Our ongoing series about EMR data accessibility and usability continues. This article from the New Yorker points out that some clinical tasks that were formerly considered "routine" are now falling to clinicians. Those same clinicians may be frustrated with time-consuming aspects of administrative detail they'd not envisioned in medical school.
In some ways, it’s not surprising that EMRs come between doctors and patients. After all, the technology is commonly referred to as screens.
But the question of why doctors hate their computers is worth exploring, and it’s one that Atul Gawande sought to answer in a recent New Yorker article. Gawande, a practicing surgeon with Partners HealthCare, notes that digitization “promises to make medical care easier and more efficient.” He pushes readers to ponder whether that promise is truly being realized – or whether the shift to EMRs has actually hindered the doctor-patient relationship.
As a physician who has worked on several different systems over the years, I’m confident that 99 percent of my peers would say that screens are definitely coming between doctors and their patients – and most would add that digitization has largely failed to make it easier for us to efficiently deliver patient care.
In Gawande’s recap of the saga of his hospital system’s EMR implementation, you’ll hear echoes of the same challenges every provider has heard or said over the last 10 to 15 years: EMRs cost too much, slow physicians down, and provide too few benefits for users. In addition, EMR use contributes to physician burn-out.
The article also highlights the deepest ironies of the shift. As Gawande observes, some physicians now rely on scribes to enter details of their patient encounters. EMRs were created to reduce the inefficiencies of paper; physicians are now relying on paper to minimize the inefficiencies of EMRs. One doctor in his circle has even resorted to hacking into the system to remove “useless functions” and add useful ones. Others have turned to third-party apps to bolster their EMR functionality without changing the core application. Stacking technology on technology on technology.
Gawande’s article gave me cause to reflect on EMRs, how they’re implemented, and what stakeholders can do to help doctors feel a little less hate towards their computers.
Elevating Physicians’ Perspective in the Technology Discourse
Understandably (because it’s a large enterprise) but unfortunately (because it literally determines physicians’ day-to-day work), larger health systems tend to give physicians less control over their own workflows. The truth is, all too often, ancillary staff dictate physician workflow. In the worst cases, there’s little regard for the impact on physician productivity. In the best, there’s simply limited understanding of the true impact.
Gawande shares the story of a longtime office assistant who saw this up close and personal. “Each new software system reduced her role and shifted more of her responsibilities onto the doctors.” Prior to implementing EMRs and the cascading technology stack associated with them, she would draft letters to patients, prep routine prescriptions and handle other tasks to lighten the doctors’ role. Then came the EMR. Now she’s not trained or authorized to perform these functions, leaving doctors to do it all themselves. This real-world example is problematic because a passion for administrative tasks isn’t what motivated physicians to practice medicine. It isn’t why they attended years of school and finished even more years of arduous medical training. That’s why it’s not surprising that physicians are frustrated by their long EMR to-do list, which could easily simplified or completed by others – and that frustration isn’t without merit.
Gawande also shares the complaints he’s heard or voiced about the system’s illogical setup. One physician points out the obviously unnecessary yet nonetheless mandatory fields that create inefficiencies. Before the new EMR was implemented, she could document a Pap smear with a few quick clicks. Fast forward to today, and she has to manually enter such details as the physician and the date of service – as opposed to, you know, defaulting to the doctor entering the note and the current date of service.
To place that anecdote in a broader technology context, imagine you were signed into your email, but each time you wanted to send an email, you had to key in your email address and the time it was being sent.
Gawande shines on a spotlight on the fact that many organizations fail to consider how particular configuration decision will impact physician users. Rather than optimizing EMRs to enhance physician productivity, administrative users dictate based on the limits or efficiencies they see on their side. That isn’t a sustainable model. Clinicians must be given a bigger voice in decisions that impact their workflows.
Data, data everywhere – but how much of it is useful?
To be clear, EMRs do have very tangible benefits, most notably that all of a patient’s data is stored in a single record. But unless all this data is well-managed, clinicians end up drowning in data and are forced to waste time sifting through irrelevant information to find what’s usable.
An example: a colleague of Gawande’s points out that problem lists have “become a hoarder’s stash” because everyone across the organization can modify the lists. Three providers may list the same diagnosis in three different ways, creating a long, deficient, and redundant list. Then the problem is compounded by additional data, both from internal sources and third-party providers. Because there is no true editor or arbiter of the data, the clinician is left to hunt through screens upon screens of information just to find details relevant to a patient’s current reason for utilizing the health system.
In effect, technology is creating inefficiencies rather than solving them. Doctors should not have to go through the time-consuming task of combing through every transaction within a patient’s chart to confirm a suspected diagnosis or make a treatment decision. Rather than drowning physicians with data, organizations should incorporate solutions that make sense of available patient data and create a more streamlined view. Ideally, clinicians should be presented diagnostically-relevant details that support decision-making. The true potential of technology in this instance is that it can identify and interpret all the disorganized data within a patient’s chart and translate it into clinical insights at the point of care.
In the absence of this type of filtering/translation technology, physicians will continue to feel overwhelmed with EMR data.
The diagnosis is clear – and physicians are demanding a better solution
The enduring role of scribes in many organizations is also a testament to the fact that physicians will find ways to work around inefficiencies created by technology. Scribes give physicians the freedom to devote their complete attention to patients, rather than the computer screen. But as Gawande points out, they aren’t an end-all solution. Physicians still have to review the final chart note. Looking at the bigger picture, physician workloads aren’t actually lightened, because the time that scribes free up is used to see additional patients. Scribes also don’t necessarily improve overall physician satisfaction. The fact that the physician is not engaged with the system negates the benefit of critical alerts that could impact patient care. What would be the reaction of the physician when the scribe pipes up and says, “hey Dr. X, the EMR is telling me you are out of compliance with a colonoscopy?” Think about it….
Gawande’s article reinforced my belief that the most viable solution is expanding the availability of third-party applications so that both clinicians and administrative staff can add new functionality to address their needs. Rather that stacking unrelated tech on top of tech, healthcare technology and EMRs in particular need to operate as more of an ecosystem. Some EHR vendors have been hesitant to open up their systems. In some cases, that’s due to an understandable fear of loss of control or the misguided perception that our developers know best what the physician needs and they should be happy with what we gave them. In some cases, it’s concern over missed potential revenue opportunities. If we ever want physicians to fully embrace EMRs as a productivity-enhancing tool that makes it simpler to deliver quality patient care, this mindset must change.
Digitization does hold the promise of making healthcare more seamless and efficient – but today, that’s still just a promise. If we give physicians more control over their workflows and genuine solutions to the growing deluge of clinical data, we’ll also be giving them more reasons to fully engage with EMR technology. And maybe they’ll hate their computers a little less too.