Most of us in the EHR visioneering and/or implementation space have been struggling with (or avoiding) the question “does EHR use add time to a doctor’s day?” For those new to the field, one of the key hurdles that an EHR had to pass to gain user acceptance was passing a “documentation challenge.” In these very public challenges (typically held at EHR or medical meetings), someone would play the role of a patient and call out a scripted history, and the audience could see for themselves how EHRs compared against each other, and against scribbling on paper. And for those who never witnessed a documentation challenge – spoiler alert – scribble almost always won.
Learnings from these challenges included:
- EHRs must continue to be refined to make documentation easier and more intuitive;
- Data entry (note writing) is always painful, and never a way to demonstrate benefit of an EHR; and
- Documentation as the driver of physician activity (defining the basis for payment as per the 1995 and 1997 E&M documentation guidelines) is a big part of the problem. It makes documentation difficult on paper; and for EHRs it results in either even ‘clunkier’ documentation or just ugly notes.
Additionally, documentation challenges almost never allowed for a basic benefit of electronic systems to be displayed – “write once, use many times.” And that, coupled with another key principle– training and experience matter– led to another conclusion… While scribble on paper could almost always trump any EHR for documentation ease of an acute visit for a new patient; documentation of return visits in the hands of well-trained and experienced users could be faster than scribble. Thus, our final, final answer to the question of “does EHR use add time to a doctor’s day” aside from “it depends” was “for most docs, after a period of training and use, productivity (as the proxy for documentation effort) returns to baseline.”
Of course because healthcare processes aside from documentation were never considered “on the table,” few of us ever considered that EHR use could be significantly faster than paper records.
In 2003, I gave a presentation to the eHealth Initiative titled “Frictionless Medicine: Using the EMR to Decrease Process Friction While Increasing Quality Friction.” The themes of the talk (as evidenced by the title)… we have friction / barriers in the wrong place in the delivery of care. Documentation is hard and time consuming; but there are no guardrails when making top-of-mind decisions that could have enormous impact on quality and safety. Prescribing Claritin (at that point the only prescription non-sedating antihistamine and no comparable OTC choices) was a nightmare requiring phone calls, paper forms, repeat calls, etc.; yet prescribing warfarin without an indication, target range, last INR, etc. was effortless. My thesis… if we want to use EHRs to make care better, even the most elegant solutions will add time at the point-of-care; and to create the time and space such that EHRs are used optimally, we must strive to also use them to decrease unnecessary process friction. Of course reducing what I termed “process friction” had previously been described as “administrative simplification,” which should have been implemented with HIPAA, but for a variety of reasons never actually happened.
Fast forward to yesterday…
I had the good fortune of being asked by David Cutler (Professor of Economics at Harvard) and one of his doctoral students, Beth Wikler, to contribute to a paper on that aspect of healthcare delivery that most of us never ponder, the world of administrative burden and what is needed to reduce it as much as possible. That report “Paper Cuts” was released yesterday by the Center for American Progress (full pdf may be downloaded at http://www.americanprogress.org/issues/2012/06/pdf/paper_cuts.pdf).
Aside from the clear financial benefit that would benefit all stakeholders (and thus allow for more actual care to be provided to more patients); I was particularly struck by the findings regarding time and effort burden on doctors and their staff. Quoting from the report, “Physicians in the United States spend an average of 43 minutes per day, or three weeks per year, interacting with health care plans. This is in addition to the 21 hours that nursing staff and 53 hours that clerical staff spend per physician per week on administrative transactions, particularly claims and prior authorizations. This time spent on excessive administrative processes is expensive, resulting in less clinical time, less time reviewing and acting on quality initiatives, higher overhead costs, and lower quality of care.”
While we have been busy conducting EHR documentation challenges and determining how to make EHR use time-neutral at best, most of us have neglected to aggressively pursue this aspect of administrative care delivery reform (started by HIPAA and strengthened by the Affordable Care Act). My comment at yesterday’s press event… “Every minute devoted to unnecessary administrative burden is a minute not devoted to patient care; every dollar spent on unnecessary administrative burden is a dollar not spent on patient care.”
So back to the title of this blog post, “What could you do with an extra 43 minutes each day?” In 2003 McGlynn and others woke up many in healthcare with the disquieting assertion that while we think we do the right thing all the time for our patients; we don’t. Specifically, we provide appropriate preventive and chronic care services only ~ ½ the time. Shortly after the publication of this article, there were two articles in the family medicine literature that together estimated that to do everything that Dr. McGlynn suggested would add an additional 4-17 hours to each doctors day… essentially countering her findings with “that may be true, but it is not possible.”
In a small scale study at my health system, we found that using an electronic health record embedded with targeted clinical decision prompts and support, we could achieve most of what Dr. McGlynn referenced, but in a far shorter time – approximately 45-60 extra minutes each day (instead of 4-17 hours). So I want every one of those 43 minutes back.
Without a sustained commitment to reducing administrative burden, it will not happen; and without that reduction in burden, we may never have a healthcare system that is patient and consumer friendly, and is optimized for quality and safety.