Digital Antidote

Back in January when I was deciding on what to write for my first article in the Houston Chronicle, I thought talking about physician burnout would be a worthy topic for the public to hear about. Afterall more research is linking physician burnout to lower quality healthcare, higher malpractice rates, and lower patient satisfaction. Moreover, around that time of researching this topic, Medscape just published their annual report of “Physician Lifestyle Report.”  In this report, it showed that the majority of the more than 14,000 doctors surveyed were suffering from burnout.  When they asked physicians to rate their causes of burnout, one of the dominant reasons were that there are too many bureaucratic tasks and increasing burdens of electronic health records systems (EHR).  

When you think about it, in almost every other industry the introduction of computer technology and I.T. have improved that industry, so it seems remarkable how negatively the use of computers in the daily practice of physicians this has become.

So why is the use of EHRs linked to physician burnout? To understand this answer, I think some historical context from the traditional physician practices and the involvement of the Affordable Care Act is necessary.

In 2008, the Obama administration envisioned a transition from a fee-for-service payment model for doctors to more of a value-based payment model.  Many who understand the healthcare system and public health issues also understand that there is a significant need in this country to improve our healthcare quality and control our health care costs.  So to measure quality, the Obama administration understood that a universal digital infrastructure would be essential for implementing these changes.  In 2008, less than 15% of physician practices were using EHRs.  Moreover, less than 5% of practices were using fully functional EHRs.  Many of these EHR systems lacked data-capture capabilities, order entry, or patient portal platforms.

So the Obama administration knew that creating this digital infrastructure in the healthcare system wouldn’t be an easy task. These computerized systems are costly causing challenges of high upfront costs for many physician practices and hospitals. This would have really affected doctors in private practice the hardest, but large healthcare organizations were also not immune to the financial consequences of implementing a universal EHR.

There was also the challenges of the culture change that would come with it and doctors are traditionally resistant to radical changes in their practice unless there is evidence of great benefit in their patient care.

To address these challenges of costs and cultural resistance,  the Health Information Technology for Economic and Clinical Health (HITECH) ACT, passed in 2009,  provided nearly $30 billion in incentive payments for EHR adoption and “Meaningful Use” for physician practices around the country.

The mandate for universal EHRs and incentives offered appeared to have been successful for Washington.  Less than 10 years later, over 80% of physician practices now use EHRs, and over 70% have a fully functional EHRs capable of order entry, patient portal, and data capture capabilities.

There remain many challenges from this rapid, widespread implementation of a complete EHR digital infrastructure.  For one, the hope for a healthcare IT system that is universally interoperable-meaning doctors and patients can easily share healthcare data electronically between different health systems- is still a pipe dream.

But there has been an unforeseen damage from this rapid mandate of a universal EHR system.  It has been a major contributor to the worsening physician burnout problem.

One adverse effect of EHRs is that it has changed the workflow of physicians in their practice leading to more interruptions and delays for doctors.  Before EHRs,  a patient would come see their doctor in the office after calling to make an appointment.  The doctor would see the patient in the exam room and usually did not have a computer in it.  When the doctor was finished talking and examining the patient, they would dictate that patient encounter into a telephone recorder or a tape-recorder.  That “dictation” would then be transcribed by a medical transcriptionist who would create the physical document of that encounter.   If labs or imaging were needed, then the doctor would usually have the office staff enter these orders.

Now as many EHRs which are fully functional,  many of the clerical burdens have been relegated to physicians.  At the same time, the EHR softwares are perceived to be cumbersome, unintuitive, and frustrating to use which has been problematic in the clinical workflow of an office practice. Many doctors resent that they are required to spend the majority of their time doing clerical work when the value they bring is to examine patients and make complex medical decisions and treatments for their patients.

For some physician practices, the computer has changed their relationship and communication habits with their patients.  EHRs are testing one of the most sacred traditions of physician-patient relationships and that human to human connection. For some doctors, it has taken away the time and attention connecting with their patients.  A study at Johns Hopkins showed that interns spend 12% of their time with patients but spend 40% of their time in front of computers

To be more efficient, many physicians have computers in their exam rooms. Some doctors will spend most of their time sitting in front of the computer while seeing their patients inputting what the patient is discussing and putting orders in–all while the patient is talking to the doctor.   

The physician now either has to type in the note,  use a premade template, or use a computerized voice recognition dictation system. Some doctors argue that these computer dictation systems are just not as good as a human such as medical transcriptionist.  For one there are issues with voice recognition and these computer recognition systems can be slow and cumbersome to use as well.

Furthermore, since the Affordable Care Act has shifted healthcare to a value-based model, there are now many practices which are part of an Accountable Care Organization (ACO) or they have to report quality metrics in their EHR.  This physician reliant data entry of quality metrics into EHRs has further compounded the physician burnout problem with EHRs.

Meanwhile, as doctors are required to input more data and clerical duties into their daily clinical work, many have not adapted well, and for some, it would be unsustainable since they would have to turn away patients to find more time to meet these documentation and clerical requirements.

But forget about the extra clerical and regulatory burdens posed on physicians.  The physician work-life balance has also been significantly impacted.  In a study of four different outpatient clinics, researchers found that for every one hour physicians see patients, they spend another 2 hours in front of EHR during the clinic.  Even more remarkable was that after clinic, they spend 1-2 hours of their personal time at home in front of EHR.

This use of EHR charting at home has become such a common practice that it has euphemistically been called “Pajama Time” since usually, physicians are doing this during their personal time like laying in bed with their laptop working on EHR charts for a couple hours a night.

The patients are also negatively affected by current EHR practices. “Many studies have documented lower patient satisfaction when physicians spend more time looking at the computer and performing clerical tasks,” Dr. Susan Hingle, a professor of internal medicine at Southern Illinois University School of Medicine wrote in a companion editorial in the Annals of Internal Medicine. “Patient satisfaction can affect health outcomes via adherence to the care plan and can also affect physician and hospital reimbursement, so the stakes are high.”

But what has been detrimental for doctors has been a boon for the healthcare IT industry.  In 2015, ten healthcare IT vendors accounted for 90% of the EHR market share.  Judie Faulkner, CEO, and founder of EPIC is now estimated to be worth 3.4 billion dollars, making her one of the richest tech CEOs.

I am no Luddite, many who know me, know I am a big believer in technology for not only in improving our lives but also improving healthcare.  I certainly don’t want to return to the days of paper charts. Computerized medical records are much more convenient to sort through, and as a doctor with bad handwriting–a friend once said I had the handwriting of a serial killer- EHR records are much more legible reducing the risk of medical error from illegible handwritten notes.  Yet the theoretical advantages of EHRs improving healthcare quality has seen mixed evidence so far.  It has certainly not improved in controlling costs.  So EHRs have yet to fulfill their enormous promise in clinical practice.

How EHRs were mandated into the healthcare system, and the softwares created for providers have been an abysmal failure.  The current implementation of EHR system has led to some unintentional consequences of increasing physician burnout rates.  It has been nearly 10 years since the mandatory EHR implementation, and unfortunately, the vast majority of doctors still see their EHR technology as highly unsatisfactory.

Moreover, one of the big goals of a universal EHR system to create a universal interoperable EHR system that would help improve the healthcare system communication and decrease costs has yet to become reality. So if the next Steve Jobs for healthcare IT is out there, now is your time to transform the EHR industry.