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What Could You Do With an Extra 43 Minutes Every Day?

What Could You Do With an Extra 43 Minutes Every Day?

 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.

 

About Peter Basch, MD

Medical Director, Ambulatory EHR and Health Information Technology Policy
MedStar Health

Washington, DC

Comments

  1. Phil Smith, MD says:

    Peter,
    In 1993, I implemented an off the shelf EMR in my Family Practice office, and demonstrated 44-66 hours/month of reduced time by me. First benefit was prescription printing that was seamless for me from the EMR. The second was having to deal with payment denials, that essentially went away once the EMR was implemented…I just wasn’t seeing charges denied, and if there were questions, a printed document was always available. The third was the ability to print with one click a summary of care document for the patient (essentially today’s CCD) who was travelling or living 6 months a year in another state (In Florida, we call them snowbirds). The fourth was the proactive ability to have my staff call all patients between 8-9 AM the next morning based on them being new patients, being work-ins from the prior day, or getting a new med. The patients loved this, and it prevented them calling in themselves, being routed from the front desk to the nurse, who then interrupted me, then had the call the patient back. By removing this reactive workflow, doctor and nurse are more productive. The fifth is looking for charts, which is probably 2-3 minutes per patient on the hospital side as well. Finally was the benefit of a nice summary screen that was always up to date, and much more robust than the prior inside left cover of my prior paper chart. The benefits are there, once you adapt your workflow and leverage your EMR.
    Phil Smith, MD
    VP, CMIO
    Adventist Health System.

    • Peter Basch, MD says:

      Thanks Phil,
      And in fact many colleagues, primarily in FM or IM have seen similar care efficiencies demonstrated. However, this has not been a universal experience. If you have time to read the exec summary of the report – http://www.americanprogress.org/issues/2012/06/pdf/paper_cuts_intro.pdf – please note that even where a good implementation such as what you describe is done, there is still waste and/or potential for converting wasted minutes to better use.

  2. I, too, have used an EMR since 2001 in my solo gyn practice. I have loved it from the start. It not only saved me 43 minutes, but it allowed me to start a practice with only a single employee! It saved me lots of money.

    Peter’s post is timely considering the fresh new issue of the NEJM contains this article http://www.nejm.org/doi/full/10.1056/NEJMp1203102 (“The EHR Trap”).

    • Peter Basch, MD says:

      Thanks Joe,
      And thanks for pointing out the new article in the NEJM – which depending one your perspective could be titled “The EHR Trap,” or “The EHR Opportunity.” A theme I have been pushing for the past few years is the value of moving forward now, rather than waiting for “EHRs to be perfect.” The idea… the first several chapters of CPR/EMR/EHR history and functionality were written by computer scientists, informaticists, and early adopters, and mostly (not always!) with the lens of building for the world that is, and not what could be. Also, many of us have a blind eye towards usability – so we would forgive obvious flaws – as long as the final product got the job done, or was way cool. My point, unless someone does something to move us away from EHR authorship by this limited group – EHRs will not see their ultimate potential.

      One of the great values of the MU program is that it created a mass market for EHRs and meaningful functionality, and also created an alternate path for use such that the healthcare provider could use components and not just a complete EHR. At least in theory, this creates a huge market for people without the same blindspots that many of us have, and the room for innovators to come up with new solutions.

      I see this new perspective piece in the NEJM as a companion to the work that Beth Wikler, David Cutler and I just published. We lay out new (well, not really new – but not typically part of EHRs or the EHR ecosystem) functionality requirements / opportunities; the EHR Trap correctly points out that as we pause and consider EHR x.0, that we dont simply think of legacy application +, but rather less bulky functionally defined applications.

  3. I appreciate the thoughtfulness that went into this proposal. There are certainly merits to making incremental improvements on the status quo. In many ways they are easier politically to achieve and low cost in the short term.

    There are also dangers inherent in creating additional bureaucracies. For whatever reason, once created, bureaucracies seem only to expand into related issues until they are far afield of their original purpose and they never die even after their original usefulness wanes. Rather than create a new agency, how would you feel about an existing agency working with a new advisory panel (populated providers, vendors, health plans, and others) instead? Advisory panels don’t tend to expand their power base and can provide the direction to existing agencies to identify and recommend ways to reduce administrative costs.

    Similarly, I do not think that expanding MU criteria (and creating a new provider burden) is wise. I do think that it is reasonable to add eligibility checking, authorization and the other administrative tasks you mentioned to the certification criteria. In other words, I do not think this should be a provider burden, but rather a vendor feature available to providers. Maybe we are saying the same thing using different semantics, but the recommendation needs to be clear.

    Lastly, I think that many administrative burdens can be safely eliminated by simply changing when a plan is permitted to require an authorization. We know that most providers receive close to 100% of their requests approved, so the authorization process serves only to delay patient care and increase administrative cost. Why is an authorization for referral or treatment required of providers for whom 100% of their requests have been granted in the prior 3 months, 9 months, or 5 years? Wouldn’t it be better to require health plans to set internal standards for automatic authorization based on provider history? That way, only those rare providers who have frequent denials would continue to be reviewed. The (prospective and retrospective) data exist. Why not use the data plans currently have to look at the problem in a new way?

    • Peter Basch, MD says:

      Thanks so much for your thoughtful response Larry. You raise two great points. First, how should the principle of wherever possible, reduce admin burden be accomplished. The paper suggests a new office – not really a new agency. At the press conference there was lively debate as to who should do this, and whether it should be managed by ONC, CMS, or someone else. The panel moderator ended the session by asking each panelist directly, “Who should manage this program?” While David Cutler and Karen Ignati had clearer ideas, my answer was that of a typical internist, “I am not sure… However, I am sure that it has to be someone’s day job; otherwise, it will not get done, or only get done half-way.” (Ok – I probably didnt actually use those words – but that was what I meant.)

      And perhaps your suggestion Larry, of a multistakeholder advisory panel, reporting to XXXX, is the one that is least costly, and least likely to add additional cost and bureaucracy – but it still should be at least an individual’s sole focus to make sure that there are deliverables and something actually happens. As we all know in our work in practices or hospital systems – crises happen regularly. Admin burden typically falls under the “wouldnt it be nice if we could do x instead of y; and if we ever had a free week and could bring the right people into the room; and then after it was built had another free week to see if what we designed was right; and then while it was in feasibility testing, had another free week to evaluate if it solved the problems in a controlled environment, etc.” Maybe its just me, but I have many of these grand ideas, but almost never have the time to see them thru, and keep them fresh.

      For example, your correct assertion (at least IMO) that most prior auth is actually pointless. Its not like we call a payer and say a secret phrase or recite the Kreb’s cycle to get a test, procedure, or drug approved – we typically go thru a process and things get approved. My favorite med prior auth… waiting 7 minutes on hold, then speaking to someone who clearly had no medical training who asked me “does the patient need this medication.” My answer, “No, I just had an extra 10 minutes to kill, and I like being put on hold.”

      However, from the payer perspective, as they keep these processes in place, something must be working for them. So the idea would be to:
      1. Start with an admin burden and clearly identify it. Describe the burden from the patient and provider’s perspective.
      2. Work within some structure to understand why that burden is there (payer perspective) and if the need for a hurdle in approval is actually necessary, and if it can be better managed without “going thru a toll booth that doesnt accept Easy Pass.”
      3. Build solution
      4. Test solution
      5. Release solution
      6. Continual learning / improvement process…

      Re your point about adding MU requirements… Payers are concerned that if they build the infrastructure to make these burdens less, that providers wont do their parts to acquire and use them. I am not one for adding more difficulty to MU, but I do think we at least have to listen and respond to payer concerns – as we want them to listen and respond to ours.

      • Thanks Peter. Several threads to address.

        It sounds like we might reach a consensus on an advisory panel. I think that HITPC and HITSP have worked effectively with volunteers and I would think a similar process could work in this domain. As to funding one paid staff person to support the process, if that was what you meant, I can see value in that. However, I wouldn’t want someone with a title specific to this panel, because then you create someone with a vested interest in that title, creating the same motivation for preserving bureaucracies past their need.

        I certainly can’t speak for those plans that continue to require authorizations as to why, but several years ago United Health Group realized they were spending money that served no purpose and stopped. I don’t know if they have resumed, but a Google search should find that original announcement. There is speculation that plan delays feed interest gains on claims not paid, but in this current economic environment with sums over $50 million being charged interest (as opposed to being paid interest), I don’t see that as a motivator. Sometimes I think it is as simple as “We’ve always done it this way.” Paradigm shifts require an action. Interia does not.

        I don’t believe the validity of the stated concern by payers that providers might not use the tools. If certification required vendors to feature access to authorization and eligibility systems, what provider in his or her right mind would prefer to spend 7 minutes on the phone? Adding a MU criterion serves only to require another check box that serves no useful purpose and in the name of reducing administrative burdens would serve to increase them

        • Firoz says:

          Nice post. Seem true on most accounts but I also think ttthaoday medical practitioners are looking to avail of this federal incentive by trying to comply with the definition of meaningful use but at the same time EHR providers are looking at their own set of profits.This misunderstanding is mostly I believe as a result of wrong interpretation of the federal guidelines. The EHR providers need to look at these guidelines from the prospective of the practitioners who deal with different specialties.Each specialty EHR has its own set of challenges or requirements which I believe is overlooked by in most EHR vendors in a effort to merely follows federal guidelines. This is resulting in low usability to the practitioners, thus less ROI, finally redundancy of the EHR solution in place.I think ROI is very important factor that should be duly considered when look achieve a meaning use’ out of a EHR solution. Though one may get vendors providing meaning use’ at a lower cost, their ROI / savings through the use of their EHR might be pretty low when compared to costlier initial investment. Found a pretty useful that is pretty customizable and easy to use. It also accounts for the different specialty EHR’s too.Some of the other useful resources on this topic:Also the introduction of REC’s through the is a great way to avail of quality EHR solutions at competitive prices. The stiff competition among not only these REC’s but also among EHR vendors ( to become a preferred vendor of a given REC) will result in lot of positives to medical practioners.Looking the funding provided to the REC’s, the also promises to be an unbiased way of allocating funds. It will also help in the concept of REC’s helping out each with their own unique business models. It can be one of the possible answers to the as discussed by many critics.

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