I got this idea today while reading the usual Twitter
complaints about the electronic health record. A post by physician I knew was
particularly poignant. She pointed out that she was getting burnout from the
excessive time it takes to do EHR documentation compounded by the fact that
nobody ever reads it. This is a complaint I have had for a long time. I was lucky enough to be on the ground as the
EHRs rolled out. There was quite a prelude to the rollout with about a solid 10-year
buildup of documentation and billing requirements. Those requirements originated
with the federal government specifically HCFA – the precursor to CMS. All of
the initial EHRs were designed around these documentation and coding templates.
It was strictly a business focus sold as something necessary for medical
practice.
I can recall the first people on the medical staff who were designated to sell the system. They came to see me and I pointed
out that I have never been a touch typist and the fastest I can type is 12
words a minute with two mistakes. When they realized I wasn’t kidding they tried
to soften the blow by saying that we would be slowly transitioned to creating
the entire document. During that transition time we would still be able to
dictate admission notes and discharge summaries. When I complained that this
would still be quite a burden on physicians producing all these documents I was
told by an internist (who I had a very high opinion of) “You need to thank our
CEO for getting us this state-of-the-art system.” That was one of the more
depressing remarks that I’ve heard in my career.
I did try to make the most of it. I got an early version of
Dragon and started dictating all my notes and into Word and pasting them into the EHR.
It was not pretty. There were many mistakes and if I missed some of
those mistakes it could prove to be an embarrassing document. The nursing staff
I worked with helped to edit those documents and point out the mistakes but
some mistakes invariably went through. I learned that the nursing staff in my
immediate proximity were the only people who ever read those notes. I was
generating multiple 500 to 1000 word documents a day and suddenly realized that
I had to complete that work between 10 PM and midnight every day. Within a few
years the new car smell was off the EHR and things were getting ugly. I started to see 18 to 20 page progress notes
based on import and cut-and-paste features. My speculation is at
one point the vendor was desperate to prove they could introduce some physician
friendly features. The ability to start a new daily progress note based on
yesterday’s note soon became history. Administrators decided that the new note
looked too much like the old note even though they were based on same template.
EHR politics is always interesting to observe. There are a
cadre of administrators and “super users” who are tasked with selling the
product to the frontline physicians. There are also various helpdesks that are
run by the vendor. Staff at those helpdesks are supposed to be available for
troubleshooting and problem solving. The troubleshooting and problem solving eventually
fades away. EHRs are typically implemented in modules. I walked into work one
morning and realized that the module that allowed electronic prescribing was
completely changed. The change was not announced and since it was an
enterprise wide implementation there were hundreds of physicians trying to
figure it out for themselves. It added hours to everyone’s day.
With the shift of billing, coding, and documentation to
physicians many other jobs were lost due to the EHR. For 15 years I would go to
the basement of the hospital every Sunday and make sure all of my records were
dictated and signed. I ran into the same staff there every weekend who greeted
me and assisted me with completing those records. Suddenly they were gone
because now I was doing all of their work in the EHR. When I first started
working at my job, I would dictate daily progress notes and they would be
pasted into the chart by the secretarial staff the next day. Billing and coding
specialists would come to the unit, read those notes, and attach a billing fee.
I had no idea about the billing system and didn’t really care. With the EHR all
of those staff were replaced. I was not only doing their jobs but now I was
legally responsible for any billing errors and the suggested penalties were
high. All of this additional work and responsibility was directly transferred
to physicians through the EHR.
The only real bright spot from the EHR was the ability to
see imaging studies, electrocardiograms, and laboratory results as soon as they
were available. It took years to get that implemented to the point it worked
effectively.
Are there workarounds to successfully use the EHR without
burnout, depression, and excessive work? I think that there are. The last few
years I have been seen by ophthalmologists who were retinal specialists and an
otolaryngologist or ENT physician. In both cases these positions were using a
scribe or a third person in the room who documented the history, exam,
findings, and treatment plan as indicated by the physician. In the case of the
retinal specialist he was working with an ophthalmology fellow and made
corrections to that examination by directions to the scribe. The same thing
happened with the ENT physician but in that case the scribe was also an RN who
could provide more details about the suggested treatment plan. In both cases
the physician walked out of the room at the end of the encounter with no further
documentation burden. That led one of my colleagues to point out that the only
reasonable workaround for the EHR problem is to use two people - the physician and
a scribe or staff person who could also function as a scribe.
That led to my idea about the Physicians Preservation Act
at the top of this post. It addresses all the flaws in the system that were
brought about by heavy lobbying and Congressional advocacy for a burdensome
inefficient electronic documentation system. As I pointed out in a 2015 post, the
system has never lived up to claims of efficiency or savings even when
physicians started to do the work of four or five people. This entire
administrative structure is there to produce excessive documentation that
nobody reads. There is also a massive environmental cost since the system must
operate through thousands of networked personal computers that in many cases
are operating 24/7 along with the associated data storage facilities.
My suggested solution is a compromise between the likely
inertia of the current EHR system and the politics that keep it in place and the
massive burden it places on physicians and their families. There are just too
many special interests in Congress keeping this system afloat. The question is
how long can the country afford to lose doctors because of it.
My guess is not too much longer.
George Dawson, MD, DFAPA
