This article is based on episode #19 of A Bridge To Wholeness podcast. You can listen to the episode on iTunes, Stitcher, and on our website.
Today I would like to talk about what an electronic health record is, how it relates to physician burn out, and also how it relates to you as a patient or a client and some things that you may want to keep in mind as a patient or client when you are dealing with electronic health records. Over this past weekend, I found an article in Fortune Magazine, it showed up in my Facebook feed, and the title of it really caught my eye, and it’s called Death by a Thousand Clicks, Where Electronic Health Records Went Wrong.
I thought to myself, “Wow, that’s probably a really interesting article.” What I didn’t realize was how long the article was, but so well written, absolutely amazing research, and so I’d like to talk about that today. The article was written by Erica Fry and Fred Schulte. That’s Erica Fry, F-R-Y, and Fred Schulte, S-C-H-U-L-T-E. It was posted on March 18th 2019, and the subtitle under that says, “The US government claimed that turning American medical charts into electronic records would make health care better, safer and cheaper. 10 years and $36 billion later, the system is an unholy mess. Inside a digital revolution gone wrong, a joint investigation by Fortune and Kaiser Health News.”
I really want to say great accolades to them because this was a lot of work, you can tell. It takes a while to get through the article, but if you’re in the health care industry or if you’re a physician, any type of a health care provider, I would strongly suggest that you read this, because it’s really, really amazing the amount of information that’s in here.
The article goes into various patient stories that happened secondary to electronic health records and misinformation, or information that was not done correctly, or information that was not shared between physicians and hospitals. There’s quite a few stories in the article about that. They’re not very comfortable to read, but it’s what’s happened. Electronic health records, they’ve done a lot for us over the years, because it is easier to get information now if you’re a patient or a client.
Often, physician practices will have a way for you to connect to your own patient portal, and you can find information in there, which is a great thing. That’s wonderful. They were supposed to make medicine a lot safer, according to the article bring higher quality care, empower patients and save money. That’s all according to the article. This was great, but it’s really not functioning the way it should, and in the article it says, “10 years after President Barack Obama signed the law to accelerate the digitization of medical records with the federal government so far sinking $36 billion into the effort, America has little to show for its investment.”
It says in here that, “Kaiser Health News and Fortune spoke with more than 100 physicians, patients, IT experts and administrators, health policy leaders, attorneys, top government officials and representatives at more than a half dozen electronic health record vendors, including the CEOs of two of the companies. The interviews reveal a tragic missed opportunity. Rather than an electronic ecosystem of information, the nation’s thousands of electronic health records largely remain a sprawling, disconnected patchwork. Moreover, the effort has handcuffed health providers to technology they mostly can’t stand, and has enriched and empowered the $13 billion a year industry that sells it.”
That is an actual paragraph that was in the article. That pretty much sums it all up right there. This is a $13 billion a year industry selling software products to physician practices, to hospital systems and it’s not working the way they thought it was going to work. What happens here? I think it’s, again, one of those things that we often take for granted in this day and age of technology is that when we have technology as electronic health records, we just don’t think about it. We just take it for granted that it’s working and that it works well.
What this article is pointing out is that there’s a lot of things that really need to be worked through electronic health records to straighten out a lot of glitches, a lot of situations, and also how does it affect health care providers in general? What type of stress is it causing physicians and doctors? This is something that we never think about, although I’ve heard quite a few of my friends and family talk about the fact that when they go to see a doctor, oftentimes the doctor will walk in, sit down on the stool, open the laptop, and begin asking questions without even saying hello to the patient, or they say hello and they immediately start looking at their screen.
You just feel like, “Why am I here? They’re not even looking at me. They’re not even looking at me in the eye.” I think part of the problem is because the physicians and these health care providers have so much documentation to do inside these systems that it’s taking up a lot of their time. That’s very unfortunate, because it puts a lot of stress on both the patient and the health care provider.
Here’s a statistic for you that was in the article. According to an American Journal of Emergency Medicine study, the approximate number of computer clicks that an ER doctor makes over the course of a single shift, which is usually 12 hours, is 4,000. That’s a lot of computer clicks. I can’t even imagine dealing with that, although I’m sure I used to do that as a nurse when I used to have to document on the computer.
I do know that for me I started out with paper documentation and then we moved to a computer system when I worked at the hospital, and it was overwhelming just to learn the system, and then to have to document and make sure that you’re doing it correctly. It took quite a bit of time to do that. I just never felt really good about it. I didn’t feel like it was intuitive for the health care providers or staff to actually use. I’m sure they’ve gotten much better over the years though. That’s been a while ago.
Here’s another statistic that you might want to think about. The average time that doctors spend on filling out electronic health records compared with how many hours they actually spend with patients is really amazing. They spend 5.9 hours on average documenting in those electronic health records, and only 5.1 hours spent with patients. That’s according to a 2017 study in the Annals of Family Medicine. That’s not a good thing, because they’re spending over half of their time in a normal work day documenting and less time with patients. This is something that we hear about all the time.
Some other statistics that you might find really interesting. There’s a real epidemic of burn out with physicians. I’m going to go ahead and read this from the article. “The numbing repetition, the box ticking and the endless searching on pull-down menus are all part of the cognitive burden that is wearing out today’s physicians and driving increasing numbers into early retirement. In recent years, ‘physician burnout,’ has skyrocketed to the top of the agenda in medicine. A 2018 Merit Hawkins survey found a staggering 78% of doctors suffered symptoms of burn out, and in January the Harvard School of Public Health and other institutions deemed it a ‘public health crisis.'”
One of the co-authors of that Harvard study, Ashish Jha, J-H-A, pinned much of the blame on “the growth in poorly-designed digital health records that have required the physician spend more and more time on tasks that don’t directly benefit patients.” That is really unfortunate, because physicians want to spend time with their patients. They don’t want to spend time dealing with documentation all the time. Yes, it is part of what health care providers do, but if more than half of your day is spent documenting on a computer system that is not intuitive to you, that’s got to be very frustrating.
There’s a glossary they have inside this article, and there is a few terms in here I thought were really interesting. There is alert fatigue, which evidently a lot of these electronic health records have alerts on them that are well-intentioned safeguards, they say, for workers. Evidently according to a lot of the users, there are many that are just irrelevant, and so they just tend to ignore them after a while.
There’s another one called pajama time, and this has to do with hours that physicians log after work spending time documenting above and beyond what they’ve already done in the office which is close to six hours. They spend an additional 90 minutes of work every day documenting when they get home. That 12 hour shift then turns into a 13 and a half, 14 hour day. Then there’s note bloat, they have in this article, that says, “The voluminous form that doctors’ notes take in the electronic health records have evidently really doubled in length over the past decade.”
“Many blame the swelling records on extensive documentation requirements, and the physician’s tendency to cut and paste notes from previous encounters.” That’s what they’re doing, so the records are getting longer and longer and longer, so they’re spending more time doing it, because they’re copying and pasting, or cutting and pasting from previous notes, so they can bring everything forward. That’s becoming an issue.
Information blocking, this was really interesting, and I’m going to read this exactly as it’s written, “The act of keeping health information from entitled parties, including patients and the health providers they want to share it with. Health systems hold that data dear, and they often behave as if that electronic information is harder to share than it is.” They hold it near and dear to their hearts. They don’t want to let it go. They don’t particularly like to share it, and because of that they make it seem like it’s really hard to do that.
Physicians’ offices don’t want to lose a patient to another physician. I mean no business wants to lose a client to another client, but you have to be willing to let them go when they’re not being served by you. Something else that’s really going on here is that there’s quite a few medication errors that are being found inside these electronic health records. Remember, one of the original purposes to have an EHR was to cut down on medical errors. Well, evidently that is not happening.
Here’s another statistic for you to think about. The number of medication errors linked to electronic health records. Usability issues at three pediatric hospitals from 2012 to 2017 was 3,243 medication errors. That’s according to a Health Affairs study. That’s only three hospitals. That’s only three, so multiply that times the hundreds and thousands of hospitals that we have here in the United States. That’s a lot. That’s a lot of error.
Many of the electronic health records vendors, the makers of these products, evidently they realize and they know that physician burnout is real, and they’re trying to do something about it. It is an ongoing problem, and I think it’s something that we as patients or clients really need to be aware of, because you are, first of all, you’re entitled to your medical records. Secondly, you can get them if you ask for them nicely. Sometimes there’s going to be a charge, but if it’s something exorbitant, that means probably maybe they’re just not willing to turn them over to you, I’m assuming. It shouldn’t cost you $500 to get medical records, at least I don’t think so.
Also, I really believe though because this problem does exist, it’s up to us as patients and clients to make sure that the information that we are giving the physicians is probably repeated back to us during the consult, making sure that they’re getting the information correctly. Why not ask to see the information right after the physician has documented it? Is there anything wrong with that? Could we actually say, “Hey, let me have a peek at that, make sure you have the information correct”? Could we do that? I’m not sure, but maybe that’s something that we can think about.
Also, I would definitely be asking for a copy of your records of your visit when you go that day, because that’s always really helpful. A lot of physician practices do this routinely. They have patient portals, you can check in. You can get your records, but you probably need to really start going in there now and making sure that the information they have in those electronic health records is actually correct. Because there are a lot of errors, and we want to make sure as patients and clients that we know and we can have them corrected for ourselves, so we don’t get into trouble later.
Some of the things that are being done to address this situation are some steps that hopefully will be put in place soon by these electronic health record companies and by the government, and that is to have voice, so doctors don’t have to document a thing, when the EHR knows what’s being said. Basically it’s just transcribing the voice of the doctor right into the electronic health record, so they actually don’t have to sit there and type the notes in, which would be great.
There’s another one, making mobile devices more user friendly for the health care providers so that they have a mobile platform that allows them to chart more intuitively, and they have portable touchscreens. That’s something else they’re also working on. Also, human scribes. Wow, this is really going back in time, having somebody take notes for you as you’re speaking to the client. If you’re the health care provider, you have a human person who comes in with their computer and they take the notes while you as the health care provider are talking to the patient.
I actually had this experience with my own father. We went into his pulmonologist office, and the scribe came in. The scribe was shadowing him, because I think she was going to school for this particular thing, and the physician was thinking about hiring one. She was probably working there doing an internship. She actually took all the conversation down while the physician was speaking to my father and speaking to myself. I thought, “Wow. This is pretty amazing.”
He was actually able to give his full attention to my father and to myself during that visit. I thought that was really great. The problem there is that it’s very cost prohibitive for the physicians to use that. Obviously, it was a great thing, because I could really see that the physician was a lot more relaxed when speaking with my dad, because he didn’t have to sit there in front of a computer.
Let me tell you something, when you’re dealing with, and this is something you probably don’t think about, but when you are dealing with an elderly patient who has dementia or Alzheimer’s, as my father did, that’s a big deal. I can remember my dad going in to a physician’s office, and they would sit there with their computers, and my father would just ask me over and over again, “What is he doing? What is he doing? What is she doing? Why does she have that computer up there? Why aren’t they talking to me?” I mean seriously, that’s also a level of stress that the patient has to deal with and the physician has to deal with.
I wanted to bring this article up today because I thought it was really important to get this information out there. I have a copy of the article. I posted it on my Facebook page, which is Jennifer Crisp RN, Whole Health Educator. You can find it on my Facebook page, if you want to have a copy of that. It’s also coming out in Fortune Magazine in April, so a copy of that will be in the Fortune Magazine article. I would go ahead and look for it. Especially if you are in the health care world, you will find this information to be absolutely fascinating.
Throughout the article there are also some little documentary that they also did after this, and you’ll see it. I believe it’s in four parts. I haven’t even taken the time to watch those yet. I do really want to stress that the electronic health records companies, they’re aware of what’s going on. The physicians, health care providers, they’re aware that there is this situation of discontent with electronic health records. People are looking into trying to make things better. I want to say from a patient’s point of view that we need to be aware of this as well, so that we can be supportive of our health care providers when we go to the office or when we’re going to the hospital.
Take a minute when a physician comes in, a nurse comes in, whoever comes in, if they’ve got a computer with them and they just start right in and they don’t even look at you, stand your ground. Take a minute. Be very nice about it, and just say to them, “Excuse me. I know you’re really, really busy, but could you just put the laptop down for a minute and let’s just introduce ourselves, make eye contact, so that when I’m talking to you and giving you information you know that I’m really here. You know I’m a human being.”
They are in the same position. They’re also human beings. They’re under a lot of stress, and we want to make sure that our health care providers are also allowed to be human. We don’t want to burn them out before they’re ready to retire. We need them. Whether you’re in conventional medicine where this is very, very common, or in some alternative practices, I haven’t seen that many alternative practices that use the computer that much for their patients’ notes, but be aware of this. Be mindful. Be courteous to your health care providers. We need them.
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