Blog: EHR is burning physicians out

BySaleh Aldasouqi, MD, FACE, ECNU

In my previous post, “It only takes 18 seconds,” I discussed the disconnect in doctor-patient communication. In the post, I alluded to the underestimated, negative effects of electronic medical records, or EMR, on physicians and on the patient-doctor relationship.

Little did I know that a discussion about this topic would be published this month in Annals of Internal Medicine (Downing NL, et al. 2018;doi:10.7326/M18-0139).

Inspired by this article, I will expand in this post on EMR’s negative effects on physicians. Before proceeding, I wish to explain that the acronym “EMR,” which stands for electronic medical records, is used in the medical literature interchangeably with “HER,” which stands for electronic health records. The two terms mean the same thing: While I personally prefer the acronym EMR, both terms will be used interchangeably in this post.

In the aforementioned article, Downing and colleagues assert that a major factor in the burnout of physicians nowadays is underestimated (ignored): EMR.

“Although EHRs have great potential to improve care, they may also have perverse effects,” the researchers wrote. “Some studies suggest that U.S. physicians now spend as much time on ‘desktop medicine’ (interacting with the computer) as they do face-to-face with patients. Providers must divide their attention between patients and the EHR, and many believe that this compromises patient-physician relationships. Although few physicians support reverting to paper, there is a growing sense within the medical community that the EHR is driving professional dissatisfaction and burnout.”

The authors discussed a very intriguing issue: Is it EMR, per se, that is the problem, or is it the documentation requirements imposed by health authorities that is the problem? They smartly analyzed the differences in EMR utilization between the U.S., Australia and Singapore. They stated that the EMR system they use in their own practices (Stanford University, Brigham and Women’s Hospital and the University of California, San Diego) was also adopted by the Royal Children’s Hospital in Melbourne, Australia, and Jurong Health in Singapore. They noted more physician satisfaction in the other countries vs. their U.S. counterparts. They attributed this difference to the strict documentation requirements imposed by U.S. health authorities. On average, the physician’s note in the U.S. is four times longer than that in other countries.

As a confirmation to the anecdotal assertion that I made in the prior blog post, Downing and colleagues cited a recent study that showed that, during an average patient clinic visit, U.S. physicians spend 44% of that time facing the computer vs. 24% on patient communication.

“The highly trained U.S. physician, however, has become a data-entry clerk, required to document not only diagnoses, physician orders and patient visit notes, but also an increasing amount of low-value administrative data,” the researchers wrote.

Because of the relentless glitches in EMR functioning and the sophistication inherent in EMR applications, it is frustrating for physicians to complete tasks that were not asked of physicians. To order an ultrasound or a CT scan in the “old days,” for example, the physician would check a box, or fill a couple of items to finish the order, with the rest of the process completed by the clerk. Now, the physician is required to do the whole thing online. Similarly, a referral was initiated in the old days by checking a box or writing a few words. Now, it is a very lengthy process on EMR. Take the example of ordering a medication: a big ordeal. Each task takes boxes, clicks and fields to complete.

Then there are the not-uncommon computer glitches, internet interruptions, you name it. For physicians who are not computer savvy, that is an overwhelming burden. For physicians who do not type, that is another overwhelming burden.

Of course, things get better with time as physicians get used to EMR, but at the end of the day, these emerging tasks imposed on physicians drain their abilities at the expense of their attention to patients’ needs during the clinic visit. Face-to-face, doctor-patient communication is the direct victim of the EMR intrusion into the exam room. If physicians do not bring their laptops to the exam room, then they will have to spend time outside the exam room completing EMR tasks necessary for patient discharge. This does not include the extra time needed to complete and close the EMR notes.

Downing and colleagues conclude their piece by stating, “The nation's shift toward value-based care is welcome, but physician burnout is also a critical priority — we risk losing many physicians if the root causes are not addressed.”