Physician burnout has been labeled a public health crisis by the Harvard School of Public Health and other institutions.1 A 2018 Physician’s Foundation survey found that 78% of physicians had symptoms of burnout,2 which result from chronic workplace stress and include feeling depleted of energy or exhausted, mentally distanced from or cynical about one’s job, and problems getting one’s job done successfully.3 Among ObGyns, almost half (46%) report burnout.4 One-third of ObGyns responded on a recent Medscape Burnout Report that the computerization of practice is contributing to their burnout, and 54% said too many bureaucratic tasks, including charting, were adding to their burnout.5
Inefficient electronic medical records (EMRs) have been implicated as one reason for burnout, with improvements in efficiency cited as one of several potential resolutions to the problem. About 96% of hospitals have adopted EMRs today, compared with only 9% in 2008,6 and many physicians report recognizing value in the technology. For instance, 60% of participants in Stanford Medicine’s 2018 National Physician Poll said EMRs had led to improved patient care. At the same time, however, about as many (59%) said EMRs needed a “complete overhaul” and that the systems had detracted from their professional satisfaction (54%) as well as from their clinical effectiveness (49%).7
With this roundtable, we explore the concerns with hours spent on the EMR with several experts, and whether it is a problem that has been contributing to burnout among staff at their institutions. In addition, are there solutions that their institutions have implemented that they can share to help to cope with the problem?
OBG Management: ObGyns report that the computerization of practice and too many bureaucratic tasks, including charting, are contributing to burnout. Do you see this problem at your institution?
John J. Dougherty, MD, MBA: Yes, absolutely. There is not a day that goes by that I don’t hear about or experience “Epic Fails.” (We use Epic’s EMR product at our institution.) Too many clicks are needed to navigate even the simplest tasks—finding notes or results, documenting visits, and billing for services are all unnecessarily complex. In addition, we are being held accountable for achieving a long and growing list of “metrics” measures, education projects (HealthStream), and productivity goals. When do we have time to treat patients? And it is not just practicing physicians and clinicians. Our resident physicians spend an inordinate amount of time in front of the computer documenting, placing orders, and transferring patients using a system with a very inefficient user interface, to say the least.
Megan L. Evans, MD, MPH: I absolutely agree. Over the years, my institution has created a conglomerate of EMRs, requiring physicians across the hospital to be fluent in a multitude of systems. For example, you finish your clinic notes in one system, sign off on discharge summaries in another, and complete your operative notes in an entirely different system. As busy attendings, it is hard to keep ahead of all of these tasks, especially when the systems do not talk to one another. Fortunately, my hospital is changing our EMR to a single system within the next year. Until then, however, we will work in this piecemeal system.
Mark Woodland, MS, MD: EMR and computerization of medicine is the number 1 issue relating to dissatisfaction by ObGyn providers in our institution. Providers are earnest in their attempt to be compliant with EMR requirements, but the reality is that they are dealing with an automated system that does not have realistic expectations for management of results, follow-up tasks, and patient communications for a human provider. The actual charting, ordering of tests and consults, and communication between providers has been enhanced. However, the “in-basket” of tasks to be accomplished are extraordinary and much of it relies on the provider, which requires an inordinate amount of time. Additionally, while other members of the medical staff are stationary at a desk, physicians and other providers are not. They are mobile between inpatient units, labor and delivery, operating rooms, and emergency rooms. Time management does not always allow for providers to access computers from all of these areas to facilitate their managing the expectations of the EMR. This requires providers to access the EMR at off hours, extending their workload. Finally, the EMR is neither personal nor friendly. It is not designed with the clinician in mind, and it is not fun or engaging for a provider.
Can EMRs be a safety hazard for patients?
EMRs are not just inefficient and contributing to physician burnout, according to a joint report from Kaiser Health News (KHN) and Fortune magazine, they are inadequate and contributing to patient safety concerns.1 This was not the intended goal of the HITECH Act, signed into law in 2009 as part of the stimulus bill. HITECH was intended to promote the adoption of meaningful use of health information technology by providing financial incentives to clinicians to adopt electronic medical records (EMRs). It also intended to increase security for health care data--achieved through larger penalties for HIPAA violations.2
Ten years later, however, "America has little to show" for its $36 billion investment, according to KHN and Fortune. Yes, 96% of hospitals have one of the currently available EMRs, among thousands, but they are disconnected. And they are "glitchy." At least 2 EMR vendors have reached settlements with the federal government over egregious patient errors. At least 7 deaths have resulted from errors related to the EMR, according to the firm Quantros, reports KHN and Fortune, and the number of EMR-related safety events tops 18,000. The problem is that information, critical to a patient's well-being, may get buried in the EMR. Clinicians may not have been aware of, because they did not see, a critical medication allergy or piece of patient history.1
The problems with health information technology usability do have solutions, however, asserts Raj M. Ratwani, MD, and colleagues. In a recent article published in the Journal of the American Medical Association, the researchers propose 5 priorities for achieving progress3:
- Establishment of a national database of usability and safety issues. This database should allow sharing of safety information among EMR vendors, hospitals, and clinicians, and make the public aware of any technology risks.
- Establishment of basic design standards, which should promote innovation and be regulated by a board composed of all stakeholders: EMR vendors, researchers, clinicians, and health care organizations.
- Addressing unintended harms. Causes of harm could include "vendor design and development, vendor and health care organization implementation, and customization by the health care organization." Along with shared responsibility and collaboration comes shared liability for harms caused by inadequate usability.
- Simplification of mandated documentation requirements that affect usability. Reducing clinician's "busy work" would go a long way toward simplifying documentation requirements.
- Development of standard usability and safety measures so that progress can be tracked and the market can react. EMR vendors cannot be directly compared currently, since no standards for usability are in place.
Ratwani and colleagues cite shared responsibility and commitment among all of the parties invested in EMR usability success as keys to solving the current challenges affecting health information technology, with policy makers at the helm.3 The federal government is attempting to respond: As part of the 2016 21st Century Cures Act and with an aim toward alleviating physician time spent on the EMR, the Department of Health and Human Services is required to recommend reductions to current EMR burdens required under the HITECH Act. It plans to revise E&M codes, lessening documentation. And the Centers for Medicare and Medicaid Services aims to make meaningful use requirements more flexible, require information exchange between providers and patients, and provide incentive to clinicians to allow patient access to EMRs.4,5
References
- Fry E, Schulte F. Death by a thousand clicks. Fortune. March 18, 2019. http://fortune.com/longform/medical-records/. Accessed September 9, 2019.
- Burde H. The HITECH Act: an overview. AMA J Ethics. March 2011. https://journalofethics.ama-assn.org/article/hitech-act-overview/2011-03. Accessed September 9, 2019.
- Ratwani R, Reider J, Singh H. A decade of health information technology usability challenges and the path forward. JAMA. 2019;321:743-744.
- Hoffman S. Healing the healers: legal remedies for physician burnout. Case Western Reserve University School of Law. September 2018.
- Morris G, Anthony ES. 21st Century Cures Act overview for states. Office of the National Coordinator for Health Information Technology. https://www.healthit.gov/sites/default/files/curesactlearningsession_1_v6_10818.pdf. Accessed September 11, 2019.
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