COMMENTARY

To EHR Is Inhumane—Addressing the Shortcomings of the Interface

Peter M. Antevy, MD; Tracey A. Loscar, BA, NRP

Disclosures

March 26, 2019

Documentation is a vital part of medicine, both the science and the art. It's a series of notes and observations, recording interactions and treatment that eventually coalesce into the sum of a patient's medical history. It is by turns probably one of the most crucial, and tedious, tasks in patient care delivery.

The modern age has replaced the scratch of a quill with the muted click of the keys, and as the Information Age progresses, so does the amount of input it requires to keep the healthcare machine turning. Instead of working with a snapshot of time, practitioners have years' worth of history available instantly at their fingertips. Electronic health records (EHRs) have the capacity to make the physician's job more efficient and effective, increasing both scope and clarity.

What is the cost for this potentially infinite wealth of information? Is there such a thing as too many records? Or does it become more of a matter of devising a system that balances amount of input with the quality of output?

HIT-Related Stress and Exhaustion

Today the utilization of health information technology (HIT) and the completion of the EHR has become a fundamental part of any form of practice. But technologies advance at different rates, and the EHR can have a steep learning curve. While transitioning from one smartphone to another may be seamless, the same cannot be said for the various EHR applications. You can switch from app to app with a swipe of the thumb, but requesting outpatient tests may require multiple log-ins and authorizations on a patchwork of proprietary programs that may or may not communicate with one another.

HIT-related stress is not only miserable, it's also measurable, and it's emerging as a major factor in clinician burnout.

The amount of effort required to navigate today's HIT systems is directly inverse to its original intent. It has morphed into an exhaustive, time-consuming requirement that is damaging the very systems of healthcare delivery it was designed to assist. HIT-related stress is not only miserable, it's also measurable, and it's emerging as a major factor in clinician burnout. Studies report that as many as 70% of physicians report HIT-related issues as a major factor in their stress level, with insufficient time for documentation being the strongest predictor of burnout overall.[1]

While no specialty is immune, the highest prevalence was among primary care–oriented specialties, with pediatrics and psychiatry almost doubling the rate of other respondents. Working in an era when billing is driven by documentation, the EHR is pulling more and more time away from direct patient care. Physicians estimate that they are spending over half of their time doing HIT-related tasks, with only a portion of that directly relating to patient care.

Treatment Errors Still Common Despite EHR Implementation

The medical profession is renowned for its poor handwriting. Often a loosely organized series of scratches resembling bird tracks across the page, the inability of the average person to read what's written has become easy fodder for litigators and patient safety advocates. It is not a far reach to wonder just how frequently poor handwriting or incomplete notes have resulted in errors in treatment and medication administration.

Patient files become bloated, full of identical-looking forms and repetitive entries in order to satisfy requirements.

With the implementation of the EHR, it would be easy to assume that there would be a reduction in treatment errors and adverse drug events (ADEs). Unfortunately, this is not the case. Electronic records may be legible, but their digital nature makes them easier to retain. Patient files become bloated, full of identical-looking forms and repetitive entries in order to satisfy requirements. Like their paper predecessors, Colicchio and Cimino recently noted that "clinical notes produced with EHRs frequently contain redundant information and errors and may never be read despite containing relevant information for patient care."[2]

When writing for compliance and not necessarily comprehension, fragments of redundant information lose their impact. This includes important notes about test results, individual events, and current (or prior) medication regimes. Minor events that did not have a negative effect, but still triggered an automated warning in an EHR system, can go overlooked, disregarded, or silenced—like so many IV pumps in care units everywhere. This text-based alarm fatigue is both costly and dangerous. It is estimated that approximately 5.5 million medication-related alerts were inappropriately overridden, resulting in approximately 196,600 ADEs nationally, costing between $871 million and $1763 million.[3]

More Time Documenting, Lower Quality of Patient Care

America's unrelenting need to reduce risk has forced physicians and nurses into a pool of redundancy, where 1 hour of hands-on care requires 2 hours of documentation. Their workday rarely ends with the last patient, and many invest hours at work or at home doing remote EHR data entry in a vain attempt at catching up. While the rest of us break our digital fast in the morning with a quick swipe through the social media of our choice, clinicians are having their coffee with a side of unfinished notes from the day before. Notably, physicians consistently working after hours at home on EHR data entry demonstrated twice the rate of burnout.[1]

If the workflow remains complicated, errors are still an issue, and burnout rates continue to increase as a result of HIT-related clinician burden, then what does all of this documentation in the EHR actually do for the patient? It turns out that a majority of physicians and nurses do not believe that it is beneficial to patient care at all.

Today's doctors struggle with 'bedside manner,' demonstrating difficulty in relating to patients on a face-to-face basis.

There is no current research that supports how the EHR should be used and its actual impact on the quality of care. Even with an objective digital framework, it relies on the quality of the input, which is done by a human and is therefore subjective and inconsistent. In one study revolving around the care of patients with post-traumatic stress disorder, providers tended to subjectively decide when to include sensitive information in a patient's medical record.[2] Information deemed to present a risk to a patient's access to care was frequently left out of the note (eg, sexuality or nonmilitary trauma). Inadequate training and differences in systems mean that common clinical tasks can have a huge range of variability in recording and execution, ultimately inviting errors or oversights.

Physicians are inherently scientific and in the modern era have remained current with science's advances. Just because they may not understand the intricacies of say, Snapchat, it does not mean that they are Luddites incapable of learning how to navigate HIT. Yet, doctors with identical backgrounds utilizing two proprietary programs to complete tasks will yield different results. APRNs working in primary care curve differently, having more favorable perceptions of EHRs and HIT in general.[4] Over 60% of APRNs, double the rate of physicians, feel that EHRs improve patient care.[4] Is that due to different job responsibilities or type of fundamental training?

How Can We Improve the Problematic Workflow?

If working with HIT is so onerous, why hasn't it been identified or addressed more rapidly? Physicians do not work in silos; independent practice has dwindled. "Across the United States, more than half of physicians are employees, and some work for nontraditional medical employers such as insurers and payers," reports Strongwater in a recent video.[5] Preapprovals, justifications, and multiple screen entries that must be entered and navigated in identical processes all produce a 2:1 ratio of time where it takes the clinician twice as long to justify an act as it was to do one.

The Information Age makes screens an extension of our lives, and medicine is no exception. Personal efforts to streamline workflow result in doctors staring at screens and typing, appearing to listen with only half an ear while attempting to complete a physical exam and develop a treatment plan. Today's doctors struggle with "bedside manner," demonstrating difficulty in relating to patients on a face-to-face basis. How can we expect them to when their care justification is dictated by the screen?

It becomes incumbent on organizational leadership to address problematic workflow and care for the clinicians who work for them. Clinician burnout and patient safety have led to a campaign that aims to identify and address the issues that stem from poor EHR usability. In their latest joint effort, Washington, DC-based MedStar and the American Medical Association are making available, for the first time, videos from the clinician's point of view that demonstrate the risks and challenges caused by poor EHR usability.[6] The videos have been made available on a new website, EHRSeeWhatWeMean.org, and they present "compelling evidence for the need to act," according to officials.

Organizations should seek to address the fundamental faults with EHR usability and the impact it has on their clinicians and their agencies. Some have already begun to implement process changes to decrease clinician burden, such as better training, operator involvement in EHR development, the use of scribes, and the implementation of policies that restrict doing EHR work from home or on vacation. Additional empathy training to help clinicians improve direct patient interaction may reduce stress and frustration, enabling them to be with the patient, not the screen.

Today's healthcare practitioners are drowning in a sea of text, and if they cannot stay ahead of the tide of virtual paperwork, they get tossed ashore, exhausted and uncompensated, their cries for help unheeded, as the sound of unfinished entries buzz around their heads with angry clicks.

Interoperability and third-party integrations are the key concepts to watch for in 2019 as EHRs look to enhance their offerings, improve usability, and provide clinicians a better user experience. The Fast Healthcare Interoperability Resources (FHIR) standard has taken hold, accompanied by a bridled optimism among those in the industry. By allowing the silos of healthcare to connect seamlessly, the FHIR standard may prove to be a leap forward for both healthcare providers and consumers alike. The full potential of FHIR has yet to be unlocked, with EHR vendors, healthcare startups and large consumer brands (Apple, Google, and Amazon) all beginning to play in the sandbox together.

The EHR, and how clinicians use it to document care, is in the midst of a significant transformation. Steve Case, in his book The Third Wave: An Entrepreneur's Vision of the Future, describes the Internet's evolution as a similar transition, one with which HIT vendors and developers are now fully engaged.[7] Multilevel collaboration and the "Internet of things" concept will bring with it happier clinicians, improved patient safety, and ultimately better outcomes.

It's been 20 years since the publication of the Institute of Medicine report To Err Is Human: Building a Safer Health System, when paper charts ruled our lives.[8] Only time will tell if the EHR can adopt a level of humanity that puts the patient back in the center, breaks free from its silos, and allows clinicians to give their patients more of a human touch.

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