Death by 10,000 Clicks: The Electronic Health Record

Once promised to revolutionize healthcare, the Electronic Health Record (EHR) is becoming a burden. We audited his EHR log at our institution, the University of California, San Francisco, to examine the work of a neurosurgical resident to better understand the benefits and burdens. The results shocked us. The on-call resident had him logged into the EHR for 20 hours in one shift.

Residents were not surprised when we shared these results with them. They feel the EHR burden every day.

EHR expectations and disappointments

EHRs have many benefits. Gone are the days of searching for films in the radiology basement, searching the floor for lost charts, or deciphering the handwriting of notorious doctors. For patients with a place of usual care, having quick access to historical records is valuable.

I wondered if this hectic work had been replaced by a more efficient EHR workflow. To see if this was the case, we looked at what tasks the resident was performing while interacting with specific areas of her EHR. This “active time” (time spent moving the mouse or clicking the keyboard on patient charts) totaled 9 hours per shift, excluding non-patient chart computer activity, especially imaging. it was done. This active time log revealed some inefficiencies, such as him spending an average of 45 minutes a day finding orders, reconciling orders, and navigating order decision aids. This in-depth study showed that old scat work is being replaced by worse EHR burdens.

Our program is not unique in this regard. A surgical resident says he spends nearly eight months on her EHR out of five years of training. The resident regularly takes her EHR work out of the hospital and completes up to one-third of it at home. The non-surgical resident is even worse, spending about 40% of her time on her EHR and only 12% on direct patient care. More than 90% of his residents say the documentation obligations are excessive and take time away from his patients.

The EHR burden does not only affect residents. It takes 73 trauma surgeries, 24 hours a day, to complete the required paperwork for just one year of billing. In ambulatory care, the doctor spends her two hours at the computer for every hour of her patient time. EHR use is linked to physician burnout, a problem that costs billions of dollars in the US

Many of the inefficiencies we found are due to Medicare regulations. A good use criteria program is a good example. It was developed to reduce unnecessary imaging by doctors. When ordering a CT or MRI, a doctor must click a few boxes to confirm that the order is suitable for diagnosis. Our EHR audit of her found that this would add only a few minutes to the resident’s computer time per day. However, there is no evidence that this regulation reduces unwanted imaging. We believe it is totally unnecessary. There are many regulations that add minutes here and minutes there. 10,000 clicks and you die.

Steps to lighten the load

Systematic identification of these inefficiencies is necessary to eliminate them. Our study, which includes a detailed breakdown of EHR tasks, is just the beginning. There are many regulations around billing, coding, value-based reimbursement, and physician order entry that add to the EHR’s burden. Adding these numerous regulations was easy, but identifying and removing them is difficult. The Centers for Medicare & Medicaid Services’ “Patients Over Paperwork” initiative is off to a good start as it reduces some of the paperwork required for physician notes. The effort should continue.

Part of the inefficiency comes from the EHR itself. The doctor often has little say in which her EHR is chosen and how it is set up. However, physician-owned hospitals, where physicians had more opinion, reported greater satisfaction with the EHR and more positive perceptions of time spent on documentation. By overturning the de-facto ban on doctor-owned hospitals, the doctor will get more say in her EHR purchases, and the market will shift towards those less burdened with computers.

Of course, increasing the support of advanced healthcare providers will help reduce the burden of remaining EHR tasks. The Accreditation Council for Graduate Medical Education (ACGME) encourages this. However, meaningless administrative tasks should be eliminated rather than simply passed on to other employees. This changing burden explains why healthcare must employ more and more workers to care for the same number of patients. Advanced practice providers also don’t want to be burdened with pointless administrative tasks.

What doesn’t help is a mandatory wellness program, Physician Appreciation Day, or an EHR training session. In fact, our data showed that EHR efficiency did not improve as trainees became more experienced. Problems do not stem from a lack of mental strength, health, or ambition. built into the system.

Conclusion

As neurosurgeons, we need to advocate for policies that reduce the administrative burden. It spoils the educational experience of our trainees. Healthcare costs are increasing due to inefficiencies associated with EHRs. We need to be aware of this to protect our citizens and protect our industry. Continued engagement in advocacy is required to reverse her ever-increasing EHR burden.

Anthony M. DiGiorgio, DO, MHA, is an Assistant Professor of Neurosurgery at the University of California, San Francisco, and an Associate Professor at the Institute for Health Policy. Praveen V. Mummaneni, MD, MBA is Joan O’Reilly Endowed Professor and Associate Director of the Department of Neurosurgery at the University of California, San Francisco.