EHRs that suck away the physician's soul

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Elizabeth Newman
Elizabeth Newman

It's not a secret that in long-term care, direct-care workers often resent physicians.

The complaints that I hear range from administrators who say physicians default into telling the facility to ship the resident to the emergency room, to physicians who rarely show up when needed, to outright bullying of nurses. But if there's one thing that can unite both the frontline long-term staff and primary care physicians, it's a new report on how much time physicians are spending with electronic health records.

Many of us, as patients, have seen this ourselves, with physicians required to click through questions on EHRs during visits, often making you wonder if they're focused on you. But I was shocked to see the report out of the University of Wisconsin and the American Medical Association found that primary care physicians spend 355 minutes, or nearly 6 hours, of an 11.4 hour workday in the EHR. And more surprises were to come.

These physicians spent close to an hour and a half after hours, and 4.5 hours during clinic, wrapped up in EHR work. About half of the time was related to managing clerical tasks, while 24% related to managing the inbox. (I am assuming that this involves handling lab results and other professional correspondence, not an inbox with cat videos attached).  All of the data was extracted from the enterprise Epic EHR database.

While this study has focused on primary care, a report last year found family medicine, internal medicine, cardiology and orthopedics spend about two hours in the EHR for every hour of patient care.

To me, one of the most important findings of this new study, published in the Annals of Family Medicine, related to computerized physician order entry. For years, we've been hearing that it increases patient safety, but the researchers said “minimal evidence” exists to support that. They recommend having clinical staff enter verbal or handwritten orders as a way for the physician to focus more on the patient and to save time.

Also surprising: In our efforts to increase documentation in long-term care, we may be misleading people as to the best way to communicate. By putting all communication in the EHR, it's adding “layers of inefficiency and distracts the team from higher-quality verbal communication. Face-to-face communication is associated with increased efficiency, whereas more electronic communication among team members leads to greater clinician and staff dissatisfaction as well as poorer clinical outcomes and increased healthcare use among patients with coronary artery disease,” the authors wrote.

No study is perfect of course -— the research focused on EHR time, not total patient care time, giving us an incomplete picture of how many hours the physicians are spending at work. Additionally, regional clinic physicians still receive a huge amount of faxes and other paperwork, the authors noted. It's also possible that sometimes the EHR window was open while a doctor was talking to a patient or colleague, although the researchers applied a cutoff of 90 seconds when there was no activity.

However, there are still ways for those running long-term care facilities to use recommendations from the article to decrease burnout related to EHR.

• A single sign-in system. The researchers found the physicians were spending 10 minutes on system security, after which the leadership invested in a single sign-in system to reduce clinician time spent on that.

• Billing and coding. Physicians were spending around 14 minutes a day on billing and coding, time which, if reassigned, could allow them to fit in another 15-minute appointment. Are your clinicians spending time wrangling with billing when their time is more valuable elsewhere?

• A task-analysis framework. EHR users are encouraged to analyze their own event-log data to see what people are spending their time on, researchers say. This could potentially allow them to assess effectiveness around EHR work.

Over the past decade, long-term care providers, begrudgingly, have installed EHR systems. But in the next decade, I believe the University of Wisconsin report will be the first of many to give us ideas on how to make the systems work better in long-term care.

Follow Senior Editor Elizabeth Newman @TigerELN.

Daily Editors' Notes

McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Marty Stempniak.