I read the article “EHR Satisfaction: User Characteristics Matter” by Kenneth G. Adler, MD, MMM, Joel Shields, MA, and Robert L. Edsall [July/August 2010], and I would like the authors to consider another variable in electronic health record (EHR) satisfaction. I am a salaried physician in a 12-member, multispecialty medical group in the Los Angeles area. Our group is owned by a parent company that owns several other much larger medical groups. There are about 200 physicians in the medical groups combined. The EHR we use in our office was chosen and purchased by the parent company and then rolled out to each of its medical groups and to many of its contracted IPA doctors.

Most of the doctors in our medical group have been using the EHR for 18 months and are unhappy with it. The main reason for our dissatisfaction is not because of the EHR software program or because we were not involved in selecting the EHR. Actually, the EHR software has great potential for functionality and user-customization, but the dissatisfaction comes from the unwillingness of the IT support persons to change any of the templates in the EHR for fear that doing so may cause the physicians in the other groups and IPA to complain or may harm the EHR programming. In other words, our EHR has become a “one-size-fits-all” product. My conclusion is that the greater satisfaction in smaller offices comes from the ease in ability to customize the EHR to the individual doctor's practice and habits; the greater dissatisfaction in larger groups comes from the inability of doctors to effectively change the EHR program to meet their needs.

I would ask the authors to include these questions in the next survey: “How easy has it been to customize your EHR to your practice needs?” and, for doctors in larger groups, “What is your overall satisfaction with your IT department in customizing the EHR to your needs?” Then correlate those answers with the overall satisfaction of the EHR. I think they will find that the dissatisfaction with EHRs in larger groups is not in the vendor but comes from a lack of customization of the program.

Author's response:

Dr. Drummond brings up a great point. Customization both at the group and individual level is undoubtedly an important factor in satisfaction. In our first two FPM user-satisfaction surveys (2005 and 2007), we included several questions on satisfaction related to customization. These were dropped in the 2009 survey as we trimmed the number of questions substantially. The payoff for us was a much higher response rate.

Dr. Drummond correctly points out that implementation decisions commonly trump software capabilities. For those who implement and administer EHR systems, find-ing a balance between standardization and customization can be challenging. I suspect that many large groups, in their zeal to achieve standardized outcomes and in their reluctance not to have to manage the same process six different ways, err on the side of standardization.

In my view, wise EHR administration involves allowing as much customization as possible while still encouraging effective EHR use (i.e., “meaningful use”). One function that lends itself well to customization is documentation. Except in a research setting, it generally doesn't matter whether you record your patient's history using templates, macros, voice recognition, typing or transcription. Yet it does matter how you record problems, medications and allergies. Experts agree that these should be entered in a structured fashion.

The new, final meaningful-use rules will undoubtedly promote more standardization in EHR use. While this will certainly promote better quality care, further erosion in user satisfaction could be a result.