All Clicked Out: Working Around the EHR’s Digital Deluge

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Every day, cardiologists make hundreds, if not thousands, of mouse clicks, encounter countless notifications and manage a steady stream of alerts that pop up on their computer and device screens. Some say these demands of the electronic health record (EHR) are distracting clinicians from patient care and contributing to physician burnout. Yet there are workarounds that can help cardiologists handle the digital data deluge.

In “a fit of frustration” last summer, Edward J. Schloss, MD, downloaded a mouse-click counter to his laptop. Schloss, medical director of cardiac electrophysiology at The Christ Hospital in Cincinnati, wanted to find out how many times he clicked his mouse during a single patient visit.

In the end, the number wasn’t all that surprising to Schloss, who has had to replace his laptop’s trackpad three times in as many years. “It takes about 100 clicks to see a patient,” he says. “I’m pretty computer savvy… but it’s still 100 clicks.”

And that tally didn’t include Schloss’s other clicks throughout the day—reading test results, reviewing notes, answering emails—or the computer work done by the nurse practitioner who trails him, medical assistants or the transcriptionist who handles his dictated records. “It’s busy work,” he says. “[Physicians have] become very highly paid data entry clerks.”

The problem, Schloss says, is that EHR systems are laid out in such a way that it takes dozens of clicks to get through a single visit. In the “old days,” patient evaluations were considerably quicker and physicians could look patients in the eyes as they jotted notes on paper. “In the end, you want to do the best thing for your patients,” he says, “but it’s harder now than it used to be.”

Counting Clicks: According to a mouse-click counter, Edward J. Schloss, MD, enters an average of 100 clicks into his hospital’s electronic health record for every patient he sees. An electrophysiologist at The Christ Hospital in Cincinnati, Schloss sometimes shares his click tallies with his 7,000+ Twitter followers. He says his tweet from July 2016, which showed 1,233 clicks at 11:33 AM, after he had seen 12 patients, is his most popular post among his more than 10,000 tweets during the five years he has participated on the social media channel. Source: Edward J. Schloss, MD; reprinted with permission.
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Scope of the problem

Specialists, including cardiologists, receive about 29 notifications per day, including about 10 test results, says Daniel R. Murphy, MD, MBA, assistant professor of general internal medicine at Baylor College of Medicine in Houston and lead author of a study that categorized notifications of physicians at three large practices in Texas and analyzed the time spent processing them (JAMA Intern Med 2016;176[4]:559-60).

EHR systems have come a long way, Murphy says, but the sheer number of mouse clicks and navigation they require means they’re not yet efficient. There are obvious medical benefits to these new digital tools—for instance, the continuity of care that’s established when a clinician is notified that a patient was admitted to the hospital—but electronic workflows and reimbursement models need to catch up.

While most digital advances have decreased workloads for the end-user, Schloss says, the advent of EHRs has created a bigger burden for physicians. While he isn’t advocating reverting back to the paper record—he loves the convenience of reviewing patient information from anywhere in the world—he’s often frustrated by their electronic replacements. “The way the stuff is formatted and organized, it’s so horrible,” he says. “It’s very difficult to find anything.”

Impact on clinicians—and patients

With the demands of the EHR, there’s simply less time for patient interaction, physicians say. “It really puts a barrier, almost a physical barrier, between the patient and the physician,” says Jennifer Kiessling, MD, a cardiologist at the Huntsville Cardiovascular Clinic and medical director of the Chest Pain Center of Excellence at Crestwood Hospital in Alabama. “We almost spend the majority of the time just staring at a computer screen.”

Physicians who are navigating the EHR for lab work, test results, prescriptions and other information may appear to be distracted and miss nonverbal cues, such as the tell-tale squirm of a patient who hasn’t been following the doctor’s orders to weigh him- or herself regularly. “We’re trying to use technology,” Kiessling says, “but we’re losing the art part of medicine.”

Schloss estimates he spends only about one-quarter of his nonprocedural work time in front of patients; the rest of his time is at a computer. Lab work and procedures are “a breath of fresh air,” he says,  “[because] you’re rescued from your computer master.” Yet even laptop-free time in the lab requires digital follow up. “There are many procedures where the documentation takes longer than the case,” Schloss says.

All this computer time can result in burnt-out physicians. A doctor could be scheduled for eight hours of clinic time without even one dedicated hour—let alone three—for processing messages, alerts and notifications, Murphy says. That means more physicians spend their off hours, including weekends, clicking through electronic records. “That clearly affects burnout and work–life balance,” Murphy says.

Kiessling worries that these extra hours of administrative work could deter young people from considering a career in medicine. “If the physician satisfaction decreases,” she says, “then that will ultimately have an impact on the type of people who go to medical school.”

Source: JAMA Intern Med 2016;176[4]:559-60.
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Staying ahead of the avalanche

Kiessling tried abandoning her laptop outside the exam room but found it led to hours of extra work transferring her paper notes into the EHR, so she adopted a new strategy. Now, she brings a nurse into the exam room with her to input information while she focuses on the patient. “I’m still compliant with usage of an electronic medical record,” Kiessling says. “I have a [nurse] … to alleviate some of that burden, so I can have a good relationship with the patient.”

Her ancillary staff also help with inputting and auto-populating digital charts, so the practice gets credit for payment-related requirements that don’t necessarily apply to the visit, such as reviewing tobacco usage.

Schloss says he probably sees the same number of patients as he did in the pre-EHR days, but now a nurse practitioner tags along with him. In fact, he recently tweeted two side-by-side graphs showing the parallel growth of EHR usage and nurse practitioner graduates. “#EHR systems slow MDs down,” Schloss tweeted. “Patients still need to be seen. What to do? Ask for help.”

Other ways support staff can help ease the electronic burden on physicians include handling alerts that aren’t test results and don’t need a doctor’s eye, such as completing forms and prescription refills, Murphy says. “A lot of the messages they receive don’t really require physician decision making,” he says.

Breezing through the notifications certainly makes them disappear faster, Schloss says. “You do click through a lot of these,” he says. “So many of these alerts are for things that are irrelevant or wrong.” But, once in a while, you come across something meaningful, and “you hope you don’t miss any of those,” he says.

And while some doctors simply ignore the messages building up in their inbox—Murphy interviewed a physician with 60,000—perhaps the best way to stay ahead of the deluge is to schedule time for it. Physicians who reserve an hour or so specifically to process notifications, he says, tend to have more success than those who try to rush through them between patients.