The patients vs. paperwork problem for doctors

Every doctor I know has been complaining about the growing burden of electronic busywork generated by the E.M.R., the electronic medical record. And it’s not just in our imaginations.

Danielle Ofri MD, The New York Times November 14, 2017

The hard data have been rolling in now at a steady pace. A recent study in the Annals of Family Medicine used the E.M.R. to examine the work of 142 family medicine physicians over three years. These doctors spent more than half of their time — six hours of their average 11-hour day — on the E.M.R., of which nearly an hour and a half took place after the clinic closed.

Another study, in Health Affairs, tracked the activities of 471 primary care doctors over a three-year period, and also found that E.M.R. time edged out face-to-face time with patients.

This study came on the heels of another analysis, in the Annals of Internal Medicine, in which 57 physicians were observed directly for 430 hours. The researchers found that doctors spent nearly twice as much time doing administrative work as actually seeing patients: 49 percent of their time, versus 27 percent.

These study results hovered over my head as I worked through a recent clinic session, most of which felt devoted to serving the E.M.R. rather than my patients. It was the kind of day that spiraled out of control from minute one, and then I could never catch up. The kind of day, nowadays, that is every day.

Part of the issue is that there are simply more patients, most of whom are living longer with many more chronic illnesses, so each patient has many more health concerns that need to be taken care of in a given visit.

But the main reason that I can’t keep up is the E.M.R. Like some virulent bacteria doubling on the agar plate, the E.M.R. grows more gargantuan with each passing month, requiring ever more (and ever more arduous) documentation to feed the beast.

I try to spend as much time as I can directly focused on each patient, listening to what she is saying, thinking hard about her clinical situation. This is the essence of good medicine. But it’s not the essence of what makes the clinical enterprise proceed forward. In today’s medical world, nothing exists until the E.M.R. requirements are tended to.

The painful truth is that every minute I spend talking with my patient or doing the physical exam — that is, any time not spent on the E.M.R. — simply grinds down the progress of the day.

To be sure, keeping electronic records has benefits: legibility, electronic prescriptions, centralized location of information. But the E.M.R. has become the convenient vehicle to channel every quandary in health care. New state regulation? Add a required field in the E.M.R. New insurance requirement? Add two fields. New quality-control initiative? Add six.

Medicine has devolved into a busywork-laden field that is slowly ceasing to function. Many of my colleagues believe that we’ve reached the inflection point at which we can no longer adequately care for our patients. The E.M.R. isn’t the only culprit, but it’s certainly the heavy-hitter.

Medicine traditionally puts the patient first. Now, however, it feels like documentation comes first. What actually transpires with the patient seems like a quaint trifle, something to squeeze in among the primary tasks of getting everything typed into the E.M.R.

More and more doctors are concluding that the overbearing E.M.R. actually jeopardizes patient safety, by pushing patients to the margin of the medical encounter.

It’s time, then, to take action, as we do in other areas that harm patients. Currently, hospitals can be fined for hospital-acquired infections, bedsores, medical errors, privacy violations, and patients who are readmitted within 30 days. The same logic should now be applied to electronic busywork.

Health systems should be required to periodically measure the E.M.R. burden, and should be fined when it detracts too much from face-time with patients. Hospitals might then think twice before tossing in 10 more required fields that cover their own needs but end up leaving patients with even less attention from their doctors and nurses. Things might actually change if money were on the table.

Similarly, E.M.R.s themselves need to be held to a higher standard. Given how much they affect patients’ medical care, they should be treated like any other medical device and subjected to thorough scrutiny before being allowed onto the market. E.M.R. vendors ought to be held responsible when their medical documentation product harms patient care.

If patient safety — and patient satisfaction — truly are goals of 21st century medicine, then we need to rethink how we view the E.M.R. and the related electronic burden on clinicians.

“Soap and water and common sense are the best disinfectants,” wrote the esteemed physician Sir William Osler. However, it took medicine more than a century to incorporate hand-washing as one of the best investments in our patients’ health. Let’s hope it takes less time when it comes to common sense and the E.M.R.

Danielle Ofri, a doctor at Bellevue Hospital and an associate professor of medicine at the New York University School of Medicine, is the author, most recently, of What Patients Say; What Doctors Hear.

Source The New York Times

References

Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations, Brian G Arndt MD, John W Beasley MD, Michelle D Watkinson MPH, Jonathan L Temte MD PhD, Wen-Jan Tuan MS MPH, Christine A Sinsky MD, and Valerie J Gilchrist MD. Ann Fam Med September/October 2017 vol. 15 no. 5 419-426. doi: 10.1370/afm.2121

Electronic Health Record Logs Indicate That Physicians Split Time Evenly Between Seeing Patients And Desktop Medicine, Ming Tai-Seale, Cliff W. Olson, Jinnan Li, Albert S Chan, Criss Morikawa, Meg Durbin, Wei Wang, and Harold S Luft. Health Affairs vol. 36, no. 4. https://doi.org/10.1377/hlthaff.2016.0811

Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties, Christine Sinsky MD, Lacey Colligan MD, Ling Li PhD, Mirela Prgomet PhD, Sam Reynolds MBA, Lindsey Goeders MBA, Johanna Westbrook PhD, Michael Tutty PhD, George Blike MD. Ann Intern Med. 2016;165(11):753-760. DOI: 10.7326/M16-0961

Also see
Why I Almost Fired My Doctor The New York Times
The Doctor-Patient Relationship Is Alive and Well The New York Times
Taking Care of the Physician The New York Times