Wednesday, June 29, 2016

Guess What: Docs Don't Like EHRs

It's kind of "dog-bites-man" type news, but there is even more evidence that physicians not only don't think EHRs are helping them but actually see them as contributing to burnout.

Researchers at the Mayo Clinic found that use of EHRs (or computerized physician order entries -- CPOEs) was associated with lower satisfaction with time spent on clerical tasks, with nearly half of physicians saying the amount of time spent on clerical tasks was unreasonable.  No wonder the AMA CEO recently complained that physicians were turning into the "most expensive data entry force on the face of the planet."

Not surprisingly, 63% of physicians believed EHRs made their jobs less efficient.  Also not surprisingly, their use was  associated with a higher rate of physician burnout.  Most importantly,  physicians were split on whether EHRs improved patient care or not.

It is almost shocking that "only" 44% said they were dissatisfied with EHRs.

The burnout is a problem not just for the physicians themselves, but also for patients.  As the lead author said,
Burnout has been shown to erode quality of care, increase risk of medical errors, and lead physicians to reduce clinical work hours, suggesting that the net effect of these electronic tools on quality of care for the U.S. health care system is less clear.
That doesn't sound like a good return on our $33b HITECH investment, does it?

A separate study by researchers at Cleveland State University agreed that EHRs presented a number of "clear challenges," including increased workload for caregivers, issues around trust in the technology and the information in it, and a perceived over-reliance on technology.

The CSU study found that, in many cases, physicians simply created "workarounds" to circumvent aspects of the EHR, a finding that was echoed by a VA study looking at EHRs and test results.  The VA study found that 43% of physicians used EHR workarounds to follow-up on test results, most commonly paper-based methods like sticky notes.

The respondents complained it was hard to find test results in the EHR a second time, that the EHRs generated an overload of alerts and reminders, and that paper was necessary to track results from providers not on the same EHR.

Yet another study found that one of the most common workarounds by health care professionals had to do with cybersecurity.  They've found lots of creative ways to do so, including posting sticky notes with passwords, passwords shared by entire hospital units, and preventing automatic logouts.

The authors concluded:
"We find, in fact, that workarounds to cyber security are the norm, rather than the exception.  They not only go unpunished, they go unnoticed in most settings — and often are taught as correct practice."
No wonder hackers are having a field day with health data.

Interestingly, as much as we see physician complaints about EHRs, the CSU researchers warned of a "culture of silence" that physicians found in their organizations which keeps them from speaking up about issues with EHRs and ensuring that they are properly addressed.

Since health systems are spending millions of dollars on implementing EHRs, they may not be eager to hear physicians complain about them.  It may be easier to chalk issues up to short-term implementation snafus or to user error, rather than to structural issues with the EHRs they've chosen.

The authors of the various studies had similar recommendations, urging that future generations of EHRs needed to do a better job of integrating with clinical workflow, as if this was a novel idea.  It begs the question: how has so much money been spent on products used by so many health professionals for so long now, with such dismal results?

And despite all that spending and all those headaches, we're still failing on key goals.  There's not much confidence by anyone that EHRs are helping patient care, we're still failing at sharing patient data across providers (which Commonwealth Fund president David Blumenthal calls "the biggest obstacle to the health care revolution"), and we're not making it easier for physicians to do their job.

For example, an analysis of drug treatments on 250 million people with diabetes, hypertension, and depression found that at least one on ten patients had a unique course of drugs, one that no one else had.  That figure as as high as 25% of hypertension patients.  This is the kind of variability that electronic records make possible to detect, and that EHRS should be able to instantly warn about  - both to the prescribing physician and to the persons/organizations overseeing/regulating them.

Yet here we still are.

At the risk of grossly oversimplifying, the problem that current EHRs are really "solving" is that most health care records were still on paper.  We're fixing that problem all right, but that's not one of health care's big issues.

What we should care about is tracking and improving patients' health.  We need better data -- and more information -- in order to coordinate care, reduce duplication of services, measure outcomes, and track performance.

Having ONC certify acceptable EHRs is a classic example of stymieing innovation through government regulation.  Through lots of good intentions, we've frozen the market in a very early stage of development, and the physician dissatisfaction with EHRs is the result.  Which EHR a provider uses -- or even if they use an EHR at all -- is not the point.  The ability to provide the data we need is.

Let the market figure out the products that will delight their users while delivering that data.

Imagine what mobile phones would look like if the federal government had mandated in the beginning of the century what they had to do and how they had to do it.  We'd probably all be using versions of the classic Blackberry.  Most of us would not settle for that, and we shouldn't settle for what EHRs are doing now.

EHRs causing workarounds and physician burnout are the proverbial canaries in the coal mine, signaling we are on the wrong path with them.


  1. Kim, the biggest flaw in the current system is the thought that the data should reside within the "EHR" program in the first place. It's easy to see how this came about in the "digitization" of paper records. But to really move the bar on health delivery, a patient's health record is something that should follow the patient in ALL their interface with the HC system, as something the patient has personally, or delegates to a third-party "data custodian". "EHR", as a program, would then be only the front-end to this longitudinal patient record. Interoperability need only be with this record, not with other EHR programs data stores. Getting EHRs in the current system to interoperate on data is tantamount to "herding cats". It's not going to happen.

    1. Tim -- I couldn't agree more, and I know you and others are trying to move the market there. Keep at it!