EHR design and dissatisfaction: It's a matter of time

Around 40 percent of physicians would not recommend their EHR to a colleague
By Edmund Billings, MD
02:22 PM

As reported last year at HIMSS and by many online news and opinion sources since, physician dissatisfaction with EHRs is growing. Indeed, while this blog post doesn’t focus on the broader picture, general physician career dissatisfaction is disconcertingly high.

The breakneck push for more and better EHR use as a component of regular medical care is a significant part of that malaise, but it is insufficient as an explanation. For the most part, doctors really don’t like what the health IT industry is giving them to work with. The HIMSS survey proves it, showing that around 40 percent of physicians would not recommend their EHR to a colleague.

One would expect an industry to develop better products and improve usability, acceptance and satisfaction over time. In health IT, the opposite has occurred, with most pointing fingers at Meaningful Use as the culprit for awkward workflows and Rube Goldberg solutions cobbled together so everyone can get paid in a timely manner. 

It seems EHRs are taking more time to use rather than less, which was the original goal.

According to a survey published this week in JAMA online, this is exactly the case. In an article called, “Use of Internist's Free Time by Ambulatory Care Electronic Medical Record Systems,” a team led by Clement J. McDonald, MD, looked at the amount of time EHRs carved out of what physicians consider their free time.

Here is a summary of their findings:

  • 411 physician respondents
  • 61 different EHRs used
  • 9 EHRs used by 20 or more physicians
  • 59.4 percent said they lost time after moving to an EHR from paper
  • 63.9 percent said note writing took longer with an EHR
  • 33.9 percent said it took longer to review EHR charts than paper
  • 32.2 percent were slower to read other clinicians’ notes

So, how much time did physicians lose to EHRs? 

On average, they lost 78 minutes a day or 6.5 hours per week.  If a clinic workday is 8 hours, these physicians were spending almost a full extra day each week on EHR-oriented stuff. Because responsibilities and lurking error potential are relentless, physicians operate in a state of constant urgency. (This is also a potential explanation for unreadable handwriting.)  It’s no surprise, really, that losing the better part of a day to the EHR will cause significant frustration. 

Naturally, since 78 minutes extra per day was the average, some EHRs took much longer and others took less time. The EHR that took the least amount of time was VA VistA, which averaged about 20 minutes per day and 100 minutes per week—80 percent less than the overall average of 6.5 hours. 

Think about that. How much more would your level of job dissatisfaction rise if technological change added 78 minutes to your day versus 20?  

Understanding why VistA requires so much less time means understanding the evolution of system design. VistA was created to be rapidly adoptable. All other goals were and have remained secondary.  Physicians interning at the VA rotate through frequently and cannot spend a day or more learning the health IT system. Generally, they get a two-hour orientation and the rest they learn on the job. The EHR has to be inherently straightforward to learn and use or efficiency is lost and the VA ends up like every other hospital in America. 

VistA’s core functions—orders, notes, notifications and chart review—are easy to manage and enable rapid workflow. In large measure, this is the product of a community development process as opposed to a company competing in the feature function wars that have bloated most EHRs. The effectiveness of VistA is validated by a recent Medscape EHR study in which VistA CPRS was rated number 1 overall for physician satisfaction, number 1 in data entry, and number 1 in usefulness as a clinical tool.

The key component in the effective use of EHRs is time. A well-worn axiom tells us it takes a long time to write a short note. So, perhaps it also takes a long time to design an EHR that generates short notes … that helps get work done efficiently. Ultimately, EHR’s should create time for patients, not take it away. Technology may make patients safer—an arguable point for many in medicine—but if it can’t improve efficiency, it will only contribute to what looks like the ongoing disintegration of American healthcare.

This post originally appeared at the Medsphere blog.

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