by Craig Klugman, Ph.D.
Most people choose to go into the health professions to help others, to make a secure living, and to challenge themselves on a daily basis. Few people would rank “doing paperwork” as a reason to choose a career in health. However, according to a new study in the Annals of Internal Medicine, paperwork in the form of electronic health records (EHR) might be the activity on which doctors spend the most time. According to Sinsky et. al, who conducted direct observations, motion studies, and self reports of 57 physicians in 4 specialties in 4 states, doctors spent over 49% of their time on record keeping and 27% on direct patient care.
Two decades ago, physicians only spent one-fifth of their time on record keeping. A 1998 study of emergency departments found 21% of time was spent on records and 32% on patient care. As recently as 2014, another study found that administrative work occupied only one-sixth of physician time. This same study also found that the more time spent on administration, the less happy physicians were in their work. Perhaps this is one reason for the dramatic decline in physician satisfaction of their work life. The trend is clear: Doctors are spending less time with patients and more time with computer records.
The main move to electronic health records came about as part of the Affordable Care Act. A provision in the ACA aimed to “reducing paperwork and administrative costs” began in October 2012: “Using electronic health records will reduce paperwork and administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care.” As Sinsky et al’s study demonstrates, the actual effect has been an increase in paperwork and administrative burdens. With more doctors seeing fewer patients, the net effect has to be an increase in costs.
Such a change in how doctors spend their day seems staggering. Consider that the average cost of medical school is $280,000 (private) or $207,000 (public) plus a minimum of 7 years post-college education and we have some of the most highly skilled, highly paid, highly in-debt professionals in our society spending nearly half of their time shuffling electronic paper. Is this is a wise use of physician time and expertise? That suggests that 2 of the 4 years in medical school should be spent on learning how to manage electronic paper. Consider that physicians and their time are a limited health care resource. The AAMC projects a shortage of 61,000-95,000 physicians in the next ten years. Perhaps if more time was available to care for patients, the shortage would not be quite as acute.
Sinsky’s analysis suggests that the emphasis on electronic records has not been a boon to medical care. However, the intent of such records was not only about time and money, but also to reduce errors and improve care. In most cases, it has not been long enough since EHRs are in widespread use to see how they will change patient care. What studies do exist seem mixed. The government’s IT website suggests many ways that EHRs will improve quality of care: diagnosis, efficiency, improved compliance, reduced liability. But they do not offer many empirical studies that support these noble visions. EHRs are not a panacea, and at least one study suggests that there may actually be new types of medical errors (diagnosis, complicated treatment, medication errors, poor implementation, outdated information (copy and paste of information), privacy and access) that appear when one relies on such record systems.
Studies from voluntary adoption of EHRs (before required by the ACA) suggest that such systems do not improve quality of care in ambulatory settings. Even physicians do not perceive an improvement in quality of care as a result of EHRs.
I do not want to suggest that we should abandon EHRs and go back to paper records. That ship has sailed and in the future, big data analytics may provide better care and fewer errors. However, the system as it is exists is imperfect and needs improvement to achieve these ends. The possible good cannot come at the expense of removing physicians from patient care to becoming data entry drones. Beyond technological improvements, we need to add EHR design and use to the medical school curriculum, and to rethink the workflow that has decreased the amount of time doctors spend with patients and tripled the amount of time they spend in recordkeeping. In a rush toward technology as a cure to woes, we must not forget the human element of doctors, nurses and other health care providers. There is an obligation to provide for a good quality of work environment for these highly trained professionals. Nothing less than our national health is on the line.