From the Editor
I’m running late – and I’m more than a bit concerned. I need to get to a meeting at the other campus, but first, I need to discharge a patient. That involves printing out a prescription and writing a short note. I’m in my fourteenth year of inpatient work, not counting residency, and I’m pretty good with prescriptions and notes. I believe I can do this. But does the EHR believe I can do this?
Many of us are frustrated with electronic health records (EHRs). In this week’s selection, we consider a new essay by Harvard University’s Atul Gawande, a surgeon, who considers EHRs and practice. Dr. Gawande talks about his own struggles with computers, and ties into the larger literature.
Big computer system, big problem?
We discuss his essay, and the potential and problems of EHRs. We touch on the Canadian experience and wonder about quality improvement. To that end, we look at “Getting Rid of Stuff,” just published in The New England Journal of Medicine.
Computers and Docs
“Why Doctors Hate Their Computers”
The New Yorker, 12 November 2018
On a sunny afternoon in May, 2015, I joined a dozen other surgeons at a downtown Boston office building to begin sixteen hours of mandatory computer training. We sat in three rows, each of us parked behind a desktop computer. In one month, our daily routines would come to depend upon mastery of Epic, the new medical software system on the screens in front of us. The upgrade from our home-built software would cost the hospital system where we worked, Partners HealthCare, a staggering $1.6 billion, but it aimed to keep us technologically up to date.
More than ninety per cent of American hospitals have been computerized during the past decade, and more than half of Americans have their health information in the Epic system. Seventy thousand employees of Partners HealthCare—spread across twelve hospitals and hundreds of clinics in New England—were going to have to adopt the new software. I was in the first wave of implementation, along with eighteen thousand other doctors, nurses, pharmacists, lab techs, administrators, and the like.
The surgeons at the training session ranged in age from thirty to seventy, I estimated—about sixty per cent male, and one hundred per cent irritated at having to be there instead of seeing patients. Our trainer looked younger than any of us, maybe a few years out of college, with an early-Justin Bieber wave cut, a blue button-down shirt, and chinos. Gazing out at his sullen audience, he seemed unperturbed. I learned during the next few sessions that each instructor had developed his or her own way of dealing with the hostile rabble. One was encouraging and parental, another unsmiling and efficient. Justin Bieber took the driver’s-ed approach: You don’t want to be here; I don’t want to be here; let’s just make the best of it.
I did fine with the initial exercises, like looking up patients’ names and emergency contacts. When it came to viewing test results, though, things got complicated. There was a column of thirteen tabs on the left side of my screen, crowded with nearly identical terms: “chart review,” “results review,” “review flowsheet.” We hadn’t even started learning how to enter information, and the fields revealed by each tab came with their own tools and nuances.
But I wasn’t worried. I’d spent my life absorbing changes in computer technology, and I knew that if I pushed through the learning curve I’d eventually be doing some pretty cool things.
So begins a long essay by Dr. Gawande.
The piece opens with his experience with Epic – the medical software system that his health system is spending $1.6 billion to implement, with under $100 million spent on the software itself, and the rest on lost patient revenue and the cost of support staff. The support staff have been needed: 27,000 help-desk tickets were filed in the first five weeks, or three for every two users.
Drawing from the literature, he notes how EHRs have changed health care:
- More time on documentation. “A 2016 study found that physicians spent about two hours doing computer work for every hour spent face to face with a patient—whatever the brand of medical software. In the examination room, physicians devoted half of their patient time facing the screen to do electronic tasks. And these tasks were spilling over after hours.”
- Longer hours. “The University of Wisconsin found that the average workday for its family physicians had grown to eleven and a half hours.”
- Burnout. “In 2014, fifty-four per cent of physicians reported at least one of the three symptoms of burnout, compared with forty-six per cent in 2011… Female physicians had even higher burnout levels (along with lower satisfaction with their work-life balance). A Mayo Clinic analysis found that burnout increased the likelihood that physicians switched to part-time work… Burnout seemed to vary by specialty. Surgical professions such as neurosurgery had especially poor ratings of work-life balance and yet lower than average levels of burnout. Emergency physicians, on the other hand, had a better than average work-life balance but the highest burnout scores. The inconsistencies began to make sense when a team at the Mayo Clinic discovered that one of the strongest predictors of burnout was how much time an individual spent tied up doing computer documentation.”
But Dr. Gawande also notes that EHRs can have an impact on the quality of care.
- Lower mortality. “Researchers looked at Medicare patients admitted to hospitals for fifteen common conditions, and analyzed how their thirty-day death rates changed as their hospitals computerized. The results shifted over time. In the first year of the study, deaths actually increased 0.11 per cent for every new function added—an apparent cost of the digital learning curve. But after that deaths dropped 0.21 per cent a year for every function added.”
Dr. Gwande’s essay is enlivened by a story of his interaction with a patient (and his computer). After a first meeting, the surgeon asks the patient if he was on his computer too much. The patient responds:
I’ve been in your situation. I knew you were just trying to find the information you needed. I was actually trying not to talk too much, because I knew you were in a hurry, but I needed you to look the information up. I wanted you to be able to do that. I didn’t want to push you too far.
The article also notes a developing American trend to compensate for the hours of documentation: the medical scribe.
A few thoughts:
- This is a good essay.
- The essay is written by an American for an American audience. But EHRs have been adopted widely north of the 49thparallel. A majority of Canadian physicians now use an EHR, based on the National Physician Survey (about 80% at least partially used computer charting in 2014, up from 36% in 2007).
- The EHR was supposed to usher in an era of cost savings. Back in 2005, the RAND Corporation predicted that large-scale adaptation of computer records would save the US health care system billions of dollars in a major Health Affairs paper. “Our findings strongly suggest that it is time for the government and others who pay for health care to aggressively promote health information technology,” commented Richard Hillestad, a RAND senior management scientist. Like many promised savings in health care, EHR has failed to deliver. Years later, in a follow up analysis, RAND researchers found the savings to be “disappointing.”
- But change in health care isn’t necessarily about cost savings. What about quality care? Dr. Gawande reports on a study suggesting an improvement in mortality rates. Wow. With so much data (from patients and providers), EHRs would seem to have incredible potential for quality improvement.
- What about mental health care? Ontario Shores adopted an EHR with some success in terms of improving the quality of care. In Riahi et al., they report: “In the 12 months following CPG [Clinical Practice Guidelines] implementation, modest improvements were realized in CPG adherence. Adherence to CBT-P and vocational rehabilitation guidance was increased from 6.5% to 11.4% and 36.6% to 49.1%, respectively. Adherence to antipsychotic monotherapy guidance increased initially from 53.4% to 62.7% but fell back to 55.1% by 12 months. Adherence to metabolic monitoring increased slightly from completing 76.7% of all required metabolic measurements to 81.6%.” Their paper can be found here: https://medinform.jmir.org/2017/1/e1/.
- Strangely, Dr. Gawande doesn’t mention medico-legal considerations, which are probably a significant issue in the chunkiness of EHRs. The unfortunate consequence of Canadian hospitals and clinics buying EHR package from the United States is that we are importing the paperwork requirements of the super-litigious American environment.
- How to make EHRs less frustrating? The New England Journal of Medicine has a snappy essay titled “Getting Rid of Stuff.” Dr. Melinda Ashton, a vice president of Hawaii Pacific Health, discusses an initiative to modernize their not-so-modern computer system. She writes: “Our EHR was adopted more than 10 years ago, and since then we have made a number of additions and changes to meet various identified needs. We decided to see whether we could reduce some of the unintended burden imposed by our EHR and launched a program called ‘Getting Rid of Stupid Stuff.’”
The project seems to be the ultimate quality improvement effort, with an invitation to all employee to nominate anything in the EHR that they thought were “poorly designed, unnecessary, or just plain stupid.”
She notes many positive suggestions to simplify documentation. “For example, we received a request from a nurse who worked with adolescent patients asking that we remove a physical assessment row called ‘cord.’ This entry had been intended to reflect care of the umbilical cord remnant in newborns, and the planned suppression of the row after 30 days of age had never occurred. This row has now been appropriately suppressed.”
And she notes the surprising effects:
We were surprised to find that making this single click consumed approximately 1700 nursing hours per month at our four hospitals (given the average number of clicks per month and the fact that each nurse or nursing assistant spent 24 seconds per click).
What’s the status of the project?
Although they were not formally submitted as nominations, we have removed 10 of the 12 most frequent alerts for physicians because they were simply being ignored. We are also reviewing order sets and removing the ones that have not been used recently. Interestingly, we have received more nominations from nurses than physicians, even though physicians have been at the center of concerns regarding burnout.
She concludes: “When the campaign was unveiled, it was largely met with surprise and sheepish laughter, then applause. We seem to have struck a nerve.”
Dr. Ashton’s open-access paper can be found here: https://www.nejm.org/doi/full/10.1056/NEJMp1809698.
- You may get a laugh out of this “news article” from the parody site GomerBlog which begins: “Citing slow load times, confusing menu structure, and overall frustration with the user interface, St. Barnaby’s Hospital has announced that the old electronic health record will be replaced with a new state of the art binder-based system, in which a so-called ‘paper chart’ is kept for each patient.” The full article can be found here: https://gomerblog.com/2014/07/electronic-health-record/.
- For the record, I printed the prescription, added the discharge note to the e-chart, and made it to my meeting on time.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.