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The Relationship Between Perceptions of Electronic Health Record Usability and Clinical Importance of Social and Environmental Determinants of Health on Provider Documentation

Natasha Sood, Christy Stetter, Allen Kunselman, Sona Jasani

Abstract

Social and environmental determinants of health (SEDH) data in the electronic health record (EHR) can be inaccurate and incomplete. Providers are in a unique position to impact this issue as they both obtain and enter this data, however, the variability in screening and documentation practices currently limits the ability to mobilize SEDH data for secondary uses. This study explores whether providers’ perceptions of clinical importance of SEDH or EHR usability influenced data entry by analyzing two relationships: (1) provider charting behavior and clinical consideration of SEDH and (2) provider charting behavior and ease of EHR use in charting. We performed a cross-sectional study using an 11-question electronic survey to assess self-reported practices related to clinical consideration of SEDH elements, EHR usability and SEDH documentation of all staff physicians, identified using administrative listserves, at Penn State Health Hershey Medical Center during September to October 2021.

Introduction

Systematic screening and documentation of health determinants can directly impact patient care [1–8] and research efforts [1,5]. Mobilizing this data from the electronic health record (EHR) is hindered by heterogeneous provider documentation practices and interoperability issues [1,2,9–22]. Data acquisition is also deficient with only 15.6% of physician practices and 24.4% of hospitals performing comprehensive health determinants screening per The National Survey of Healthcare Organizations and Systems Responses (2017–2018) [13]. Determinants of health include settings in which people are born, live, learn, work and age [23]. The Healthy People 2030 Initiative and The County Health Rankings Model, provide organizational schemas for health determinants [1,2,12]. These health frameworks help provide guidance on what data to capture but limitations do exist. For example, misclassification biases can result from using community level data due to limited stored environmental data points in health system EHRs. Lacking is an established standardized set of determinants or method of capture [5,13,14,19] to inform care delivery and optimization efforts.

Materials and method

We performed a cross-sectional study using an electronic survey to assess self-reported practices related to clinical consideration of SEDH elements, EHR usability and SEDH documentation of all staff physicians at Penn State Health Hershey Medical Center during September to October 2021. Staff physicians were identified using administrative listservs in the Medical Staff and Graduate Medical Education Offices. Non-study team administrative personnel in these offices distributed the survey electronically using staff physician institutional email addresses via these administrative listservs to ensure anonymous participation.

Results

A total of 2,478 staff physicians (1,800 attending physicians and 678 residents/fellows) were identified using an administrative listserv at the study institution during the project timeframe. Of this total, 201 participants completed the survey (8.1% response rate) and were included in the analysis. Table 1 reports the baseline characteristics of these participants. The majority of physicians were attendings (84%) and most practiced both inpatient and outpatient medicine (63%). Approximately 63% were primary care providers and 37.1% were specialists; percentages from each department are available in Table 1. The majority of participants were not Hispanic/Latino and there were an equal number of male and female participants.

Discussion

Generally, our data supports our hypothesis that frequency of charting of an SEDH is associated with physician perception of clinical importance or EHR usability, however, not every association measured in our study showed statistical significance. Regarding all SDHs, charting frequency was significantly associated with physician perception of clinical importance. Charting frequency was significantly associated with ease of charting for all SDHs except for housing, transportation, utilities, education, financial stability, personal safety, and access to guns. However, trends in the raw data for these SDHs do show that a higher percentage of physicians consistently charted SDHs if they perceived charting to be easy (Table 2). The lack of statistical significance could be likely due to the low overall numbers of respondents who reported that SDH charting was easy. With regards to EDH, charting frequency was significantly associated with physician perception of clinical importance for infectious disease outbreaks and access to basic appliances only.

Conclusions

In conclusion, our study results show that provider documentation frequency of an SEDH is associated with clinical utility as well as ease of charting and that providers were more likely to consistently chart on SDH versus EDH. There is nuance, however, in these associations. Though a comparable percentage of physicians reported that smoking (SDH) and infectious disease outbreaks (EDH) were vital to care, there were still notable differences in charting consistency and ease of charting between these two. Inconsistent and incomplete acquisition affects the quality and use of SEDH data so understanding the factors that promote or hinder provider capture and entry should be a central consideration in any optimization effort.

Acknowledgments

The study team would like to thank the administrative staff in the Penn State College of Medicine Department of Obstetrics and Gynecology, as well as the administrative staff in the Penn State Health Hershey Medical Center Graduate Medical Education Office and Medical Staff Office (Beth Herman and Eddie Keller), in helping to distribute the survey used in this study. The team also wishes to acknowledge the participants who provided their insights in this project.

Citation: Sood N, Stetter C, Kunselman A, Jasani S (2024) The relationship between perceptions of electronic health record usability and clinical importance of social and environmental determinants of health on provider documentation. PLOS Digit Health 3(1): e0000428. https://doi.org/10.1371/journal.pdig.0000428

Editor: Anat Reiner-Benaim, Ben-Gurion University of the Negev, ISRAEL

Received: May 16, 2023; Accepted: December 6, 2023; Published: January 11, 2024

Copyright: © 2024 Sood et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data used in this submission was collected via a secure REDCap survey at Penn State College of Medicine and Penn State Health. The authors have provided access to the raw CSV file of the data along with supporting documentation in the supplementary information S2 and S3 Appendices.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Source: https://journals.plos.org/digitalhealth/article?id=10.1371/journal.pdig.0000428#ack

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