Relieve Overloaded Physicians by Overhauling Health IT

Ingrid Hein

March 27, 2017


Physicians are bogged down with administrative and clerical duties because health information technology (IT) systems are poorly designed, according to a position paper from the American College of Physicians (ACP), published online today in the Annals of Internal Medicine.

"Physicians are spending too much time entering critical data," said Nitin Damle, MD, president-elect of the ACP. "They're doing clerical work more than anything else, and the tech is still not there to make data entry and interoperability easy and functional."

"Medicine is a narrative, and each patient has a different story to tell," he told Medscape Medical News. With stringent guidelines to "hit so many bullet points" in the software, "people are doing a lot of copy and paste, and sometimes that's not appropriate; it doesn't create a narrative, just a series of notes that are incomplete."

Although "we're not spending time finding charts like we used to," Dr Damle explained, the time it takes to enter and retrieve data in various fields has grown tremendously, leading to physician burnout and a decline in the time available to spend with the patient. Exacerbating the problem are issues such as the need for prior authorization for medication and the time required to review reports and understand them.

Shortfalls in Usability and Interoperability

Deficits in the usability and meaningful interoperability of electronic health records have become a great source of dissatisfaction among clinicians, according to the position paper, which was released just two days before the start of the ACP Internal Medicine (IM) 2017 meeting in San Diego, where much of the discussion will focus on topics such as health policy and information technology.

There needs to be more uniformity across health plans "so we're not reporting different measures to different health plans with different reporting requirements," Dr Damle pointed out. In addition, the number of quality measures needs to be reduced and the balance needs to be better between the burden for the physician entering the data and the resulting benefits the data will provide.

And "to minimize the need to count up the bullet points to meet the code," he explained, "prior authorization requirements need to be simplified."

To develop their position paper, members of the ACP medical practice and quality committee conducted an environmental scan and a literature review of more than 60 research papers looking at the way increases in administrative tasks have affected physician time, practice, system cost, and burnout. Their conclusion is that a framework that assesses and regulates administrative tasks and shifts from a volume-based model to a value-based model is needed.

"We need a push for innovation from providers," Dr Damle explained. It takes 10 minutes to ask mandatory one-size-fits-all questions and 30 minutes to get authorization for an MRI, which eats into time for individualized care.

According to one study, physicians in the emergency department spend 43% of their time on data entry and, during a busy 10-hour shift, charting functions and documenting patient encounters involve 4000 mouse clicks (Am J Emerg Med. 2013;31:1591-1594).

And after all that, new administrative tasks might not even be beneficial.

Innovation Needed

Electronic health records are the future of healthcare, and are "a vast improvement over paper," Dr Damle acknowledged. However, the basic tools and data-entry technology "have not improved since the 90s, when they were introduced."

Stakeholders need to work together to improve health IT systems, to develop technologies to improve the process, and to measure the impact clerical tasks have on patients, clinicians, and costs.

The state of the electronic health record can be improved, said Dean Sittig, PhD, from the School of Biomedical Informatics at the University of Texas Health Sciences Center in Houston. Some of his published research has looked at the unintended consequences of clinical information systems, and specifically the effect of errors on the quality of care.

"Electronic health records have brought new types of problems," Dr Sittig explained. For example, "when you have a drop-down list of medications, it's easy to select the one right above or right below."

"Because it's in alphabetical order, and the next medication is not necessarily related, and you could end up with an entirely incorrect medication." In fact, one patient died after receiving a paralytic medication instead of an antinausea medication, he reported.

The persistent use of paper is also a problem, and the negative emotions the technology engenders can lead to an inability to carry out other tasks. What's more, entering data often leads to the "illusion" of communication with other team members, but the information might never get to the next care provider.

Ultimately, the responsibility for fixing the system has to be shared. "You can't just blame the computer and say someone needs to fix it. Computer scientists and informaticians don't always know about these problems," Dr Sittig pointed out.

Although changes to the technology are needed, policies and practices also have to change. "Perverse incentives" in the current system, for example, often make looking at previous health records unprofitable, he explained. "Why look at an old MRI when I can order a new one and bill for it?"

"We wanted to build systems to make lives better. In some ways we've done that, but in others, we've made it worse. Nobody expected that," Dr Sittig told Medscape Medical News. "We need to acknowledge that."

"Technologically, we need to get to the next step," Dr Damle pointed out. Although some clinicians use scribes to meet clerical requirements, that does not work for everyone, and it can add costs and problems. He said he is confident the technology will improve, but the current state needs to be addressed.

"Eventually, we'll be able to have clinicians using voice recognition to add information and get access to a charts, but we're not there yet," he explained. "We're really in a disruptive technology phase of computerization. Artificial intelligence — whether in home or care or health records — will come."

Algorithms will eventually overtake some of the "mundane things we do," Dr Damle predicted. "Maybe 20 years from now, or longer, the keyboard will be a thing of the past. That is the vision."


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