Opinion | Death by 10,000 Clicks: The Electronic Health Record

Electronic health records (EHRs), once promised to revolutionize healthcare, are becoming a burden. We audited the EHR logs at our institution, University of California San Francisco, to examine the work of our neurosurgery residents and get a better understanding of the benefits and burdens. The results shocked us: the on-call residents spent 20 hours logged into the EHR over a single shift.

When we shared these results with the residents, they weren’t surprised. They feel that EHR burden every day.

The Promise and Disappointment of EHRs

The EHR has plenty of benefits. Gone are the days of hunting for films in the radiology basement, searching the floors for that missing chart, or deciphering the infamously bad doctor handwriting. For patients who have a usual place of care, having quick access to their past records is valuable.

We considered whether perhaps this busywork had been replaced by more efficient EHR workflows. To see if this was the case, we examined what tasks the residents were doing when they were interacting with certain areas of the EHR. This “active time” (any time they spent moving the mouse or clicking the keyboard while in a patient chart) totaled 9 hours per shift but excluded computer activities outside of patient charts, most notably imaging review. This active time log revealed several inefficiencies, such as a daily average of 45 minutes spent searching for orders, reconciling orders, and navigating order decision support tools. This deep dive showed us that the scut work of old has been replaced with a worse EHR burden.

Our program is not unique in this regard. Surgery residents spend nearly 8 months of their 5-year training on the EHR. Residents routinely take EHR work out of the hospital, completing up to a third of it from home. Non-surgical residents have it even worse, spending around 40% of their time on the EHR and only 12% of their time on direct patient care. Over 90% of residents say that documentation obligations are excessive, and that they take away from time with patients.

The EHR burden doesn’t just affect residents. It takes a trauma surgery attending 73 full 24-hour days to complete the required documentation for 1 year of billing alone. In ambulatory practices, physicians spend 2 hours on the computer for every 1 hour of patient time. EHR use is linked to physician burnout, a problem that is costing billions of dollars in the U.S.

Many of the inefficiencies we found come from Medicare regulations. The appropriate use criteria program is a good example. This was developed to reduce the unnecessary imaging ordered by physicians. When ordering a CT or MRI, the physician must click a few boxes to ensure the order is appropriate for the diagnosis. In our EHR audit, we found this added just a few minutes of computer time to the residents’ days. However, there’s no evidence that this regulation reduces unnecessary imaging. We believe it to be completely unnecessary. There are many more regulations that add a few minutes here and a few minutes there. It’s death by 10,000 clicks.

Steps to Relieve the Burden

Systematic identification of these inefficiencies is necessary to eliminate them. Our study, with its granular breakdown of EHR tasks, was just a start. There are many regulations around billing, coding, value-based reimbursement, and physician order entry that are adding to the EHR burden. Adding these numerous regulations was easy — identifying and eliminating them will be difficult. The Centers for Medicare & Medicaid Services “Patients Over Paperwork” initiative was a good start, as it reduced some of the documentation requirements for physician notes. That effort should be continued.

Some of the inefficiencies come from the EHR itself. Physicians often have little say into which EHR is selected and how it is set up. However, in physician-owned hospitals, where doctors have more input, their satisfaction with the EHR was improved and they reported more positive perceptions of time spent on documentation. Reversing the virtual ban on physician owned hospitals will give physicians more say in the purchasing of an EHR, shifting the market towards those that reduce the computer burden.

Of course, increasing advanced practice provider support helps offload the remaining EHR tasks. The Accreditation Council for Graduate Medical Education (ACGME) has encouraged this. However, mindless administrative tasks should be eliminated, not simply transferred to other employees. This shifting burden explains why healthcare must employ increasingly more workers to care for the same number of patients. Advanced practice providers don’t want to be saddled with mindless administrative tasks, either.

What doesn’t help are mandatory wellness programs, doctor appreciation days, or EHR training sessions. In fact, our data showed no improvement in EHR efficiency as trainees became more experienced. The problem comes not from a lack of mental fortitude, wellness, or ambition. It’s built into the system.

Conclusions

As neurosurgeons, we should advocate for policies that decrease administrative burdens. It is detracting from our trainees’ educational experience. Healthcare costs are increasing because of the inefficiencies that come with EHRs. We must be aware of this to protect our residents and to protect our industry. Continued involvement in advocacy is needed to reverse the ever-increasing EHR burden.

Anthony M. DiGiorgio, DO, MHA, is an assistant professor in the Department of Neurological Surgery at University of California San Francisco, and affiliated faculty in the Institute for Health Policy Studies. Praveen V. Mummaneni, MD, MBA, is the Joan O’Reilly Endowed Professor and vice-chair of the Department of Neurological Surgery at University of California San Francisco.