long Care, a small NP-run practice in New London, New Hampshire, was the first nurse practitioner-led practice in the nation to reach the highest level of PCMH certification, level 3, from NCQA.

"An NP-run practice is a huge challenge," said Sean Lyon, APRN, an NP and medical home project director at Life Long Care. Working with eight physician practices in the state in a medical home project run by WellPoint, the NP practice has reported the third lowest expenses in the group. Lyon said this reflects high-quality standards. "If we were doing such a terrible job [with quality] we'd be losing all sorts of money in extra services," he said.

Should Physicians Fight the Trend or Help Direct It?

The increasing dependence on NPs and PAs is a concern for many physicians. A 2013 survey by Deloitte[18] found that 55% of doctors believe that primary care services will be delivered by nonphysicians over the next decade, and 65% believed that increased dependence on nonphysicians is likely to lower the quality of care.

Leaders of the AAFP have been particularly alarmed about the trend. Writing on the AAFP website in 2012, Roland Goertz, MD, then chair of the AAFP, warned that the country was heading toward a two-tiered system of care. "Granting independent practice to nurse practitioners would create two classes of care: one run by a physician-led team and one run by less-qualified health care professionals," he wrote.

Dr Rowe, the former Aetna CEO, accuses physicians opposing NP independent practice of protecting their own economic interests. "This is a turf battle in which physicians are threatened over issues relating to professional pride and money," he said. But even many specialists, who do not stand to compete with NPs because of their heavy involvement in primary care, are also alarmed about the trend. "This is not primarily a question of lost income to family practitioners," said Dr Dorio, the interventional radiologist in Florida. "The main concern is an erosion of clinical expertise, which may result in a decrease in overall quality of care."

On the other hand, as the AAFP fights widened scope for NPs, leaders of the American College of Physicians (ACP) have a considerably more muted response. "Physicians shouldn't get panicky about the drive to independent practice," said Yul David Ejnes, MD, an internist in Cranston, Rhode Island, and a past ACP chair. "This is the direction we're going in, but it's not going to happen quickly."

Furthermore, even in independent-practice states like his own, "this fear that NPs in independent practice will be stealing patients away from physicians is ludicrous," said Dr Ejnes, adding that he wasn't expressing official ACP policy. In Rhode Island, "very few NPs take advantage of the law," he said. "They like to be part of a team." Besides, he added, "if the small practice model isn't working well anymore for a lot of physicians, why would it work for NPs?"

Dr Ejnes thinks it's much better to work with NPs in the interest of better patient care than to fight a rearguard action against them. In 2008, he and other ACP leaders invited leaders of the AANP to ACP headquarters to chat about common goals. It was a historic event. The NP leaders "couldn't recall ever being invited for a talk by a major physician organization," Dr Ejnes said. They had dinner together and "we spent the whole next day talking about different situations. When we got down to the level of the patients, we started finding some common ground." Everyone agreed to avoid words like supervision, autonomy, and independence. "Those words make everything grind to a halt," Dr Ejnes said.

Dr Ejnes added that physician supervision, in addition to being resented by many NPs, is often pointless. "In a busy practice, supervision can exist in name only," he said. "You can't be constantly monitoring in real time. By the time you find out that something went wrong, the damage has been done."

However, Dr Ejnes stressed that NPs and PAs are "not interchangeable" with doctors, and that NPs and PAs in his practice don't have their own panels of patients, as they do in some other practices. Dr Ejnes said physicians are still superior in differential diagnoses of new patients. He also suspects that NPs and PAs order more tests because they may be less sure of their diagnoses, but he added that he had no proof of that.

What Are the Limits on NPs' and PAs' Responsibilities?

The movement to greater autonomy for NPs and PAs is complicated by a lack of clear limits on NP/PA clinical skills. Traditionally, each supervising physician defined those limits in the written agreement with each NP/PA, but there is no universal set of skills and limitations that applies to all NPs and PAs.

Policymakers say NPs and PAs can take care of the less challenging cases, but don't try to define just what those cases are. Maria Schiff, author of the National Governors Association's paper on NP independent practice, wrote that "with NPs playing a more prominent role in providing ongoing patient care in a team model, primary care physicians should be freed up to perform the tasks that only physicians have been trained to perform," she wrote.

This sounds simple, but it gets complicated when whole states rather than individual physicians regulate what NPs can do. When physicians supervise NPs and PAs through a written agreement, they can consider that person's individual skills, but state laws can't be fine-tuned like that. Some independent-practice states like Connecticut require newly graduated NPs to be under supervision for two or three years, but even experienced NPs' skills may vary widely.

As NP training falls under more scrutiny, the nursing profession is lengthening NPs' required amount of education by about one to two years. By 2015, all NPs who start training must earn a doctorate of nursing practice (DNP), which requires four years of study, compared with two to three years for the old master's degree. And before entering NP training, candidates must have a bachelor of science of nursing (BSN) degree, which requires completing four years of undergraduate study in nursing. That means a DNP spends a total of about eight years studying nursing. In most cases, nurses practice for a few years between getting their BSN degree and entering a DNP program, but there are also fast-track programs in which nurses can get a degree all at once.

NP training, however, tends to be less demanding than that of physicians, said Hugh Parker, MD, a cardiologist in Eureka, California. He remembers his wife going through the fast-track NP program at Yale School of Nursing while he was in residency training. In the Yale program, "all of them were very smart," he said, "but the clinical work was not as demanding as in medical school clerkships, in terms of the number of hours that are required, and there's no residency."

The new DNP programs have doubled the amount of clinical training to 1000 hours, according to a blog post by David G. O'Dell, DNP,[19] president of Doctors of Nursing Practice, an informational service for NPs. "The extra clinical hours could be considered a residency," he wrote. "This was the intent."

However, the 1000 hours of clinical training is still well below what doctors get, and Dr Parker is worried that the shorter educational pathway for NPs will become a shortcut for people who would otherwise have gone to medical school. "Allowing a shorter pathway to the same functional result as becoming a physician undermines the principles of medical training that have developed for good reasons," he said. Like Dr Ejnes, he thinks the abbreviated training affects diagnostic skills. "NPs can treat basic medical problems, such as uncomplicated hypertension, asthma, and high cholesterol, but primary care also involves patients with less obvious problems."

How do independent NPs deal with patients who have complicated cases? Deonne Benedict, the independent NP in Washington State, said she refers complicated cases to specialists, but not because her training is inferior. "I don't work with some very complex issues such as frail elders or significant heart failure, but I think that is pretty standard for family practice," she said.

What Should Still Be Done

As NPs and PAs take over more responsibility for patient care, what can be done to ensure the best patient care?

Dr Parker said the role of NPs and PAs has to be better defined. "I do think there is a role for NPs and PAs, but the big unanswered question is what that role is," he said. "We need a system that can transition care from them to a higher level of care, just like an internist would consult the cardiologist." That would require writing specific guidelines on referrals.

Dr Parker also thinks NPs and PAs should undergo a form of residency training. Dr Stoller, the New York otolaryngologist, agrees. This could be built on requirements by states like Connecticut, such that new NPs have a couple of years of supervision. At this point, "there is not a lot of learning going on" in these arrangements, he said, but "it could be made into something more like a preceptorship than a residency."

Such arrangements, however, would add to NPs' training expenses and would require cooperation between boards of medicine and nursing in each state, which does not always exist. However, the Federation of State Medical Boards, which oversees physician boards, has been working for several years with organizations representing the boards of nursing and other healthcare professions to establish principles on scope of practice.[20]

Whether or not such reforms are implemented, Dr Rowe said physicians cannot stop NPs and PAs from taking a much larger role in the provision of healthcare. As access to coverage expands under the Affordable Care Act, "it's a hollow promise to offer someone health insurance if they can't get access to a healthcare provider," he said.

Dr Dorio agreed that there's a great deal of pressure to expand NPs' and PAs' roles, but he cautioned that these changes have unintended consequences that may not be fully understood. "The goal of expanding scope of practice was to get NPs and PAs to work in underserved areas, but you can't really control where they go or what they do," he said.

Latest in Family Medicine/Primary Care



Medscape EHR Report 2014

Leslie Kane; Neil Chesanow  |  July 15, 2014



  1. US Department of Health and Human Services. Doctors and hospitals' use of health IT more than doubles since 2012. May 22, 2013. Accessed June 26, 2014.

Contributor Information

Leslie Kane
Executive Editor
Medscape Business of Medicine

Neil Chesanow
Senior Editor
Medscape Business of Medicine

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Medscape EHR Report 2014: Physicians Rate Top EHRs
Electronic health records (EHRs) have changed the way physicians practice medicine. Medscape invited physicians to participate in a survey of current EHR use; 18,575 physicians across 25 specialties responded during the period from April 9, 2014, through June 3, 2014. They answered questions about their use of an EHR and rated their systems in terms of overall ease of use and other performance traits, as well as their satisfaction with the EHR vendor. Physicians also described how their EHR affects practice operations and patient encounters. The results give an eye-opening portrait of how EHRs are affecting medical practices.

Are You Using an EHR?
EHR use has penetrated the physician market to the point where physicians who don't use one are an increasingly dwindling group. Over 80% of physician respondents say they now use an EHR. This is in line with what the Centers for Disease Control and Prevention (CDC) reported in 2013: that 78% of office-based physicians use an EHR.

If one adds in the 4% of our respondents who are currently installing or implementing an EHR, and the 6% who plan to purchase or start using an EHR in the next 1-2 years, that should bring EHR market penetration to over 90% in the near future. Only 7% of our physician respondents have no plans to buy or use an EHR in the next 1-2 years.

Are You Using an EHR (vs 2012)?
In Medscape's 2012 EHR Report, 74% of participating doctors said they were currently using EHRs, and another 20% said they were either in the process of installing or implementing an EHR, or planned to purchase or start using an EHR in the next 1-2 years. In our 2014 report, the percentage of current users climbed to 83%, with another 10% of soon-to-be users of EHRs.

The percentage of physicians who have no intention of switching to an EHR has remained fairly constant. In 2012, 7% of respondents had no plans to buy or use an EHR in the next 1-2 years; in 2014, the percentage dropped slightly to 6%. They say they're avoiding EHRs because they interfere with the doctor-patient relationship, are too expensive, and/or the incentives and penalties aren't worth the trouble.

Who's Using an EHR?
More than half of respondents (56%) using an EHR are part of a hospital or health system network using their institution's EHR. This partly reflects the fact that a majority of hospitals are now using EHRs. As of 2013, more than 80% of eligible hospitals have demonstrated meaningful use of EHRs.[1]

It also relates to the fact that many doctors are leaving the financial headaches of private practice to become salaried hospital employees. Hospitals have been purchasing physician practices, and the number of employed physicians has risen in recent years.

Only 39% of physicians using an EHR are in independent practice using their own EHR. This partly reflects the fact that independent practices are declining in number, and also that many such practices are run by older physicians nearing retirement, for whom the cost of investing in an EHR, and the steep learning curve, aren't worth it.

Most Widely Used EHRs
Epic and Cerner, two of the earliest EHR vendors, were first and second among our survey participants in usage in 2014 (23% and 9%, respectively). Both focus on hospitals, health systems, and large physician practices.

However, the difference in usage for other widely used EHRs is not large. eClinicalWorks, for example, is used by 6% of our respondents, Practice Fusion by 3%, Amazing Charts by 1%, and e-MDs by 1%, suggesting a tight horserace for market position in the small to medium-size physician practice sector.

Almost a quarter (22%) of respondents use systems other than those listed. More than 500 EHR vendors offer certified EHRs. Among those cited more regularly by respondents were Aprima, Quest Diagnostics' Care 360, CureMD, DocuTap, HealthFusion's MediTouch, Kareo, and Medicat.

Top Five Most Widely Used EHRs vs 2012
There were no dramatic changes in the five most widely used EHRs since Medscape's 2012 survey. In 2012, Epic was the most widely used EHR (22%); in 2014, Epic stayed on top (23%).

Allscripts was rated second in usage in 2012 (10%); in 2014, Allscripts' two EHRs (Enterprise and Professional) garnered 8% of usage, putting it in third place. Cerner claimed the same percentage of users over 2 years (9%), as did eClinicalWorks (6%).

Most Widely Used EHRs by Practice Situation
Epic dominates the EHR market for hospitals and health systems, with 37% of users, nearly three times as many as Cerner, its next-largest competitor, with 13% of hospital users.

Ronald Sterling, CPA, MBA, Principal of Sterling Solutions in Silver Spring, Maryland, is a national EHR expert and the author of Keys to EMR Success. "The lack of diversity is basically due to the fact that a number of hospitals, and even health systems, require use of specific products by their employee doctors," he says. "The decision is not up to the doctor. Therefore, they are going to have a tendency to use a more limited set of products."

Independent private practices with their own EHRs, including many smaller practices, generally use a different set of products. More than a third (34%) use "other systems." eClinicalWorks rated first in usage (10%), and NextGen and Practice Fusion tied for second place, with 8% each.

Most Widely Used EHRs by Practice Situation (cont'd)
Although many EHRs are less widely used, it's worth noting that several were rated highly in categories such as ease of use and overall physician satisfaction.

The Top Rated EHRs
Survey participants were asked to rate their EHRs by several key criteria, including ease of use, vendor support, overall satisfaction with the product, how well it connects with other systems, and usefulness as a clinical tool. We used those scores to develop the ratings shown in upcoming slides. In this and forthcoming slides, a rating of 5 is excellent, 4 equals good, 3 equals average, 2 is below average, and 1 is poor.

The highest-rated EHR, with a score of 3.9, is the Veterans Administration EHR: VA-CPRS. It's regarded as one of the best overall by our physician respondents. Practice Fusion and Amazing Charts tied for second in the ratings for overall user satisfaction (3.7). Medent and e-MDs tied for third place in the ratings (3.5).

Five Top Rated EHRs vs 2012
The same 5 EHRs that physicians rated highest in Medscape's 2012 report are again the top 5 in our 2014 report. Amazing Charts, rated number one in 2012 (with a score of 4.2), slipped to the number-three spot in 2014 (3.7). Some EHRs rated higher in certain attributes — for example, ease of use, user satisfaction, and clinical usefulness — than others, so a similar overall score doesn't necessarily mean that the EHRs performed equally well in the various EHR attributes measured.

Why such variation in ratings? One reason is that earlier products focused on creating an acceptable E&M note, says Ronald Sterling. When care and clinical management, quality, and meaningful use became important, older EHRs had to be retrofitted to deal with the new issues, with varying degrees of success.

Top Rated EHRs by Practice Situation: Hospitals and Health Systems
Among survey participants who are part of a hospital or health system network and are using that entity's EHR, the Veterans Administration EHR, VA-CPRS, led the pack in overall ratings, with a score of 3.9.

No EHRs had an overall score of 4 or higher. Several reasons are possible, says EHR expert Ronald Sterling. "EHRs have basically been focused on creating E&M-acceptable documentation for office visits, but physicians want better tools to manage care and track patients," he says. "Meanwhile, EHR vendors have been overly focused on meeting the demands of meaningful use rather than addressing the focused needs of doctors."

In addition, "ease of use is still a significant stumbling block, with physician productivity a continuing problem," he says. "If you cannot get the EHR to support doctors at their speed, then they are not going to consider their EHR any better than average."

Doctors may also use one EHR in the office and another at the hospital. "Doctors are recording information in the hospital EHR that should be in their own records but may be difficult to transmit," he says.

Top Rated EHRs by Practice Situation: Independent Practices
Among independent practices using their own EHR, VA-CPRS scored highest (4.1), with Amazing Charts, Practice Fusion, and Epic tied for second place in the ratings (3.7). Epic is among the EHRs in longest use (over 20 years), reengineered versions of which have been adopted by Kaiser Permanente, Geisinger Health System, and other integrated delivery systems.

Amazing Charts and Practice Fusion, popular in smaller practices, also appear popular with respondents in hospitals and health systems using their entity's EHR. However, EHRs designed for smaller practices aren't used by hospitals. Rather, physicians who are part of a hospital or health system may use EHRs for smaller practices, even though the entity itself may use a more heavy-duty system such as Epic or Cerner. A hospital may not want the expense of installing its EHR in a physician practice, Sterling notes. "Epic for doctors is not cheap!"

Top Rated EHRs for Ease of Use
Ease of use, the most important category for many physicians, is measured by several factors: "easy to learn," "ease of data entry," "ease of EHR implementation," "reliability," and "overall ease of use." For many physicians, "ease of use" determines their overall perception and experience with the EHR, affecting patient interactions and time spent documenting.

Amazing Charts, which is not used by hospitals and health systems but is more popular with smaller practices, was rated most highly, with a score of 4.0 for overall ease of use. Practice Fusion and VA-CPRS tied for second (3.9 each) in ease of use; both also scored highly in those attributes in 2012.

Top Rated EHRs on Satisfaction
Satisfaction with EHRs includes various key attributes that are critical to the EHR experience.

Value for the money is related to, among other factors, the complexity of the system compared with what it offers. Some EHRs for large hospital systems contain far more extensive features than do some EHRs for smaller practices, and consequently cost much more, particularly in terms of software and installation.

"Sometimes it takes years for older products to update their look and operation to take advantage of new technology," EHR expert Ronald Sterling points out. "It can be difficult to retrofit a new capability into an older piece of software. For example, the way e-prescribing works in older EHRs may not be as cool as newer implementations. Some older products don't even do as good a job with the Microsoft Windows interface or images."

Practice Fusion, which rated highly on "value for the money," is billed as a "free" EHR with an "ad-supported model."

Top Rated EHRs for Vendor Support
Vendor support is a key to satisfaction with one's EHR. Some physicians have reported that after their EHR was installed, the vendor was difficult to reach, and the practice lost time trying to work around or solve EHR problems. Not surprisingly, the top five EHRs in overall satisfaction also head the list of top rated EHRs for vendor support.

Practice Fusion was highest rated both in "adequacy of vendor training program" (3.7) and "vendor continuing customer service" (3.8), followed by Amazing Charts (3.5 and 3.8, respectively), VA-CPRS (3.5 and 3.6, respectively), e-MDs (3.4 and 3.3, respectively), and Medent (3.3 and 3.6, respectively).

It's worth noting that Practice Fusion, Amazing Charts, and e-MDs are cloud-based systems that are intrinsically easier to support than installed, office-based systems. With the former, the vendor's tech staff can immediately troubleshoot an EHR problem remotely via the Web. With office-based systems, a tech must often physically visit a practice to troubleshoot, a more complicated and costly operation. The three systems rated lower in vendor support — McKesson (2.7), Meditech (2.7), and NextGen (2.6) — are office-based.

Top Rated EHRs for Connectivity
Medscape asked about EHR connectivity across four domains: with diagnostic devices (eg, ECGs, laboratory information systems); practice management systems; reference and hospital labs; and other physicians (especially in supporting electronic referrals).

The Veterans Administration's VA-CPRS rated highest, scoring 4.0 or better in all domains measured. Epic came in second in three of four domains (3.5-3.7), although third-rated Athenahealth outscored it in the "works with my practice management system" domain (3.9 vs 3.6, respectively).

Connectivity becomes increasingly more important as concepts of "care coordination" take hold, and also as hospitals and private practices work to make their operations more efficient.

Scores in the last domain, "connectivity with other physicians," were not typically high. According to the Office of the National Coordinator for Health Information Technology (ONC), only a minority of physicians with EHRs from different vendors are exchanging clinical summaries of patient visits with other physicians.

Top Rated EHRs on Usefulness as Clinical Tools
The use of an EHR as a clinical tool is one of its most important functions. Physician participants rated their EHRs in four domains. VA-CPRS scored the highest in all aspects of use as a clinical tool, including appropriateness of clinical content, ability to support the physician's workflow, patient services, and patient portal.

EHRs' Effect on Your Practice Operations
Despite complaints that EHRs make documentation too burdensome, 63% of our respondents said that an EHR improves documentation; only 27% disagreed. Among participants, 39% felt that EHRs improve collections; only 9% disagreed.

Responses overall showed that physicians are somewhat split in whether they like or dislike their EHRs. Thirty-four percent of participating doctors maintained that an EHR improves clinical operations, yet 35% said it worsens them. Thirty-two percent felt that an EHR improves patient service; 38% said it worsened patient service.

Ten percent of respondents listed other ways that the EHR affects practice operations. A representative sample includes: "E-prescribing is awesome"; "More organized"; "Legibility"; "Accessible from home after hours"; and "Saves all my data in one place."

EHRs' Effect on Patient Encounters
One of the most dramatic differences since our 2012 survey shows up in how physicians feel that an EHR affects the doctor-patient relationship. In 2012, 36% of respondents said the EHR had a positive impact, 30% said it had a negative impact, and 34% said it had no impact on patient encounters.

This year, however, some responses were significantly more negative. For example, 70% of respondents said the EHR decreases their face-to-face time with patients, and 57% said it decreases their ability to see patients. Still, about a third (35%) said the EHR improves their ability to respond to patient issues, and 33% said it allows them to more effectively manage patient treatment plans.

Satisfaction With EHR Vendor
Dissatisfaction with EHR vendors has been a perennial sore spot for many physicians. Our survey pointed out encouraging news, although there's still room for improvement. Fully 42% of respondents said they were either very satisfied or somewhat satisfied with their vendor. Less than a fifth (17%) were neutral, and a third (33%) were either somewhat dissatisfied or very dissatisfied.

A small percentage of respondents (9%) don't interact with an EHR vendor, most likely because they are employees or work in large group practices, where vendor interaction is handled by a site administrator or other staff member.

Has Your EHR System Become...More Comfortable to Use Over Time?
Familiarity seems to be vital in using an EHR. While physicians new to EHRs often find them hard to use, use over time appears to make a big difference.

In our 2014 report, 81% of respondents agree that their EHRs have become easier and more comfortable to use over time; only 19% disagree. The likelihood is that practice may not make perfect, but it does enhance the experience.

And as far as managing one's staff, EHR expert Ronald Sterling says that "'managing staff' includes being able to assign them tasks, move issues and messages around the office, and document the completion of patient service items, as well as allowing doctors and supervisors to follow up on when a given item was completed and which items are still open and need to be addressed or upgraded."

Just over half of our respondents (53%) feel that their EHRs do not help with these issues. "The reason," explains Sterling, "is that some EHRs do not have workflow tools to meet all of these requirements." Office workflow and staff management capabilities, he adds, are not requirements for certified EHRs.

Will You Keep or Switch Your EHR?
Despite the fact that many physicians dislike their EHRs, there's no mass migration to new systems among our survey respondents.

Fully 84% of participating physicians say that they plan to keep their EHRs. Many physicians, particularly those who are employed, don't have a choice in whether or not to keep their current system.

This year, 16% of physicians are planning to switch EHRs for a variety of reasons, some by necessity: 5% are switching because their job has changed; 2% because the vendor was not certified for meaningful use Stage 2; and 1% because the vendor went out of business.

Do You Have Patient Privacy Concerns?
What a difference two years makes!

In our 2012 EHR Report, patient privacy concerns were barely on the radar screen of respondents. At that time, fully 77% of participating physicians said they had no patient privacy concerns.

However, in 2014, only 17% of survey participants said they had no EHR-related patient privacy concerns.

"I think this greater awareness is from hospital training, as well as physicians who had to return their EHR incentive money, since they did an inadequate security risk assessment," says EHR expert Ronald Sterling.

"The real risk for small practices," Sterling observes, "is that they do not have appropriate policies and procedures and fail to train their staffs in HIPAA privacy and security requirements."

Where Do You Stand on Meaningful Use?
In 2012, 44% of respondents said they had already attested to meaningful use, 31% said they planned to attest within the year, and 11% said they planned to attest sometime after 2012. In our 2014 report, 78% of participating physicians said they were attesting to meaningful use Stage 1 or Stage 2 in 2014.

On the other hand, the number of physicians who say they will not attest is growing. In 2012, 14% of survey respondents said they wouldn't bother to attest. In 2014, 16% said they will never attest to meaningful use requirements, and another 6% of participants said they are abandoning meaningful use after meeting the requirements in previous years.

Thus, 22% of physicians surveyed this year are opting out of or disregarding the meaningful use program.

Web-Based or Installed EHR?
The percentage of doctors using installed EHRs is declining as the percentage of those using Web-based EHRs is growing.

In our 2012 survey, 46% of the respondents said they had installed EHRs; 21% had Web-based EHRs. In our 2014 survey, 36% of participants said they use an installed EHR; 29% had Web-based EHRs. Those percentages are likely to widen in the years to come. (A large percentage of physicians [34%] didn't know whether their system was Web-based or installed.)

"In a lot of respects, cloud-based systems are less problematic," says Ronald Sterling. These systems have fewer security problems, he says, because a server isn't physically in the office. Another issue is updating an EHR's drug compendium, which can take months with in-house systems, whereas "the cloud-based systems are much faster at posting changes," Sterling says.

Type of EHR System by Practice Size
In Medscape's 2014 report, just over one third (35%) of practices with one to nine physicians in the practice used an installed EHR. In our 2012 report, that number was 30%.

Among larger practices, there's a significant difference in use of Web-based or installed EHRs. In groups of 25 or more physicians, 38% had an installed EHR, but only 20% had a Web-based EHR.

Cost per Physician to Purchase and Install
Are EHRs getting less expensive? Despite a growing number of relatively economical Web-based alternatives, the overall answer appears to be no. In 2014, for example, only 8% of doctors paid less than $10,000 per physician for their EHRs, according to survey participants, and only 7% paid $10,000-$34,999. In our 2012 survey, the percentages were 5% and 8%, respectively.

In 2012, only 7% of respondents said their EHR system cost over $50,000 per physician to install. In 2014, almost a quarter (23%) of respondents said their EHR system cost that much.

More than half of the respondents are unaware of the cost of the EHR, reflecting the large percentage of employed physicians who are not privy to cost information.

Monthly Fees per Physician for a Web-Based EHR System
A benefit of Web-based EHRs is that they are generally less expensive than installed systems. Software upgrades, drug compendium updates, and other changes are all done online, EHR expert Ronald Sterling points out.

The costs, however, are creeping up.

In 2012, only 4% of survey respondents said they were paying over $700 per month for monthly fees; in 2014, 12% are paying that amount.

Why You Don't Use an EHR
The number-one reason that physicians say they won't use an EHR is that EHRs interfere with the doctor-patient relationship (40% of responses). Few physicians, even ardent EHR users, would disagree with that.

Number two on the list is that EHRs are too expensive (37% of responses). Besides the cost of the EHR, there are expenses involved in switching all current paper records to electronic records, and there is also lost work time during the transition and switchover. For doctors nearing the end of their careers, the cost and effort are not worth it. (Note: Respondents were allowed to choose more than one answer.)

The third-most-cited reason — that the incentives offered and penalties levied by the Centers for Medicare & Medicaid Services (CMS) aren't worth the hassle of adopting an EHR (32% of responses) — is something that a number of doctors have concluded.

Advice From Other Physicians
In our 2014 survey, we asked respondents to offer advice to other doctors based on their experiences with EHRs. Over 11,500 physicians did. A common theme: Many doctors don't do enough homework prior to purchasing an EHR and then are unpleasantly surprised.

Homework, our respondents say, consists of visiting the offices of your colleagues to see how their EHRs work; attending specialty society conclaves where you can test-drive many EHRs and speak with attendees about their experiences; and visiting online chat rooms for EHR users to view their comments and pose your own questions.

Another common observation: Many physicians aren't sufficiently trained in EHR use before going live — a key reason why practice workflow often suffers. In addition, if you plan to customize your EHR, you should be thoroughly versed in how it functions, because an error made on one screen may create systemic errors.

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Authors and Disclosures


Leigh Page, Freelance healthcare writer, Chicago, Illinois

Disclosure: Leigh Page has disclosed no relevant financial relationships.


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