Redesigning Clinical Workflows to Return Joy to Patient Care
The EHR – A Root Cause of Physician Burnout
The EHR – A Root Cause of Physician Burnout

In a recent Mayo Clinic Proceedings , Tait Shanafelt, MD, a practicing physician and a leading burnout researcher, published his research on the EHR and burnout in an article titled, “Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction.”  The conclusion of the article states, “In this large national study, physicians’ satisfaction with their EHRs and CPOE was generally low. Physicians who used EHRs and CPOE were less satisfied with the amount of time spent on clerical tasks and were at higher risk for professional burnout.”

With research now further supporting the premise that the EHR is a major driver of burnout, I am again posting my thoughts below.

I love the EHR and I hate the EHR.

I love it for the information that is already in the chart. It is better organized, available anywhere and anytime (to more than one person at a time), data can be put into graphs and tables to provide insights I might otherwise have missed, and it’s legible. While each of these blessings can carry their own curse, these are true advantages over paper.

I hate the EHR for the information that is not yet entered into the chart. Too many physicians have been reduced to data entry clerks who end up working anywhere and anytime – in the exam room, their office, the hospital, and home. The user interface is needlessly complex, resulting in errors in data entry and placing orders.

physician in computer

In the past week I have been impressed, and depressed, by the number of conversations in which physicians AND patients have expressed frustration with the EHR, and its impact on patient interactions, professional satisfaction, and personal lifestyle.

And this is not unique to physicians. Nurses, technicians, and others caring for patients have the same experience. That said, for today, I’d like to focus on physicians and their patient interactions.

Let’s start with what happens in the exam room. In most practices, a medical assistant “rooms the patient”, entering vital signs, meds, allergies, and a chief complaint. The patient then waits in the exam room, often for quite a while alone, until the physician enters. Upon entering the room and greeting the patient, the physician will sit down and engage with the computer, not with the patient. The physicians’ eyes are on the screen, not eye-to-eye with the patient. The physicians’ hands are on the keyboard and mouse, not examining or comforting the patient. Depending on how the room is configured, the physician may not be facing the patient.

The most important thing that we do in health care is the healing interaction that takes place between a caregiver and a patient. The opportunity to participate in that sacred relationship, and to be of service to others, is why most every doctor went into medicine. The EHR, as we currently use it, is breaking that relationship and damaging our ability to heal.

Physicians who do give their full attention to the patient in the exam room are left with a many hours of work after the patients have gone home. They miss dinners with family, or retreat to their home offices after dinner to grind through the work. Personally, there were too many nights when I fell asleep on the keyboard trying to get my work from that day completed before the next morning brought a new onslaught.

Much of the additional work is not from the patients seen that day. My prior group measured this. For every patient visit there are four other encounters that come to the physician’s in basket in the form of phone calls, email requests for care, test results to review, and prescriptions to refill. This work is usually uncompensated but can impact safety, quality, and service significantly.

As a result, physicians are burning out. Over brunch on Sunday a good friend who is an excellent internist told us she was cutting back on her hours to regain time for herself. We are impacting access to a great primary care physician.

I hate to admit all this, because I believe in the power of the EHR to significantly improve care. I want it to be a welcome partner in care. So facing this issue head on is key.

Fixing EHR Problems

There are many things that we can do. A short list includes:
– Redesigning work flows around teams who support physicians to work at the top of their license,
– Using scribes in the exam room to enter the data and pend orders,
– Redesigning the software with intuitive user interfaces and workflows,
– Integrating voice recognition, and
– Redesigning workflows to properly manage the non-visit work that consumes so much of physicians’ time.

What do you think?

Do you have a story to share?

Can you recommend a counter-measure short of seeing fewer patients?

I look forward to your thoughts….

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