- Burnt-out Caregivers
- Unhappy Patients
- Inefficiency and Rise of the Scribes
- Nonsense Notes
Do you spend more time clicking away on a keyboard than actually making eye contact and engaging with the patient? Are you spending more time after clinic completing chart notes in the EMR? Do your notes really reflect your clinical thinking and plans? A recent report found that adoption of an EMR by physicians now exceeds 90%, more than doubling since CMS launched "meaningful use" in 2011. While the EMR has improved documentation of medications and allergies and probably reduced handwriting errors, there's a dark side to all those clicks for both caregivers and patients. Clicks really do add up.
Physician Burn Out
In a recent report, almost 50% of physicians reported symptoms of "burnout." Burnout includes feelings of loss of enthusiasm for work, cynicism, stress, and lack of energy. Frustration with a clunky EMR interface requiring multiple time-consuming clicks for even simple tasks is a major contributor to burnout. A 2014 survey of practicing internists found almost two-thirds reported writing a note took more time in the EMR and added at least one hour to the workday. 70% of the doctors felt that the EMR decreased face time with patients affecting both personal and patient satisfaction. I've had many colleagues complain they've become glorified data entry clerks. A recent study in a community hospital underscores the problem. ER physicians performed almost 4000 clicks during a busy 10 hour shift! In this study, data entry (clicks) consumed 44% of the caregiver's time with only 28% spent on direct patient care. Time spent wrestling with and clicking through an EMR built with dinosaur-era technology means less face time with patients.
Do too many clicks really adversely effect the doctor-patient relationship? The best doctor-patient encounter is built on open and trustworthy communication. This relationship is critical not only to patient satisfaction but achievement of the best possible clinical outcome. A 2016 study found physicians who were "high computer users" (too many clicks, less eye contact) were found to have "less authentic engagement" with their patients and were less often rated as excellent caregivers. Patient satisfaction is one quality outcome measure but another recent report noted an increase in medication errors and misidentifying patients after a conversion to an EMR as busy caregivers struggled to input data into a user-unfriendly system.
Inefficiency and Rise of the Scribes
Shouldn't technology improve the practice of medicine by increasing efficiency and ensuring better outcomes? Unfortunately, at least with the current dated EMR technology, physician productivity has declined. Remember the 4000 clicks in the emergency room? They translate into one hour of non-clinical time per shift or a lost opportunity to see about 750 patients per year. Similar calculations in non-ER settings report productivity declines by about 10 patients per week after EMR implementation. The unappealing alternative is simply to work longer hours to stay even. Many of my colleagues lament the additonal time after clinic and in the evening required to finish documentation in the EMR. The painful and inefficient burden of documentation has even recently given rise to a new caregiver - the scribe. The scribe is present and performs data entry during the visit. In contrast to most other areas where technology typically reduces to workforce to accomplish a task, in healthcare more people are added to the payroll to maintain the pre-EMR level of work!
A less well known consequence of the current EMR is the final product - the clinical note. From the early days in med school, we all learned the bedrock of the patient encounter is a careful history and physical exam leading to an assessment and plan. This process is reflected in the clinical note. A well written note encapsulates the problem, the diagnostic thought process, and management plan. The note is central to communication to all caregivers for the patient. Typically current EMR notes consist of pages of checked boxes and lists of ICD-10 coded diagnoses and orders. As a consultant and recipient of many such notes, I can attest they were usually worthless from the standpoint of patient care. Reviewing a 2 inch stack of paper to find a few meaningful sentences describing what's been done during a prior episode of care is not a rarity in medical practice today.
The Solution: Cut the Clicks
Technology by and for Caregivers
At Dorsata, we're building solutions to empower providers to practice medicine as their first priority. We're using 21st century technology to enhance the practice of medicine, improving both provider an patient satisfaction. Neither doctors nor patients are satisfied when clicking away to complete the note in the EMR is the focus of the visit. The solution is to the make the patient the center of the encounter and not the computer. Our work begins by engaging front line caregivers in the design of clinically relevant workflows and uses state of the art technology to build a user-friendly EMR interface. We count clicks! Our "technology for caregivers" approach is driven by laser-like focus on key fundamental principles:
- Seamless integration of evidence based decision support will improve patient outcomes.
- The EMR should improve caregiver efficiency and reduce the documentation burden.
- The EMR experience should support improved patient outcome and satisfaction as the bottom line.
- The end product should be a meaningful clinical note, not just documentation.
As we move forward, I'd welcome your thoughts, comments and ideas. We can learn from our shared experiences.