Patients vs Paperwork
by Danielle Ofri
New York Times
Every doctor I know has been complaining about the growing burden of electronic busywork generated by the EMR, the electronic medical record. And it’s not just in our imaginations.
The hard data have been rolling in now at a steady pace. A recent study in the Annals of Family Medicine used the EMR to examine the work of 142 family medicine physicians over three years. These doctors spent more than half of their time — six hours of their average 11-hour day — on the EMR, of which nearly an hour and a half took place after the clinic closed.
Another study in Health Affairs tracked the activities of 471 primary care doctors over a three-year period, and also found that EMR time edged out face-to-face time with patients.
This study came on the heels of another analysis in the Annals of Internal Medicine in which 57 physicians were observed directly for 430 hours. These researchers found that doctors spent nearly twice as much time doing administrative work as actually seeing patients: 49 percent of their time, versus 27 percent.
These study results hovered over my head as I worked through a recent clinic session, most of which felt devoted to serving the EMR rather than my patients. It was the kind of day that spiraled out of control from minute one, and then I could never catch up. The kind of day, nowadays, that is every day.
Part of the issue is that there are simply more patients, most of whom are living longer with many more chronic illnesses, so each patient has much more that needs to be taken care of in a given visit.
But the main reason that I can’t keep up is the EMR. Like some virulent bacteria doubling on the agar plate, the EMR grows more gargantuan with each passing month, requiring ever more (and ever more arduous) documentation to feed the beast.
I try to spend as much time as I can directly focused on each patient, listening to what she is saying, thinking hard about her clinical situation. This is the essence of good medicine. But it’s not the essence of what makes the clinical enterprise proceed forward. In today’s medical world, nothing exists until the EMR requirements are tended to.
The painful truth is that every minute I spend talking with my patient or doing the physical exam—that is, any time not spent on the EMR— simply grinds down the progress of the day.
To be sure, the EMR has benefits: legible writing, electronic prescriptions, centralized location of information. But it has become the convenient vehicle to channel every quandary in healthcare. New state regulation? Add a required field in the EMR. New insurance requirement? Add two fields. New quality-control initiative? Add six.
Medicine has devolved into a busywork-laden field that is slowly ceasing to function. Many of my colleagues believe that we’ve reached the inflection point at which we can no longer adequately care for our patients. The EMR isn’t the entire culprit, but it’s certainly the heavy-hitter.
Medicine traditionally puts the patient first. Now, however, it feels like documentation comes first. What actually transpires with the patient seems like a quaint trifle, something to squeeze in among the primary tasks of getting everything typed into the EMR.
More and more doctors are concluding that the overbearing EMR actually jeopardizes patient safety, by pushing patients to the margin of the medical encounter.
It’s time, then, to take action, as we do in other areas that harm patients. Currently, hospitals can be fined for hospital-acquired infections, bedsores, medical errors, privacy violations, and patients who are readmitted within 30 days. The same logic should now be applied to electronic busywork.
Health systems should be required to periodically measure the EMR burden, and should be fined when it detracts too much from face-time with patients. Hospitals might then think twice before tossing in 10 more required fields that cover their own needs but end up leaving patients with even less attention from their doctors and nurses. Things might actually change when money is on the table.
Similarly, EMRs themselves need to be held to a higher standard. Given how much they affect patients’ medical care, they should be treated like any other medical device and subjected to thorough scrutiny before being allowed onto the market. EMR vendors ought to be held responsible when their medical documentation product harms patient-care.
If patient safety — and patient satisfaction — truly are goals of 21st century medicine, then we need to rethink how we view the EMR and the related electronic burden on clinicians.
“Soap and water and common sense are the best disinfectants,†wrote the esteemed physician Sir William Osler. However, it took medicine more than a century to incorporate handwashing as one of the best investments in our patients’ health. Let’s hope it takes less time when it comes to common sense and the EMR .