The EHR Is a Mirror
In almost any conversation on burnout, the topic of the electronic health record (EHR) is bound to arise. Often, fingers are pointed at the EHR as the primary cause of burnout, if not the sole cause. This type of thinking simplifies the dilemma of burnout in a very counterproductive way. It allows an organization, or any other group approaching this complex issue, to point their finger at the vendors, adopt a victim mentality, and avoid ownership of the many issues involved in this growing and destructive issue. I would note, however, that I have yet to encounter an organization that, to reduce physician burnout, has eliminated its EHR and reverted to the golden days of paper.
One of the keys to effectively approaching burnout is to understand that the EHR is really a mirror, reflecting multiple major issues in healthcare that impact the complexities physicians and nurses deal with every day in their work. Here are just five simple examples of areas that the EHR reflects to us if we are paying attention.
1. An unnecessarily over-complicated system of accessing payment
When I started in an independent family practice almost 40 years ago, at the end of a patient encounter I simply needed to provide a written diagnosis and circle whether the visit was brief, intermediate, or extended. The content of my dictated note was irrelevant to the charge for the visit, as well as to payment, thus it only reflected relevant clinical content. Over the next 10 years, we had to develop lists of ICD-9 codes that became required and then templates for coding the new E&M billing codes. Since then, the complexity continued to increase, but the most significant changes have been the identification of the correct diagnosis code, and the documentation defense of the correct billing code. Much of the increased effort of documentation in the EHR is less driven by the actual EHR as the requirement of the customer, driven by governmental complexity, for the EHR. I assure you that if the content of the physician’s note was disconnected from payment, we would see much less frustration with the existing systems. Here the EHR clearly reflects a payment system poorly designed for efficiency and common sense.
2. Ever escalating numbers of quality indicators to be collected, again often tied to the complicated payment system
The only source of quality data is the documentation of physicians and nurses. Quality improvement is critical to the care of our patients, but most doctors will tell you that there are a wide variety of data inputs that do not improve that care. Organizations bear the responsibility to limit how much documentation is required only to set parameters that truly clinically matter or have an outsized bearing on payment. Workflow and resource decisions greatly impact the work, for example when the data is collected and by whom. Operational excellence and intelligent workflow design can mitigate the data entry requirements for the doctor or nurse. Here, as in other areas, it’s not the EHR per se that creates the issues, it’s the design of workflows that really count. Here, the EHR clearly reflects how thoughtful clinical leadership and operating teams have been about collecting only what matters and designing the most efficient system to collect it.
3. Workflows and resources not changing from the days of paper
Moving from paper to electronic records necessitates the continuous redesign of workflow and resource requirements. This is not the “fault” of the EHR, just a reality around the change in process inherent in such a change. One simple example is the task list or inbox for the doctor in the EHR. In many systems, patient messages and other tasks that were handled by staff now come directly into the doctor’s inbox. How that workflow is designed, and who manages common issues can make a huge difference in the doctor’s day. The EHR has not changed the need for communication to patients, but how the tool is structured by operations can make all the difference in the world. Here, the EHR clearly reflects the skill of the organization’s operations team at workflow redesign in concert with clinicians. Also, if the doctors are not trained thoroughly to mastery of the function, it can unnecessarily prolong their work time, adding to burnout. Which brings us to training.
4. Underinvestment in training
Many CFOs imagine that during the installation of a new EHR there will be a peak of training costs in preparation for go live that will go away when go live is finished. The curve actually should look like an acute elevation of training costs in preparation for go live, followed by an elevation of training investment over pre go live baseline for years after. If an organization does not have a robust continuous training program enhanced by data on need, clinicians will struggle unnecessarily with the system and experience more frustration than necessary. Here the EHR clearly reflects the commitment of the organization to create mastery of the tool for its doctors.
5. Stagnant reimbursement systems have increased productivity requirements
Physician reimbursement has been fairly flat for a long time, necessitating increases in productivity for physicians. In an interesting corollary, inpatient intensity remains high due to more outpatient treatment of patients who once were admitted, and shortened lengths of stay, yet nursing staffing ratios have not consistently kept up. This leads to reduced capacity for change, or for adaptation to new systems. Here the EHR clearly reflects an understandable difficulty for clinicians to have the time and energy to become proficient and use new tools to optimize productivity in the best interest of patient care.
Simply identifying the single root cause of burnout as “the EHR” causes organizations to miss many opportunities to address this complex dilemma. As we endeavor to renew the joy of practicing medicine for our clinicians, we need to develop robust ways of listening to their stressors, identifying issues more precisely, and applying operational excellence and sufficient resources to deal with the issues reflected by our “EHR mirror”.