6 Oct, 16 | by EBM
By Dr. Geoffrey Modest
A recent AMA-sponsored study looked at the amount of time physicians spend on their various tasks, finding that for every hour spent on direct clinical face time care, roughly 2 hours is spent on the electronic health record (EHR) and desk work (see doi:10.7326/M16-0961).
- 57 physicians (family medicine, internal medicine, cardiology, orthopedics) were observed for 430 hours in a direct observational time-and-motion study during office hours. In Illinois, New Hampshire, Virginia, and Washington
- 79% men and 82% were aged 31-60.
- 21 physicians also completed after-hours diaries for 7 consecutive days
- They measured direct clinical face time with the patients, EHR and desk work (documentation/review, test results, meds and other orders), administrative tasks (insurance and scheduling), and other tasks (bathroom breaks, nonpatient care meetings, practice audits, EHR problems like crashing, etc.)
- Overall breakdown of time on the different tasks:
- 27% of the total time was spent on direct clinical face time with patients (and another 6% with staff and others, patient not being present).
- 49% was spent on EHR and desk work, of which
- 39% on documentation and review tasks, 6% on test results, 2% medication orders and 2% other orders
- 1% on insurance issues and scheduling
- 20% on other tasks (as above)
- While in the exam room, 53% of the time was direct clinical face time and 37% was EHR/desk work
- Of those completing the after-hours diaries, they reported a mean of 1.5 hours of time spent, 59% of which was on EHR tasks
- These have been “interesting times” for clinicians, with pretty remarkably rapid transformations of how we see patients in the past 1-2 decades. One unfortunate result has been increasing physician burnout (a recent study found that 54% of US physicians have some signs of burnout, an increase from 46% from just 2011-2014). And other studies have confirmed what we in clinical care already know: our career satisfaction is largely dependent on time spent in meaningful patient interactions and the desire to provide high-quality care. Also, conversely, physician dissatisfaction tracks with the amount of time on paperwork/computer (see blog http://blogs.bmj.com/ebm/2015/12/22/primary-care-corner-with-geoffrey-modest-md-provider-computer-use-and-patient-satisfaction/ which documents both provider and patient dissatisfaction with computer use in the patient encounter). And these satisfying parts of patient care (which, i think, are the most important in terms of developing strong patient relationships, which are ultimately themselves therapeutic) are increasingly hard to do as more and more time-consuming demands confront us:
- Dealing with patients’ clinical issues, along with the plethora of prior-approvals (PAs) for medications and radiologic studies, figuring out what meds to give patients as different insurers trim their lists of approved medications not requiring PAs, which referrals are “in” vs “out-of-network”, keeping up with the increasing number of prescribed preventive services, following up on abnormal tests ordered by us or others (see below), figuring out how to deal with the community’s specific public health challenges which are now more knowable in the era of EHRs, etc.
- And, in this context, dealing with the increasing time it takes to document, as required by EHRs. (i.e., “death by clicks”)
- Even while in the exam room, only 1/2 the time in the present study was spent with direct clinical face-time with patients!!
- Other issues, not in this study but I think which are part of the EHR syndrome:
- False or excessive documentation: it is not uncommon to read extraordinarily long notes which undoubtedly do not truly reflect the actual patient encounter, but reflects the easy ability to cut-and-paste or click a button on the screen (e.g., the hand surgeon’s note which includes a complete review-of-systems and perhaps a full physical; or the ER note so encumbered with data and notes by an array of staff that it takes several minutes to find out what really happened)
- Also, several of the EHRs do not integrate social/behavioral factors well into their documentation. As I think most of us learn in primary care over time, these factors are often some of the most important ones in treating patients’ medical problems, though they may take more time than just adjusting a blood pressure medication. We end up finding a work-around for this issue to include the psychosocial data, but it is not really formally integrated into the EHR (as has been strongly recommended by the National Academy of Medicine EHR report in 2014, calling for EHRs to systematically integrate social and behavioral determinants of health).
- Many of the concerns about dysfunction of EHRs may reflect the fact that most EHRs are designed to optimize billing over providing optimal patient care (e.g., to focus on an easily billable medical diagnosis, instead of the psychosocial issues). It just doesn’t seem that the EHR designers really ever followed clinicians around who are actually practicing medicine to see what the important functionality needs to be to provide efficient care.
- Another issue with the EHR is that it does provide access to much more information. For example, when the patient goes to the ER and has a CT scan, we in primary care can easily see the results (and probably are medico-legally responsible for follow-up if an abnormality is found). Clearly, this more-coordinated care is likely to be important for the patient, and is moving our systems to allowing for a more interconnected and coherent approach to patient care. But, it takes time. And, our reimbursement systems have not responded to that (e.g., I work in a neighborhood health center, on salary. But reimbursement by the insurers has really not changed significantly even though it takes much, much more time to see patients, leading our health center and others to still need similar levels of “productivity” in order to continue to function, which translates into seeing about the same number of patients in a clinical session, which leads to very long clinical sessions which often extend into evenings/weekends at home).
- The EHR has made many of us long for the old, often illegible, but really fast-to-use and more patient-friendly paper medical records…