Doctors' Dissatisfaction With EHRs May Be 'Early Warning of Deeper Quality Problems'
October 18, 2013 - 10:17 AM
By Susan Jones
Electronic health records (EHRs) are a source of frustration to many physicians, says a new study conducted by the RAND corporation and commissioned by the American Medical Association.
Electronic health records are a source of frustration to many physicians, according to a study on physician satisfaction sponsored by the American Medical Association.
The findings could serve as an "early warning of deeper quality problems developing in the health care system," the AMA said.
The study, conducted for AMA by the RAND Corporation, found that doctors who perceived themselves or their practices as providing high-quality care reported better professional satisfaction.
Electronic health records (EHRs) were a source of both promise and frustration, the Rand study found.
Although physicians tend to like the concept of EHRs, those surveyed said that current EHR technology interferes with face-to-face discussions with patients; requires physicians to spend too much time performing clerical work; and degrades the accuracy of medical records by encouraging template-generated doctors' notes.
I believe the title should have been "Doctors' Dissatisfaction With EHRs Is A Warning of Deeper Quality Problems". The academic-style fudge words "may be" and "early" are disposable.
"Physicians [i.e., all of them - ed.] believe in the benefits of electronic health records, and most do not want to go back to paper charts," said Dr. Mark Friedberg, the study's lead author and a RAND scientist. "But at the same time, they report that electronic systems are deeply problematic in several ways. Physicians are frustrated by systems that force them to do clerical work or distract them from paying close attention to their patients."
Dr. Friedberg commits a faux pax symptomatic of an amateur scientist (or of a politician). That is, making a statement that seems to speak for all physicians, and then for "most" physicians. Clearly he didn't interview "most" physicians. I know many who see the EHR as bureaucratic invasion of little clinical utility, and would gladly dump the poorly-engineered EHRs foisted on them that "interfere with face-to-face discussions with patients; require physicians to spend too much time performing clerical work; and degrade the accuracy of medical records" for good old-fashioned paper, supplemented perhaps with document imaging systems that make the notes available anywhere, anytime.
... Health and Human Services Secretary Kathleen Sebelius has said that EHRs will lead to "more coordination of patient care, reduced medical errors, elimination of duplicate screenings and tests, and greater patient engagement in their own care."
Sebelius is parroting others; there is little or no robust evidence supporting such a grandiose assertion (or, typical of today's politicians, she's simply lying; the reader can decide which).
For 2014, some commonsense observations and recommendations on EHRs:
1) The pioneers in the 1950's and 1960's developed systems and experimented with their use in an environment far freer of the bureaucratic need for massive amounts of ultra-taxonomized data than today, where visits were not forced to be time-limited for "productivity", and where clinical notes were pithy and terse, as they were for patient care, not bureaucratic satiation. The pioneers likely could not have conceived of what clinicians are being called on to enter manually, in 2014. (I was taught Medical Informatics by some of those pioneers.)
2) The pioneers never intended to add uncompensated burdens onto clinicians. They intended to help clinicians practice medicine more smoothly, not in a time-starved and robotic, slave-to-the-machine fashion.
3) The health IT industry and its health IT designers, and the largely medically-incompetent data processing/merchant computing personnel in hospital IT departments, appear to have not cared less about these real-world HIT issues - as evidenced by their products - until the pressure was put on by users, resulting in studies of IT safety by the Institute of Medicine (http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html) and of IT usability by NIST (http://hcrenewal.blogspot.com/2010/12/nist-provides-healthcare-it-industry.html) in just the past few years.
With these factors in mind:
... AMA noted that some medical practices are experimenting with ways to reduce physician frustration by hiring additional staff members to perform many of the tasks involved in using electronic records, such as data entry.
Actually, the use of clinicians as computer data-entry clerks was the real experiment, an experiment whose failure is becoming increasingly apparent.
The "experiments" with hiring of data entry clerks should be made official healthcare policy as follows:
1) Physicians and nurses should be relieved of the burden of data entry into computer interfaces (as opposed to merely viewing) nearly entirely. Data entry cannot be done under the real-world conditions of patient care in 2014, for most specialties, without compromising the focus on patient care (let alone clinician morale).
2) Considering the hundreds of millions per organizations spent on theses systems, a pool of data entry clerical staff can well be afforded, hired and trained to transcribe data into computers from clinicians' paper notes, using specialized forms where necessary.
3) Those same paper notes can be rapidly imaged into a document management system (e.g., Documentum, http://www.emc.com/enterprise-content-management/documentum-platform.htm; I managed a pharmaceutical department of ~55 people and a $13 million budget using such a system) and made available before transcription. The note images can also serve as a supplement to data viewing screens in the EHR, which at least in 2014 are themselves poorly engineered from the perspective of optimal presentation of information.
4) The workflows for such arrangement are known to me; I created such an environment in a busy invasive cardiology department, a critical care area performing more than 6000 procedures/year and responsible for 25% of the organization's revenues - fortunately having been able to neutralize and marginalize an IT department seemingly hellbent, perhaps through ignorance, on sabotaging the effort. See "Essential Value of Medical Informatics Expertise in High-Risk Areas: an Invasive Cardiology Example" at http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story. The offloading of data entry by clinicians into the computer, and the use of special paper forms for the clinicians, worked exceptionally well in allowing the clinicians to focus on what really matters most - patient care.
5) If healthcare organizations insist on direct clinician data entry, then clinicians' time doing so should be fairly compensated. Lawyers generally earn from $250/hr and up for profession-related clerical work, like creating legal briefs and letters. I think physicians should do at least as well. (If readers believe clinicians should take on this considerable burden and not be fairly compensated, I'd like to hear why.)
6) If healthcare organization leaders truly believe the EHR hyper-enthusiasts, the expense of the clericals will be far offset by the "billions and billions" saved by these systems.
a) If they don't believe the EHR hyper-enthusiasts, they should be far more skeptical of implementing such systems and imposing the mission-robbing burdens on their clinicians in the first place.
7) These measures will free industry resources for doing what really matters most in clinical care, namely, health IT robustness (freedom from error, security, etc.) and optimal presentation of information customized for the needs of the many different clinical specialties and subspecialties.