March, 2016

LAS VEGAS – Doctors are dreading what some have started to call EHR “pajama time.”
“That’s the hour or two that physicians are spending – every night after their kids go to bed – finishing up their documentation, clearing out their in-box,” according to Dr. Christine Sinsky, vice president of professional satisfaction at the American Medical Association.
At a session held in conjunction with the annual meeting of the Healthcare Information and Management Systems Society, Dr. Sinsky spoke about how electronic health records have not lived up to their promise of helping streamline patient care and instead have added hours and headaches to most physicians’ days.

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Data on the impact of EHR systems on physicians’ workflows and satisfaction is beginning to accumulate, she said. University of Wisconsin researchers studying the impact of EHR systems on physicians’ workflow and lives looked at how often and when doctors were accessing their patients’ medical records, she said. What they found was that so many doctors don’t have enough time in their days to finish their documentation, so they spend their evenings and weekends finishing up. Their preliminary findings were presented in 2015 at a primary care research meeting.
Dr. Sinsky said the researchers see “a bump” of time spent on Saturday nights.
“I call that ‘date night’. That Saturday night belongs to Epic, Cerner, or McKesson,” she said sarcastically. “Well, I don’t want my doctor on her electronic health record on a Saturday night. I want my doctor having fun on Saturday night, because I want her to love her job.”
That same study “found that primary care physicians were spending 38 hours a month after hours doing data entry work,” in other words “working a full extra week every month doing documentation after hours, between 7 p.m. and 7 a.m.,” said Dr. Sinky, who is also an internist in Dubuque, Iowa.
Here are 10 ways EHRs contribute to more work, Dr. Sinsky said:
1. Too many clicks.

“It takes 33 clicks to order and record a flu shot. And in the emergency room, it takes 4,000 clicks to get through the day for a 10-hour shift,” Dr. Sinsky said. “Studies have shown that physicians are spending 44% of their day doing data entry work, [but] 28% of the day with their patient.”
In her own EHR, she said, “it took 21 clicks, eight scrolls, and five screens just to compose the billing invoice, and within that EHR, the responsibility, which used to be a clerical responsibility, has transferred many things to the physician. All of those clicks, all those screens, and all those minutes add up.”
2. Note bloat.

With her current EHR, Dr. Sinksy said, “I have six pages of notes for an upper respiratory infection.” This is not efficient. She offered another example: “I had a patient recently who I sent to a local university,” Dr. Sinsky said. “I got back an enormous note, about 12 pages long. But I still didn’t know, at the end of it. Did she have cancer, or not?”
3. Poor workflow

. Today’s EHRs have a workflow that doesn’t match how clinicians work, she said. “Right now, many clinicians are encountering these very rigid workflows that don’t meet the patient’s need and don’t meet the provider’s need.” For example, “in some EHRs, the physician can’t look at any clinical data while dictating the note. This means that the physician has to rely on memory or print lab results, x-ray reports, medication lists, etc., in order to reference these data points in their clinic note.”
4. A lack of focus on the patient.

Most EHRs lack a place for a photo of the patient and his or her family, and a place for the patient’s story, a deficiency that detracts from the value of the encounter.
5. No support for team care.

Often, both a physician and a nurse or medical assistant need to add documentation to the EHR. Yet many systems are set up such that each party must log in, then log out, before another can contribute. “The nurse has to sign in and sign out; the doctor has to sign in and sign out. That’s about a 2-minute process, so it’s completely unworkable,” Dr. Sinsky said.
6. Distracted hikes to the printer

. While most health care settings have installed the computer in the exam rooms, few have also installed a printer. “The doctor types up the exit summary, hits print, runs around the corner, down the hall, around the corner to the one printer, picks up the visit summary, goes back down the corner down the hall. Meanwhile, they’ve broken their bond with the patient and been interrupted several times on that journey.”
7. Single-use workstations.

Doctors who can sit side by side with their nurses and talk about the patient as they’re working on the EHR can save 30 minutes per day. But most office practice setups don’t accommodate that interaction.
8. Small monitors.

Being able to see a large display of information rather than a tiny swatch can save 20 minutes of physician time a day, Dr. Sinsky said.
9. A long sign-in process

. Streamlining the way a doctor signs into a computer, perhaps with the use of technologies like the tap of one’s badge, “can save 14 minutes of physician time a day,” Dr. Sinsky said.
10. Underuse of medical and nursing students.

Practices are beginning to hire premed and prenursing students as assistants who shadow the physician with each patient. While the physician is “giving undivided attention to the patient, the practice partner is cuing up the orders, doing the billing invoice ,and recording much of the encounter.” At the University of California, Los Angeles, researchers found that the use of these assistants saves 3 hours of physician time each day (JAMA Intern Med. 2014;174[7]:1190-3).


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