Friend or Foe: The Electronic Health Record in Practice

It was the family medicine dream: She was delivering care in her hometown. Her practice included some multi-generational families, many of whom she had known from childhood. She was energized by seeing her patients, enjoyed being a participant in their life stories and loved the ability to find out “what happens next” with each new visit. She was working for an organization who valued the importance of primary care physicians and had built a system to provide supports for all the complexities of primary care. Nonetheless, Leah left a thriving practice in December of 2019 to take on a primarily non-clinical role. There were many reasons why she made this change, but not one of them involved the electronic health record (EHR).

Burnout is one of the top concerns in health care today, and so often, the EHR is blamed as the source of physician burnout. (1) Physicians often reminisce about “the old days,” remembering paper charting with fondness. We both started out in practice using paper charts. While documentation was easier in some ways, it came with burdens. Notes from other providers weren’t always available in a timely manner, depending upon how quickly notes and/or dictations were completed. The chart could only be in one place at a time, so if a patient had another appointment on the same day, only one office had access to the chart. Reports could be misfiled or stuck to the back of another page, running the risk of important information being missed. It wasn’t possible to quickly identify whether a patient had had a particular test without poring through voluminous charts.

Enter the EHR. The incorporation of computers and other digital tools has revolutionized many industries and professions with obvious improvements. For many physicians though, the transition from paper charting to EHRs has not lived up to promises or expectations. In many studies, physicians identify increased time spent in the EHR system as a significant contributor to burnout, and this increase in time spent utilizing a computer takes away from the time spent with the patient. (2) “Pajama time” (defined as the time a clinician spends either documenting or reviewing information in the EHR outside of work hours) has been implicated as a contributor to burnout. As a result, physicians are choosing nonclinical roles, retiring early or avoiding careers in certain specialties, particularly primary care. This is causing a significant shortage in the physician workforce, a shortage that is projected to worsen over the coming decade. (3)

The nature of the problem is multifactorial and complicated. While some physicians may long for the days when a patient’s entire medical record could fit on a three-by-five-inch index card, legal, regulatory and billing requirements make that no longer possible. The complexity of delivering high-quality healthcare to patients necessitates that we utilize electronic clinical decision support (CDS) tools in our provision of this care. An appropriately designed and utilized EHR system can be an effective tool to reach the quadruple aim of high-quality, cost-effective care and a positive patient and physician experience. Unfortunately, many EHR implementations have failed to achieve that goal.

So, what is the goal of the EHR? First and foremost, it serves as the record of a patient’s medical history and health care story, communicating clinical information to other care providers involved in treating the patient, as well as a reminder of past encounters. The note also serves other purposes including justification of billing, defense when there is a liability concern and data collection for reporting metrics necessary to meet quality and pay-for-performance measures. Many physicians complain that these purposes, which should be secondary, have become the primary goal, and many EHR systems are built solely to support those secondary concerns and sacrifice both ease of documentation and ease of reading later. A documentation template should be easy to complete and allow the physician to automatically meet all of these goals simply in the course of their normal workflow.

What many clinicians may not realize is that an EHR can and should serve as far more than electronic paper. The practice of medicine is extremely complex today and clinical “best practices” are constantly changing such that no physician can keep up with all the literature relevant to their practice. CDS tools embedded within the EHR, when part of the clinician’s usual workflow, can help drive better and more consistent care while reducing the cognitive load of the physician. The details and intervals of preventive care; appropriate billing codes and modifiers to meet the variable rules of each insurance payer; the seemingly infinite number of drug-drug, drug-disease, drug-age or drug-allergy interactions; as well as reminders for appropriate drug monitoring with labs and other testing are just some examples of the many tasks that can be automated by a computer, allowing the physician to spend more time doing what only a physician can do. Why should the physician need to memorize the nuances and intricacies of the immunization schedule or the extensive follow-up intervals and treatment plans for pap smears when the EHR system can help ease that cognitive burden?

So why aren’t we there yet? Why do so many physicians still struggle to get through their day? What needs to be done to achieve the promise of the EHR? First and foremost, physicians and other clinicians must be intimately involved in the design, build, training and optimization of the system both at the vendor and practice levels. The biggest mistake made by many large health care systems is not considering the day-to-day workflows that clinicians go through. The system should be built with this in mind so the computers work for the clinician rather than the other way around. Investment in physicians on EHR teams is a costly endeavor but it has a positive return on investment.

Another mistake frequently made is skimping on training. Taking physicians out of patient care to train on the EHR means fewer patients and less revenue during training time. However, it is even more costly if that physician indefinitely spends five extra minutes per visit navigating the EHR system because they are not trained appropriately. Costs increase even more when that physician burns out, leaves the practice and needs to be replaced . The return on investment occurs very quickly with proper training; saving a properly trained clinician 30 minutes per day will show a return on investment in 16 days. Continuing to provide ongoing optimization also helps. At our organization, preventing even one physician from leaving resulted in our ability to fund the provider optimization program for three-tofour years.

While the world of medicine now requires vast amounts of data collection and reporting which the EHR has made possible, but also now couldn’t be completed without its help, we are required to function in a world in which we need to focus on the EHR as a friend rather than a foe. Clinicians can take steps to help in this process. We offer the following advice:

1. Involve clinical personnel, including physicians, in the design, build, training and optimization of your EHR system. If your system doesn’t currently do this, advocate for that change.

2. Build the system with clinical workflows in mind. Make the system work for the providers, not the other way around .

3. Attend training sessions when offered. It doesn’t matter how busy your clinical practice is; poorly trained clinicians with ineffective workflows will ultimately be worse for the day-to-day practice experience and long-term mental health of the clinician.

4. Build workflows to utilize the expertise of every member of your team. Paper labs used to be reviewed by MAs or nurses prior to clinician review, and that workflow can remain even in an electronic setting. MAs can also help to document HPI, review systems, and perform med reconciliation and other documentation tasks. Make sure each member of your team works up to licensure to help distribute the burdens more equally.

5. Try to make the mental shift away from blaming the EHR for current issues in the practice of medicine and, when possible, work constructively to offer alternatives to make practicing of medicine better and easier for all. +

Leah Doret, MD is a family-medicine trained physician who currently provides services for disability review and works per diem in primary care.

Lloyd Fisher, MD is a primary care pediatrician, clinical informaticist and Associate Medical Director for Informatics at Reliant Medical Group.

References

1. Gardner RL, Cooper E, Haskell J et al. Physician stress and burnout: the impact of health information technology, J Am med Inform Assoc 2019;26 (2): 106-14.

2. Gesner E, Gazarian P, Dykes P. The burden and burnout in documenting patient care: an integrative literature review. Stud Health Technol Inform 2019; 264:1194-8.

3. AAMC. The Complexities of Physician Supply and Demand: Projections From 2019 to 2034. Washington DC: AAMC; 2021. https:// www.aamc.org/media/54681/download. Accessed July 31, 2022.