Thursday, July 3, 2014

The Metrics of Inefficient Electronic Medical Records

Physicians are overwhelmed with the inefficient functionality of today's current crop of EMRs whose design can be traced back to three very unfortunate origins:

(1) The Paper Mentality: Computer automation of existing paper-based medical records and billing systems perpetuated the very dysfunctional and inefficient health care processes that preceded the EMR.  As one of the early physicians to use an EMR told me early in my healthcare career, "This EMR just makes it faster and easier to be even more inefficient." In the early days of EMRs-- 1990s-- there was a missed opportunity to apply software and computerization to dramatically improve efficiency and quality of care, but instead, early software developers chose to simply computerize the familiar paper-based processes. To a large degree, today's EMR implementations are still stuck in this paradigm.

(2) Defensive Medicine: In the 1980s, the Rise of the Lawyers and malpractice litigation in healthcare also gave rise to defensive, paranoid medicine, especially among specialists.  As a result, this paranoia began to emerge in the medical record.  The information that was documented in the EMR became less about effective handoff and communication about patient care and more about protecting the physician from litigation-- and understandably so.  Clinical notes, in particular, grew longer and longer.  The software design of EMRs followed; EMRs became expensive word processors and transcription/dictation systems.

(3) Billing Complexity & Compliance: Once again, beginning in the late 1980s, the complexity of insurance plans, including Medicare and Medicaid, began to increase exponentially.  Depending on which study you believe, at least 30% of healthcare overhead in the US can be attributed to our arcane billing and insurance processing.  The requirements for clinical documentation to justify and comply with billing requirements also increased exponentially.  And, once again, the software design of EMRs followed suit.  E&M coding is just one of many examples.

If we could build an EMR from scratch today, the design and functionality would be motivated by:

(1) Clinician efficiency and throughput
(2) Quality of care for individual patients
(3) Quality of care for populations of similar patients
(4) The economic sustainability and affordability of care

Every click of the mouse, every function of the software, would tie back to one or more of these design motives.  Billing compliance would emerge as a natural consequence, as would protection against litigation.

This article, below, is loaded with the metrics that clearly describes the high and unfortunate impact of current EMRs on the lives of primary care physicians.  The article originally appeared in a newsletter by HealthFinch, an innovative software technology company, dedicated to making the lives of primary care physicians more efficient, more effective, and more fulfilling.  My dear friend, Dr. Lyle Berkowitz, is the Chief Medical Officer and driving force behind HealthFinch.


That racket you're hearing from primary care is the hum of the electronic medical world.  It gets louder every day, threatening to drown out the main purpose of the physician - to provide patient care.  

One of the unfortunate by-products of this otherwise essential innovation is the transformation of physicians into glorified data-entry clerks.   Doctors are now seeing their days eaten up with busy work including endless alerts and data reporting in the EMR. 

To find out just how busy doctors are, Murphy and colleagues assessed EMR alerts transmitted to PCPS at a large VA facility and found that practioners spend an average of 49 minutes per day processing alerts.  Similarly, Singh and colleagues conducted a survey among 2,590 VA primary care physicians and revealed some jarring findings—such as a typical physician receives 63 EMR alerts per day. Over 86% of the doctors surveyed viewed this number as excessive, and 69.6% admitted that this was more than they could effectively handle. On a more alarming note, Singh and colleagues found that nearly one third of the physicians revealed they had missed a test-result notification sent to them via an EMR-based system.

Compared with those old reliable forms of doctor busy work – namely telephone calls, document handling, test analysis, etc.—electronic alerts may seem like mere background noise.  To that end, Richard J. Baron, a physician working in a large Philadelphia practice, used the EMR to track doctor-provided work during the course of a year. Their doctors clocked in an average of 18.1 patient visits per day. Each physician received an average of 23.7 telephone messages per day, reviewed an average of 19.5 lab reports, 11.1 imaging results, and refilled 12.1 prescriptions. And let's not forget emails and consultation reports. Those averaged 16.8 and 13.9, respectively.

The day to day work required to provide high quality, guideline-driven care to patients coupled with the voluminous transactions required in the EMR leaves the average primary care physician feeling burnt out – with little to no time at the end of every day. Short of an immediate, radical shake-up of the federal and state healthcare regulation laws to allow for more delegation of physician work, there are some immediate opportunities for freeing physicians from the grind of busy work. More and more health systems are finding ways to modify workflows both inside and outside of the EMR to help remove some of this work from the busy physician’s plate.  As part of their redesign efforts, many savvy healthcare organizations are also adopting cloud-based applications powered by the EMR to delegate and/or execute clinical tasks – bypassing the physician entirely. 

1 comment:

Lyle Berkowitz, MD said...

Yes - nodding my head all the way! It's time to start building systems based on truly observing the end-users rather than trying to recreate a paper system. I often use the analogy of Dungeons and Dragons. The video game designers didn't simply look at the graph paper and dice and try to replicate those on the screen.. they went deep into the minds of those gamers and designed the system that they were seeing in their minds already - and wound up making a multi-billion dollar business because they too out the boring stuff and made all you do fun and addictive... How can we do the same with our IT systems in healthcare! We will certainly look back on this as the dark ages... but I do see light ahead!!!

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