Doctors call it “pajama time.” It’s the time they spend at home, catching up on electronic health records (EHRs) from the day’s rounds or office visits.
“You go home, you have dinner, you put the kids to bed, and at that point you open up your laptop and finish the day’s work,” says Keith Horvath, MD, AAMC senior director for clinical transformation for health care affairs.
EHRs certainly can be beneficial. For example, they can make personal records more legible and, with some exceptions, instantly available. They provide alerts to potential problems such as drug interactions. They aid communication between physicians and the physicians’ ability to follow up with patients. But they have also significantly increased the amount of time doctors sit in front of a screen.
“Caring for people, helping people, improving health—these are core reasons why physicians enter medicine, not speed typing and completing tedious forms.”
Alexander Ommaya, AAMC
Computer time is not what most clinicians signed up for. In fact, the tedium and frustration of filling out computerized records have been identified as leading contributors to burnout.
“Of the top ten reasons, reasons one through three typically are the electronic health records,” says Horvath.
Burnout has become an alarming problem for physicians. According to the National Academy of Medicine (NAM), more than 50% of physicians report symptoms of burnout, such as emotional exhaustion, depression, and a low sense of accomplishment. Consequences of burnout include reduced job performance, early retirement, fewer hours worked, medical errors, and even suicide.
To address physician burnout, the NAM launched the Action Collaborative on Clinician Well-Being, an initiative chaired by NAM President Victor J. Dzau, MD, and cochaired by AAMC President and CEO Darrell G. Kirch, MD, and ACGME CEO Thomas J. Nasca, MD. To address issues created by EHRs specifically, the collaborative organized a summit in the fall of 2017 to look for solutions. Participants came from 32 academic medical centers and four health record vendors. Following the summit, representatives from the AAMC, the American College of Surgeons, and several other health organizations wrote a discussion paper published by the NAM. It details in-depth recommendations for key stakeholders as well as suggestions for possible future studies.
“There are a variety of changes we can make to address the problem of burnout and improve the usefulness of EHRs. These require vendors, institutions, and regulators to work together,” says Alexander Ommaya, DSc, AAMC senior director for clinical and translational research and policy and an author, along with Horvath and others, of the paper.
When help becomes a hassle
Why do electronic health records contribute to clinician burnout?
One reason is they require time—time physicians could instead use connecting with patients. According to the NAM paper, physicians and residents spend more than half their time using EHR systems for documentation, ordering tests, reviewing results, and communicating with patients or team members.
But time is not the only issue.
Young medical school students may not realize “a required competency is an ability to type well while looking at the patient,” says Ommaya. “Caring for people, helping people, improving health—these are core reasons physicians enter medicine, not speed typing and completing tedious forms.”
Too often, the computer becomes a physical barrier between doctor and patient, says Horvath. Even if it’s off to the side, he notes, the physician needs to look at the screen and keyboard, not the patient.
In addition, some critics say that much of the data physicians input has little to do with providing quality care. The NAM paper notes that EHRs can grow so big and repetitive that finding pertinent information—a process clinicians call “foraging”—can be challenging.
“The underlying problem is the existing clinical documentation requirements, which should be about providing a record of patient care but became used as a tool to generate the information and backup for billing. Because of that, it’s evolved a variety of cumbersome steps, which add minimal clinical value and take additional time,” says Ommaya.
A number of steps can help decrease EHRs’ burdens and bolster their contribution to care, according to the NAM paper.
First, the authors suggest, clinicians should be responsible for entering only information that is required for a patient’s medical care. For example, Centers for Medicare and Medicaid Services (CMS)—a major force behind how EHRs are used—should clarify that other members of the clinical team can input information that doctors currently provide.
“We should focus on the physician doing the things that only the physician can do,” says Sam Butler, MD, chief medical officer at Epic, one of the largest suppliers of EHR systems.
In addition, the paper says, EHR system vendors should develop software that allows care providers to quickly see the patient’s most relevant medical, health, and social history.
The authors acknowledge that some changes in the design and use of EHRs will require adjustments to federal regulations. They recommend that CMS phase out granular documentation requirements, especially as the country’s health system moves from fee-for-transactions to value-based payments.
“We’ve got to get past the stage of being worried about legal [exposure], which again is the old mantra of ‘If it wasn’t documented, it wasn’t done.’ Well, that’s just not true,” says Pamela Cipriano, PhD, RN, president of the American Nurses Association and one of the paper’s authors.
Finally, the authors recommend that the NAM, together with other stakeholders, study ways to move away from EHRs that at present are largely computerized versions of paper-based formats. Instead, they suggest, EHR systems should take advantage of cutting-edge methods for retrieving and utilizing health data.
“Part of our call [is] for reinvention, reconceptualization, revolution of the whole way that we document. So we not only simplify, but we make the information relevant,” says Cipriano.
“Caregivers are not reluctant to document, but they want it to be a very useful part of their work that takes advantage of the power of this digital era and doesn’t just make the worker pay homage to the equipment,” she says. “Let the equipment work for us.”