Late in the summer of 1966, I saw a local internist for the physical examination I was obliged to get before I matriculated in college. The physician, whom I’d not met before, used a large share of the encounter time to do an extensive review of systems, meaning that he asked me dozens of detailed questions about symptoms that he’d memorized in his physical diagnosis course in medical school. I had none of those symptoms. He took notes in a tiny cramped hand on an 8.5 by 11–inch sheet of paper, folded lengthwise, never looking at me, never asking me an open-ended question after the initial, “So, where will you be going to college?”
In one way, things have changed drastically since then. Thanks in large part to the federal government, which has thrown about $30 billion at health information technology since 2009, the electronic health record (EHR) has become nearly ubiquitous in U.S. practice settings. The EHR has made some things decidedly better, like providing access to a patient record from anywhere that is connected to the internet.
Though there are disadvantages, like making it possible to work from the beach on vacation, most clinicians would agree that while they are on the job, not having to scour the clinic for a paper patient record or to call the medical records department to send a chart to the hospital ward, with the attendant delay, are great stress reducers. Having the information you need when you need it in the course of taking care of a patient is invaluable. Not having that information has forever been a major source of practitioner error and stress.
But in another way, that impersonal encounter back in 1966 has a lot in common with a problem that is vexing both doctors and patients today. In her piece in the December 2018 issue of Scientific American, titled “Cultivating a Computer-Side Manner,” Claudia Wallis tackles head-on the issue of the intrusion of EHRs into the patient-provider relationship. Computers are great at supplying checklists and tabulating the responses. There is nothing intrinsically wrong with checklists. After all, would you get on an airplane with a pilot who didn’t believe in them?
But Wallis points out that these checklists, designed as much for billing purposes as for patient care (the more symptoms you ask about, the more body parts you document examining, the more the practice can charge for a visit) become a distraction from the person-to-person direct communication that underlies the therapeutic relationship. Recent studies have revealed that a clinician spends about a third of an encounter looking at a monitor screen, rather than looking at or examining the patient. Patients are indeed unhappy about their providers’ divided attention. So are clinicians.
In fact, providers are very, very unhappy. Multiple surveys estimate that 40 percent to 50 percent of doctors are at some stage of professional burnout. The cheerfully named Happy MD website lists six physical, seven emotional and nine behavioral signs and symptoms of physician burnout. Among the enumerated manifestations are fatigue, insomnia, loss of libido, self-doubt, cynicism, hopelessness, isolation, substance abuse, disordered eating, road rage, family problems and work absenteeism.
The federal Agency for Healthcare Research and Quality (AHRQ) lists the major causes of doctor burnout to be family responsibilities, time pressure, chaotic environment, low control of pace, and the electronic health record. If not the first reason for burnout, the EHR always places near the top of the list. A new EHR is a major impetus for many physicians’ decision to retire.
The problem is not just what happens in the room with the patient and the EHR. It is with the overall shape of a doctor’s workday. On average, physicians spend more time in front of computer screens than with patients. In 2013 the Journal of Emergency Medicine reported that, over the course of a 10-hour shift, resident physicians in a busy emergency room spent 28 percent of their work time with patients and 43 percent on data entry, during which they made 4,000 keystrokes.
Financial people needn’t take all the blame for the proliferation of checklists at the expense of the conversations that go into the doctor/patient relationship. Numerous intramural and extramural entities, legitimately concerned with quality, have embedded pathways and standards of care into the EHR. Electronic systems make it too easy to add a subroutine that asks clinicians to collect just a little more data.
An article published in the journal Health Affairs reported that, as of 2015, there were at least 159 publicly available measures of outpatient care and that physicians spent 2.6 hours and staff 12.5 hours per week attending to them. Insurers and government massaged clinical and billing data with over 500 insurer and 1,700 government standards. You can be dead sure that the numbers of standards and measures have grown significantly since 2015 and that today providers feel that much more pressure to comply.
What you cannot be sure of, based on an abundance of reports, is that most of these measures significantly improve real patient outcomes in the longer term. You may be able to boost one set of numbers for a while by training staff intensively and tracking the results closely. But study after study has shown that to actually make a difference in patient outcomes you have to install systems that support the new behavior and keep after staff almost forever. No matter how good your intentions, if you just keep piling onto a harried clinician’s workday more stuff to do and more data to collect, you run the risk of actually making care worse, angering patients and alienating providers. Time pressure, chaotic environment, and low control of pace are all exacerbated by overzealous oversight via the EHR.
Electronic health records are here to stay. So, what’s it going to take to relieve providers of burdens imposed on them by the EHR? It will take a real culture change, more than just jiggering a few policies or procedures. Clinicians and clinical concerns need to be placed at the forefront of EHR development and deployment. People on the front lines of patient care must not only be consulted about the EHR, they—not the administrators, accountants or technologists, not even the quality specialists—must be empowered to make most of the decisions about it.
Clinicians must reclaim our identity as healers whose foundation is built on the relationship between patient and provider. Health care information systems should be constructed in a way that facilitates these relationships. Patients’ stories need to be promoted to a position in the EHR that is equal to their data.
To date, no maker of an electronic health record has figured out how to do adequate justice to stories without sacrificing data. Automated transcription of dictated notes is a start. Artificial intelligence that can parse sentences and paragraphs into data should help a lot.
Most of all we providers need to remember why it is that we got into health care in the first place. Clinical care can be tremendously taxing because it requires making high-stakes decisions, often in the face of frighteningly incomplete data and knowledge. It’s the relationship between patient and professional that compensates for provider stress and, in the process, helps to heal patients.
That’s what keeps us clinical types from burning out. It’s certainly not the opportunity to make 400 keystrokes an hour.