Recent studies document and discuss physicians’ time on “desk work” or “desk top medicine” including time working with an electronic health record (EHR). The authors in the study on “desk work” also distinguish time spent during face-to-face patient encounters between “true” time with the patient and use of the EHR. This research varies in methods and approach but shares a theme and implication that physician time with EHRs or other health IT is a burden and less valuable than speaking with or physically examining the patient. Media accounts amplify this perspective, some calling EHR time “clerical” work.
This approach to defining and being negative about clinicians’ time spent with EHRs and other health IT does not reflect the value that the technology can bring to the practice of medicine.
We live and work in a technology-driven, information-focused world. My colleagues and I are highly educated and trained; we spend our days interacting with the world through laptops, smart phones, and tablets. We are knowledge workers, not clerks, and most (but surely not all) of this technology-enabled work is professional and not clerical work. Why would we think physicians and other clinicians would also not be actively engaged with digital applications throughout their day?
Certainly, physicians face a heavy burden of clinical and administrative documentation. And there are real opportunities to enhance the usability of EHRs and other health HIT. There is also the complicating situation that multiple stakeholders want to use EHRs as a vehicle to collect more data than might be obtained in a paper world.
But documentation burdens predate broad adoption of EHRs and even financial and administrative health IT. Anyone with a family member who is a physician of a certain age can attest to complaints about clinical and health insurance documentation and stacks of charts needing attention.
Physicians must refer and add to patient-specific clinical evidence and documentation, consult with reference material, and communicate with colleagues, patients and other healthcare organizations, including pharmacies. Operating in a world of medico-legal risk and third party payment, they also have obligations to facilitate risk management and payment for services provided.
Modern EHRs and HIT automate and ideally transform these paper-based workflows, supporting and enhancing underlying clinical, financial, and administrative tasks. It makes no more sense to hold the EHR or its developer responsible for the work done using this tool than it does to attribute to the developer of my e-mail or word processing applications the work I must perform using these tools.
I am often present as a patient or parent during visits with physicians. I have a professional interest in observing clinical encounters, including how the EHR is used and integrated into the visit. Watching good doctors work, asking questions, checking data, doing physical exams, and providing guidance is inspiring. My observation is that they use EHRs as a tool and are not led by the technology; they practice (and often model for residents and medical students) the kind of medicine that works for them.
I have seen very experienced and senior “old school” physicians take explicit care to keep up a running commentary with me or my children when they work in the EHR, sometimes sharing the screen they are viewing, and then clearly and cleanly turning away from the computer to take the history and conduct the physical exam. It is unfortunate that some researchers or professional leaders would consider time spent in an EHR reviewing consolidated test results and medications, issuing orders or e-prescriptions, or using clinical decision support, whether before or during the encounter, as “desk work” and a distraction from “real” clinical work.
I recently heard a physician discuss using his EHR to identify patients whose diabetes was not under control and then how he and colleagues used this information and the EHR to secure significant improvements in these patients’ health status. Using the EHR for such population health management was not “desk work” and had real world benefits for specific patients. Moreover, research on social determinants of health emphasizes that clinical encounters have a small role in driving health outcomes relative to factors like diet, stress, genetics, economics, and clean air and water.
Many physicians have already leveraged health IT to improve clinical care. There is much more to come from capabilities like mobile access, cloud-based modules and apps, clinical decision support (and its likely increasing use of machine learning and other artificial intelligence), and patient-clinician communications tools, as well as clinicians who are increasingly “digital natives”. With such current value and future promise, it is not a good idea for researchers or professional leaders to stigmatize or define the time clinicians spend with EHRs and other health IT as wasted or non-clinically relevant.
As with any technology, there are real opportunities to understand and enhance users’ experience. GE Healthcare is intensely focused on usability and has been infusing the development of our next generation ambulatory EHR with usability perspectives from day one. Likewise, the EHR development community includes usability as a major priority in the EHR Developer Code of Conduct. We should not allow the inevitability that legacy applications will always lag the state-of-the-art in usability to generate overly negative attitudes towards such technology. The challenge and opportunity is to continually improve the usability and value of health IT, not to disparage its use.
Finally, all stakeholders should work to eliminate low-value tasks clinicians are asked to do through EHRs. Some of this opportunity involves developers working with clinicians to improve user experience. But most will come from efforts, supported by the US Department of Health and Human Service (HHS) leadership, to act on studies identifying excessive documentation and reporting requirements imposed on physicians and handled through EHRs, in many cases actually reducing usability. For example, a recent Request for Information by the Centers for Medicare and Medicaid Services (CMS) sought suggestions to reduce regulatory and documentation burdens on providers. Indeed, the new National Coordinator for Health IT has linked such efforts to his Office’s renewed focus on usability. This long overdue initiative focuses on the burden, not the tool used to handle it. I wish professional and HHS leaders well in these efforts. GE Healthcare and other healthcare industry leaders are eager to help.