Even before EHRs became physicians' No. 1 frustration, physicians were just as burnt out as they are today, according to a comparison of contemporary studies with one from The Kaiser Family Foundation in 2002.
The 2002 National Survey of Physicians — which resurfaced when Tandigm Health Medical Director Manas Kaushik, MD, tweeted it out April 30 — was conducted via mail between March and October 2001. It asked 2,608 physicians involved in direct patient care about opinions on their profession and compared results against two similar, yet earlier, surveys from 1981 and 1999.
The story of the EHR
While EHRs have been around since the 1960s, their implementation didn't really take off until the 21st century. In 2004, President George W. Bush established the Office of the National Coordinator of Health Information Technology to support health IT adoption on a national level. In 2009, President Barack Obama passed the Health Information Technology for Economic and Clinical Health Act to stimulate the adoption of EHRs. Other programs targeting EHR implementation and use later rolled out, such as CMS' meaningful use, which required hospitals to adopt and demonstrate "meaningful use" of the EHR to maintain their existing Medicaid and Medicare reimbursement levels. Between 2007 and 2012, EHR implementation nearly doubled from 34.8 percent to more than 71 percent. Now, around 99 percent of U.S. hospitals have partially or completely implemented an EHR as of 2016, a 33.6 percent increase since 2003.
The idea behind an electronic patient data storage system was to create a decentralized flow of information for the military's use — an issue the government is still grappling with as departments work to modernize their systems and just one of the many problems commonly attributed to EHRs. Privacy breaches, printing errors and miscommunications stemming from EHRs have resulted in a number of lawsuits, and some physicians have cited ethical concerns with the tech as well.
One of the most pressing EHR issues, however, is the hours upon hours spent checking boxes and entering data. Physicians often despise these tasks because they keep them away from face-to-face time with patients and tack an additional six hours onto their workdays, according to a 2017 study in the Annals of Family Medicine. All the box checking and lack of patient face time may be having a negative affect on physician resiliency. Research from Rochester, Minn.-based Mayo Clinic and the American Medical Association published in 2016 linked EHRs to physician burnout. Dissatisfaction with EHRs was a top predictor of physicians' intent to reduce clinical hours or leave their current practice, according to a separate Mayo study published in 2017.
Though the technology was designed to make physicians lives easier, it has clearly failed. But, were physicians happy in their roles before EHRs became the norm?
Burdened before tech, burdened more after
According to the KFF's 2002 survey, physician morale was waning well before most of the federal regulations on EHRs were implemented. Most physicians (87 percent) agreed overall morale decreased in the five years prior to the survey. Just over half of physicians who responded to the survey (53 percent) said they'd recommend the practice of medicine and 45 percent said they would not. Results from the 1981 survey were similar.
The No. 1 reason physicians in 2002 said they wouldn't recommend their profession was paperwork and administrative hassles (57 percent), similar to physicians' complaints today with EHRs — and the majority of respondents (74 percent) said they were dissatisfied with the hours spent on administrative activities compared to patient care. A 2017 Annals of Family Medicine study found clinicians dedicate 5.9 hours of an 11.4-hour workday to using EHRs — 4.5 of which are during clinic hours and 1.4 after hours. Almost half of the EHR time (44.2 percent) was spent on clerical and administrative tasks — such as documentation, order entry, system security, and billing and coding.
Clearly, physician burnout related to administrative work hasn't changed even with the addition of EHRs, which intended to simplify these tasks.
Moreover, the patient relationship is worsening due to the time physicians must dedicate to the computer. While the majority of physicians in 2002 (87 percent) said they were satisfied with the continuity of their relationships with their patients, that number is clearly changing, as evidenced by current surveys.
A February study found the average patient visit was 35.8 minutes, which included 2.9 minutes working in the EHR prior to the physician entering the room, two minutes working in the EHR while in the room and 6.9 minutes on EHR work outside of typical clinic hours. Only 16.5 minutes were dedicated to face-to-face time, less than half the average visit length. Because of this, 86 percent of physicians agreed they weren't satisfied with the amount of face-to-face time they have with their patients, according to a 2017 Physicians Foundation survey.
The hours spent on paperwork and data-entry also take away from the time physicians could be spending with friends and family — another common indicator of job satisfaction. While it's not clear how much time physicians spend out-of-the-office on work-related tasks, in 2002, nearly 43 percent of physicians were happy with the amount of time they had to devote to nonprofessional interests, family and friends. Now, these added EHR responsibilities are keeping physicians away from these extracurriculars.
Perhaps physicians are just experiencing an EHR hangover — once every hospital is on an EHR and physicians have some time to really work out its kinks, things will get better. But, with nearly nine years of increasing EHR adoption, it's possible the EHR isn't the best solution to relieving physicians of administrative work.
A solution on the horizon?
These issues concerning EHRs effect on physicians' happiness are no secret. A number of organizations have called on CMS to address burnout, including The American Academy of Family Physicians, which wrote a letter in February to CMS and ONC proposing seven steps the agencies could adopt to limit unneeded regulatory burdens.
CMS has taken note and is reworking some of its programs to emphasize "patients over paperwork," although it is too early to tell whether these attempts will be a success. Patients Over Paperwork is a clinical engagement initiative focused on reducing regulatory burden in which officials visit physicians across the U.S. to gain insight into which regulations they are most burdened by.
CMS also rolled out meaningful measures as a way to reduce the regulatory hurdles when reporting quality data, and it most recently renamed meaningful use to "promoting interoperability" in an attempt to show its commitment to removing outdated and redundant rules.
HHS' ONC — the agency President Bush birthed — admits that computers have made physicians' lives more challenging, a stark contrast from most other industries, ONC chief Don Rucker, MD, said in June 2017. Dr. Rucker has hinted at an interoperability policy, but the agency has yet to establish one. Instead, in January it released a draft Trusted Exchange Framework, which addressed ways of achieving interoperability.
Other groups, like the American College of Physicians, have launched initiatives aimed at alleviating clinician burnout through creating a culture of wellness, improving practice efficiencies, enhancing individual physician well-being and reducing administrative burdens.
Despite these efforts, most healthcare leaders (60 percent) expect burnout to worsen at their organizations in the next two to three years — only 15 percent think it will get better, according to an April survey published in the New England Journal of Medicine.
The No.1 method for reducing clinician burnout? Minimizing clerical tasks, according to respondents to that study, in which 54 percent cited the need to off-load those tasks to scribes and other workers as a solution and 46 percent supported improvements to the EHR.
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