The Trouble with EHR
Electronic health records have doctors working overtime.
From the March, 2017 issue
The doctor worked late last night at home, got to his Ann Arbor office two hours early this morning, and still hasn't caught up on his computer work. Now he's trying to talk to a patient while simultaneously documenting the visit in the man's electronic health record (EHR). Clicking through screen after screen, he looks up long enough to reassure the patient that he's listening, then turns back to the computer. He murmurs, "no one becomes a doctor to do this."
He's not alone. When I started asking local physicians about their experience with EHR, three of them separately sent me a December article in the Annals of Internal Medicine that analyzed how four different groups of physicians spent their day. The shocker: "For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work."
Both the U-M and St. Joe's spent hundreds of millions of dollars in recent years to implement EHR systems, which promise greater efficiency, lower costs, and better patient care. But making EHR work has been a lot harder than people thought. I talked to a dozen doctors, and every one of them felt that--at least so far--the burdens outweigh the benefits.
Some recent retirees said EHR was a factor in their decision to hang up their white coats. "The learning curve was too steep and the frustrations too broad," says geriatric specialist Jack Carman, who retired three years ago. Another geriatrician, Alan Dengiz, saw his workload swell from fifty or sixty hours a week to eighty when EHR came in. He stayed up late taking an online typing class but couldn't pull it off--and his heart wasn't in it anyway. "I was the kind of person who liked to talk to my patients, look
them in the eye," he recalls. Already struggling with health challenges, Dengiz retired last year.
EHR's troubled implementation reflects both the frailties of humans and the flaws of computer design. The transition was "really very challenging, very hard," says Paul Harkaway, former president of the Huron Valley Physicians Association and now an administrator at St. Joe's parent Trinity Health. EHR's software "tools have a long way to go to get to a mature point," Harkaway says. "They're clunky, if you will."
Local internist Martha Gray is one of those increasingly rare physicians who operate their own practices. She says that lets her use EHR very efficiently, including employing two full-time nurses who enter patient data. Even so, she estimates that it consumes an extra hour a day. And every doctor, she says, is now "suffering the same malady: We have this distracting computerized system which pulls our attention from the patient."
Hospital administration has been computerized for years, but computers were much slower to reach the exam room: somewhere between 20 to 40 percent of physicians were using electronic medical records in 2009. Then the anti-recession stimulus act budgeted $19 billion for health information technology. To encourage speedy implementation, providers who signed on quickly would receive considerably more than those who waited.
"It was just a free-for-all," recalls retired U-M medical prof Alan Weder. "The government was paying out a lot of money" for EHR systems, and vendors were eager to sell them.
Trinity Health, switched on a $400 million system that same year. In 2010, the U-M began replacing a homegrown EHR system with software from Wisconsin-based Epic Systems. Health system spokesperson Mary Masson emails that it cost "less than $300 million." Nationwide, about 80 percent of providers now use some kind of EHR.
Nurse Mary Bondie, clinical administrator at Gray's Partners in Internal Medicine, says that "one of the really positive things" about EHR is that "everything happens in the system--who did what and where and what time." Going digital also let doctors quickly access one another's records of diagnoses and treatments.
But "documenting visits takes far more time," says Saline internist Deb Peery. She doesn't use a computer in the exam room--"nobody should have to sit there watching me type"--but that means she must put in extra computer time outside it. "It's gotten more and more stressful," she says. "No question."
It's not just typing--EHR systems require physicians to enter much more information than the old paper records did, including documenting reasons for ordering a lab test or prescription. Administrators liked that, because it gives them ammunition to fight penny-pinching insurers, but doctors resented it. "We had to become desk clerks on top of being doctors," says Cheryl Farmer, who retired from private practice three years ago. "We had to become data entry people."
They also had to become billing clerks. Before EHR, Farmer says, she could just note that a patient needed a chest X-ray and a clerk would find the correct diagnostic code and put in the order. With EHR, she had to choose the code herself.
And just as EHR came in, the number of codes multiplied, from a daunting 18,000 to an overwhelming 140,000. A diagnosis of diabetes, Weder says, now "has at least 100 if not more subcategories." Many of those distinctions, he says, don't affect treatment--but may change how an insurance company pays for it. When the U-M switched to Epic, it looked to Weder like the software was "put together by people mainly interested in billing."
An Epic spokesperson says it was initially developed to track medical research. But money definitely matters now: a chart on the company's website highlights its claim that organizations using Epic earn 31 percent more per employee that those using market leader Cerner.
St. Joe's uses Cerner. The health system provides "support 24-7 if there's any question of EHR functionality," says Carol Hisscock, director of clinical informatics. But more than seven years in, the system is "well past the implementation stage," says Jessa Edelman, a hospital-based physician who provides tech help to other doctors. "Now we're on the optimization stage to make it more efficient, more safe, more user friendly."
As Epic rolled out at the U-M, Masson emails, information technology staffers "literally worked day and night" to solve problems. She admits that "physicians initially did feel slower with the new system, and a larger number of them reported having to stay after hours or access the system from home after hours to complete their day's work." However, she writes, "efficiency seminars and 1:1 training sessions ... have been extremely effective and well received" in reducing the burden. Still, every U-M doc I spoke to said they are still working longer hours because of EHR.
Weder is not among them--he says it was part of the reason he retired in 2013. He says he would have gone soon in any case--but that even young medical students he mentors are "having trouble figuring it out. It's the worst user interface that they've ever seen."
Almost every doctor I spoke to liked being able to "write" prescriptions through EHR, noting it's both faster and more accurate than the old handwritten slips. They also appreciated the systems' quick access to test results, and being able to look up other physicians' diagnoses and treatments. But several doctors I talked to complain that digital records are so detailed they're hard to use. "I get records that are 600 pages long, and there are at most six pages of useful information," says one.
Some specialists have been assigned "scribes," staffers who follow them around and handle the computer work. But "the primary care docs were never offered scribes," Farmer points out. Though they see a much wider variety of health problems, they don't bring in the income the specialists do.
Some now wonder if the 2009 mandate pushed institutions to adopt EHR too quickly. "We weren't really thinking about the complexity of the change," says U-M School of Information prof Julia Adler-Milstein, an expert on electronic medical data. "I don't think we knew enough to get the timeline right."
"There will be a day when [future physicians] look back and say 'why did people have so much trouble [implementing EHR]?'," Harkaway says. But today's doctors "are dealing with today ... They're going to keep slogging ahead."
from Call & Letters, May 2017
"You have totally missed the point," Cheryl Dehmlow emailed after reading our March article on physicians struggling with the demands of electronic health records. "Without question, physicians now must do far more data entry. The point, though, is why that data requires physician entry."
Dehmlow explained that the 2009 federal stimulus legislation that helped fund EHRs' implementation also required their "meaningful use" by physicians, specifying "exactly what must be documented in a qualifying EHR for various patient populations." When the software requires doctors to select diagnostic codes, she adds, it's only enforcing rules made elsewhere: "the code set is defined by the Centers for Medicare/Medicaid Services (CMS) ... Sometimes the nuances will determine which medications would be beneficial or harmful, such as 'diabetes with microalbuminuria' vs 'diabetes with chronic kidney disease Stage 5'. But all too often the expansion of the diagnosis code set is the result of lobbying by the specialist providers, and the 'diabetes with ophthalmic complications' codes are a prime example! Ophthalmologists gone wild ... what many primary care physicians choose not to acknowledge is that it's their own colleagues who have pushed CMS to create these codes--sometimes for research purposes, sometimes for ego."
Katia Satterfield also wished we'd delved more deeply into the source of EHRs' demands. "I commend The Observer for aspiring to teach readers about what EHR implementation looks like on the inside of the system," she emailed. "However, I expect a more thorough review that also considers how provider systems and payers have put this pressure on physicians with biased interests or insufficient support."
Jerry Frost added a patient's voice. Electronic records "have greatly enhanced my ability to manage my personal health," he emailed. "Prescriptions, appointments, lab results, visit summaries and billing are all readily available through my [online Patient] Portal." And Frost never "felt 'abandoned' by my [primary care provider] while he accessed records on his computer. In fact it was helpful when we discussed a particular test result when he pulled up an on-screen graph to illustrate his point."
And physician Amanda Kaufman emailed that while she shares the frustration of the docs we spoke to, she's also found a solution.
"Twelve years ago, when I entered medical practice, I did not complain when I spent the entire weekend catching up on paperwork from full time work during the week," Kaufman wrote. That became impractical after starting her family--"I would regularly stay up all night finishing notes after my little ones were asleep"--and impossible after she entered private practice in 2014 "with the additional work of running a business. The only way to survive was to hire a scribe, but I have never liked the idea of a stranger sitting in on this most private meeting between doctor and patient. Luckily a friend of mine from high school developed a concept to bring scribes to the masses. Interactions are recorded and professional scribes are hired to transcribe notes. This process is a Win in all directions: it is considerably cheaper than hiring a person to hang out with you all day, privacy feels less violated, and scribes can be hired in any time zone around the world ...
"While difficult to implement in large institutions for various reasons, providers in private practice need only contact john@inscribelabs .com or any of the other electronic scribing services to go from EHR hell back to the profession we entered because we want to serve. We all deserve to be cared for by physicians who love their work and have the emotional capacity to treat others the way they would like to be treated."
[Originally published in March, 2017.]
On March 31, 2017, Amanda Kaufman MD wrote:
Dear observer staff,
I appreciate your attention to the stresses of electronic health records on physicians. We go in to this profession because we are happy to devote our energy to helping others and tend to be hard-working, good-natured folks that do not complain. Twelve years ago, when I entered medical practice, I did not complain when I spent the entire weekend catching up on paperwork from full time work during the week. Then I had young children and struggling to keep up. I would regularly stay up all night finishing notes after my little ones were asleep. Many colleagues felt the struggle and wondered where the profession they so loved was lost, as the article so well reflects.
In 2014, I entered private practice with the additional work of running a business. The only way to survive was to hire a scribe, but I have never liked the idea of a stranger sitting in on this most private meeting between doctor and patient. Luckily a friend of mine from high school developed a concept to bring scribes to the masses. Interactions are recorded and professional scribes are hired to transcribe notes. This process is a Win in all directions: it is considerably cheaper than hiring a person to hang out with you all day, privacy feels less violated, and scribes can be hired in any time zone around the world. Scribes who might be going to school or work during the day, can pick up a bit more work at night. They are able to provide a better wage than in-person scribing for various reasons. While difficult to implement in large institutions for various reasons, providers in private practice need only contact firstname.lastname@example.org or any of the other electronic scribing services so go from EHR hell back to the profession we entered because we want to serve. We all deserve to be cared for by physicians who love their work and have the emotional capacity to treat others the way they would like to be treated.
Amanda Kaufman MD
2800 S. State St suite 215
Ann Arbor, MI 48104
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