Key thoughts:
• The Electronic Health Record (EHR) is commonplace, required and plays an important role in today’s healthcare environment.
• Despite many advantages, there’s growing awareness of physician dissatisfaction, reduced patient throughput and productivity.
• Understanding the Patient- Physician-EHR dynamic affords opportunities to transform these limitations into a new generation of support for patients, physicians, and the healthcare team.
The EHR was introduced in the 1980’s as a repository for patient demographics, and has evolved to be much more, as well as currently being a requirement by CMS in order to avoid substantial payment penalties for physicians. Some important roles are 1) a repository for tests and their results, 2) shared information with the patient and other providers, 3) communicating factors that go into decision making, 4) proof of service for insurance reimbursement, 5) an activity trail for medicolegal scrutiny, 6) a record for QA/QI initiatives such as MIPS, 7) an audit trail using big data to identify utilization of resources and costs, and 8) it can ultimately be used to understand and direct physician behaviors.
However, there’s growing awareness of (the easily predicted) physician dissatisfaction, which is worse and more elaborate with powerful EHR’s. Beyond the massive up-front cost, widespread reports of lost revenue and productivity range from 10-25% when instituting an EHR. The amount of time on the computer compared to direct care is a burden; I fondly recall when circulating RNs in the operating room were far more involved in the case compared to now spending most of their time documenting process flow on the computer. It requires upwards of 20 clicks and 8 minutes or more per patient, leading to a physician’s movement calling for “fewer clicks.” And there’s a real depersonalization of the visit with loss of eye contact, and time to connect with the patient. Furthermore, the many roles of the EHR leave the physician wondering for whom we’re documenting.
Present work-arounds to keep up physician productivity include: Short-cuts (templates, abbreviations of medical terminology, cryptic sentences, cut and paste from old notes to appear as higher level of service), “Blind clicks” (not fully reviewing and updating sections in the EHR), voice recognition that requires dictation, and scribes.
What is the future? Will the doctor spend an increasing percent of time documenting instead of doctoring? Drawing some analogy to the airline industry, we have many options. Standard operating procedure (SOP) is akin to clinical pathways that streamline basic decision making. Checklists have already transformed the concept of a surgical safety time out. Instrument recordings can be seamlessly integrated to document physical exam findings. The cockpit voice recorder can substitute part of a typed progress note to create documentation. And legislative and CMS reform can segregate out some requirements of the EHR from the patient visit while allowing for adequate reimbursement and audit capability.
We’re now living through this painful transition, which also affords many advantages to integrated patient care. Transforming the EHR to further support physicians efficiently will ultimately drive patient care into the future.
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This column is part of a series devoted to clarifying and enhancing the physician-health system relationship. Dr. Ken Altman is Chief of Otolaryngology at Baylor St. Luke’s Medical Center in Houston, TX. He is also Secretary/Treasurer-Elect of the American Academy of Otolaryngology – HNS, and past-President of the American Laryngological Association.