Many Docs Dissatisfied With EHRs, Job Pace, Regs: RAND Study

October 09, 2013

Physicians are happy when they see themselves delivering high-quality patient care and unhappy in the face of clinical obstacles such as cumbersome electronic health record (EHR) systems, a hamster wheel work pace, and burdensome government regulations, according to a new study by RAND, released today.

Overall, 81% of physicians say they are satisfied with their current job, but 47% describe it as extremely stressful and 19% say they are "definitely burning out."

The study of 30 physician practices in 6 states, commissioned by the American Medical Association (AMA), stated that the negative effect of EHRs on the morale of many physicians was one of the "most novel and important findings."

"The number of practices that brought this up, and the intensity of the feeling, was surprising," said Jay Crosson, MD, a study coauthor and the AMA's group vice president of physician satisfaction, care delivery, and payment, in a news conference yesterday.

Strong emotions about EHRs surface in physician remarks that appear in the report.

  • "What we've created is a monster, when really what we were shooting for was good patient care," said a physician about the government's program to promote "meaningful use" of EHRs with bonuses and penalties. The extra time spent "working the chart" to satisfy meaningful use requirements, the physician said, takes away from face time with the patient.

  • "I am not a clerk," added a cardiologist who complained how the technology increased data entry responsibilities. Sixty-one percent of physicians surveyed are like-minded, saying that EHRs require them to perform tasks others could handle.

  • "The EHR is not just a one-time investment," said a physician with practice management duties. "It's a hugely expensive, ongoing, every-freaking-day investment."

RAND, a nonprofit think tank, heard other complaints about EHRs. Key clinical data get lost in the verbosity of a template or macro-generated progress note. Information overload in general heightens stress. And practices continue to traffic in hard copy faxes because their EHR does not talk to the systems at other practices.

Getting Docked for Not Making the Quota

The dissatisfaction with EHRs dovetails with 2 other sore points in medical practice today, according to the RAND study.

One is the cumulative effect of regulations and rules imposed by government and private health insurance companies. "All these things are just sapping our strength," the study quoted an orthopedic surgeon as saying.

The regulations mentioned most often involve the EHR meaningful use program. On one hand, physicians said meaningful use requirements prompt them to deliver better patient care — reviewing and updating medication lists, for example. However, "each patient visit is taking much, much longer," said a pediatrician.

All this mouse-clicking adds to the pressure of making it through the daily schedule of patients, which is another source of dissatisfaction for many physicians.

"The unrelenting pace of patient care...not only led to innumerable long hours, but also was an error waiting to happen," said a primary care physician about a practice she left. "There isn't time to ask all the questions that need to be asked, to do all the informed consents that need to be done." Another physician described a practice where "bean counters" dock the pay of clinicians if they fail to meet their daily quota of patients.

Overall, 25% of physicians describe the atmosphere of their practice as chaotic. However, 60% of physicians said they had adequate time with patients.

7 in 10 Physicians Say Their Total Compensation Is Fair

Not all the findings in the RAND study on physician satisfaction are downers. Physicians told researchers, for example, that EHRs make patient data more accessible (think wireless access from a hotel room), more legible, and more meaningful.

"I can click a button and see blood pressures over time," said a physician. "It's not like thumbing through pages to say, 'What was your last blood pressure? Oh, what was the one before that?' "

All in all, 6 in 10 physicians with EHRs say the technology improves the quality of care, and only 1 in 5 say they would prefer using paper charts again.

In addition, physicians are relatively content with their income, it turns out: 7 in 10 agree that their total compensation package is fair, and 8 in 10 say they are satisfied with their fringe benefits. However, the RAND study found that some physicians, particularly specialists, worry about "financial sustainability" as healthcare reform shifts more dollars to primary care.

Although the Affordable Care Act (ACA) has fervent detractors and supporters within medicine, the controversial law has yet to move the needle on physician satisfaction very much in either direction, according to the RAND study.

"Health reform is a source of uncertainty for many physicians," said lead author and RAND natural scientist Mark Friedberg, MD, at yesterday's news conference. "Physician practices are reacting to this uncertainty by growing in size or merging with larger organizations...so they will be able to withstand whatever changes are coming down the pike.

"However, it is too early to know the effects of reform on professional satisfaction."

Becoming a hospital employee to play it safe, however, comes with less control over one's work, and that is a definite morale deflator, according to the study.

"In our sample, physicians in physician-owned practices or partnerships were more likely to be satisfied than those in other ownership models," Dr. Friedberg and coauthors write.

Improving physician morale is not just an end in itself, according to the RAND researchers. They found that professional contentment is strongly associated with a physician's self-reported ability to deliver high-quality care. Accordingly, taking the pulse of physicians is good for the entire healthcare system, Dr. Friedberg said in yesterday's news conference.

"[The findings] suggest that physicians could be seen as canaries in the coal mine for quality, as an early indicator of potential problems," he said. Poor morale is not always the result of a quality breakdown, he conceded, but when it is, fixing the problem benefits patients and physicians alike.

AMA President Ardis Dee Hoven, MD, summed it up this way: "When you have satisfied physicians, you have satisfied patients with good health outcomes."

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