Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause?

Subjective:
I read the Downing et al article on EMR contribution to Physician Burnout.
Agree with conclusions - significant differences between approaches to EMR documentation USA vs others.

At RCH, Australia
ROS:
1st Australasian customer using EMR from major US vendor mentioned by Downing
Go-live: Apr 2016. Enterprise-wide.
0% documentation or ordering on paper
No scribes, no transcription, no voice-recognition.

Objective findings:
Note documentation is only for clinical purposes
No regulatory, billing, compliance, or low-value medico-legal content is needed
No requirement to link orders, or procedures to anything for charging purpose
Rounding- resident writes note. Attending does not write a note or attest resident’s note.
Co-sign required for <1% of orders/documentation
Very few system alerts to clinicians
Lengthy narrative notes – discouraged. Brief bullet point style notes - encouraged.
Notes are brief and facilitate clinical care. Pertinent info is easy to find

Assessment:
RCH Physicians have embraced EMR
82% RCH physicians say EMR makes them more efficient (survey)
58% say quality of patient care is better
Physician burnout is not a major topic of conversation in Australia
Few Physicians leave the workforce prematurely

Plan:
Australian physicians should reject any attempt to change the primary purpose of clinical note keeping.
USA healthcare system may need to go back to the drawing board.

Signed
Mike South CMIO, RCH
09/0518

As Dr. Downing and colleagues point out in their article (1), changing the current unnecessary and burdensome, clinical documentation requirements in the United States will go a long way in reducing physician burnout. At the same time, much can be done to modify Electronic Medical Records (EMRs) and their associated infrastructure to reduce the strain on physicians. Years down the road, it will not be surprising to see an epidemic of musculoskeletal injuries in health care workers ranging from carpal tunnel syndrome to degenerative joint disease of the cervical spine from spending hours on a desk, glaring in to a monitor, clicking repeatedly on the mouse and continuously typing on the keyboard. The effect of light exposure at certain times of the day on circadian rhythms and its antecedent consequences on an individual’s health is well known. Based on this, it would also not be surprising to see such changes in physicians and other health care providers using the computer late in the evening, trying to catch up with their notes.

EMR vendors need to start paying more attention to the actual design of their product which is clunky and needs a significant overhaul. Examples of this could include an EMR interface which is fundamentally based on touchscreen and voice based technology, is easy to navigate, and which is highly customizable by individual physicians to meet their particular needs. Additionally, hardware manufacturers should develop and incorporate ergonomic solutions directly in to their devices which should be more robust with better processing power. Attention should be paid to improving the resolution of computer screens. Reducing the emittance of harmful light frequencies by such devices is important and touch screen technology needs to be more resilient. This should be a challenge for companies such as Apple, Google, and Microsoft to get in to the EMR arena and build a better quality software and hardware product. Another area of improvement will be network speeds – the time delay in accessing patient data is unacceptable and will need to change. The time is right for such innovation and national medical organizations should aid, encourage, collaborate on, and incentivize such efforts. In the meantime, physicians should demand compensation for the numerous hours they have to spend after work to complete their documentation because of a system which is rudimentary and non-efficient.
 
References:
1. Downing NL, Bates DW, Longhurst CA. Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause? Ann Intern Med. doi:10.7326/M18-0139

From day one of medical school I was working on an electronic medical records. I know how it several different systems work and while there are certain systems that are better than others I can't imagine working without one. For the first year of my residency one of the hospitals I worked at was still using paper charts (with the plan to switch to an EHR at the end of the year). For me, switching from electronic to paper was the type of shocking and frustrating experience that I imagine many seasoned physicians experienced when they switched from paper to electronic. I was SO relieved when the hospital finally switched to an EHR. I imagine that as the newer generations of physicians come up there will be less and less frustrations with EHR as that has been all we have known.

To The Editor: As an aged general internist I have lived through the many issues to which the authors refer. I remember with some humor my his photo at the computer was circulated through our academic center’s intramural news sites to make note of the fact that even the oldest among us could learn to use the electronic health record (EHR). I succeeded in mastering the basics. But, facing increasing and seemingly needless requirements, and less time with patients (and students, residents and other learners), I have left the struggle. In truth, my failure to meet the local EHR requirements ended my academic practice. Not only are physicians’ administrative requirements buried in the EHR staggering now, the additional requirements inherent in reimbursement change from fee for service to pay for performance and value, will make them virtually impossible to complete. The authors’ points are strong and relevant.

Lest anyone believe that the physician cohorts between the USA and Australia may be of different mind sets, and thus the explanation of difference in attitudes toward the EHR, let us attest that physicians’ attitudes and emotions relating to career satisfaction in both countries are quite similar, amazingly so. In the 1980s we performed prospective studies comparing these themes among first year resident physicians in USA’s Portland, Oregon and Long Beach, California with those of matched peers in Australia’s Sydney, New South Wales (University of Sydney and University of New South Wales) and Newcastle, New South Wales.  While there were modest demographic differences among the subjects; i.e., Australian physicians were slightly younger and less dislocated from homes than their American counterparts, there were no differences between the groups in emotions and attitudes regarding career satisfaction. All cohorts burned out, became more cynical, less satisfied with career choice, and more disengaged at mid year, only to return to baseline positive status as their first years concluded. The changes were nearly exactly the same.  

I believe these findings add strength to the authors’ hypothesis that the chaos of and subsequent discontent with the EHR in the US may well relate to the massive and mainly clinically useless information that national policies require to be included for physicians’ completion.

Donald E. Girard, MD, MACP, Professor Emeritus, School of Medicine, Department of Medicine, Oregon Health & Science University, Portland OR 97239

References:

1. Girard DE, Elliot DL, Hickam DH, Sparr L, et al.  The internship:  a prospective investigation of emotions and attitudes.  West J Med 1986; 144:93-98.
2. Gordon GH, Girard DE, Hickam DH.  04 of mood changes and satisfaction among first year medical residents in three programs.  J Med Educ. 1987; 62:428-430.

3. Girard DE. Comparison of Emotion Change and Career Satisfaction between U.S. and Australian Resident Physicians. National Meeting, Society of General Internal Medicine, Plenary Session.  Washington, D.C., May 1992.

In 2005, one year after the Office of the National Coordinator for Health Information Technology (ONCHIT) was established to lead the way in the modernization of healthcare, 50% of healthcare providers were expected to use EHR by 2020 (1). At that time it was difficult to imagine that EHR implementation would not lead to higher quality care provided at lower cost; or that it would be so disruptive for professionals.
From 2011 through 2016, the Center for Medicare and Medicaid Services (CMS) made more than $35 billion in payments through the Medicare and Medicaid EHR Incentive Programs to eligible professionals and hospitals participating in the Meaningful Use (MU) initiative. According to the ONCHIT, by the end of 2016 over 95% of all eligible hospitals received incentive payments for meaningful use of EHRs, while only 62% of eligible office-based physicians demonstrated meaningful use – despite almost 87% having EHR capability (2). Compared to the 50% benchmark expected by 2020, MU incentives appeared to be achieving their goal of increased health IT adoption, although there is little evidence of improvements on the quality of care and the impact on physicians’ quality of work is questionable.
An interesting point raised by Downing and colleagues concerns clinical note length, which is nearly four times longer in the US than other countries (3). The authors ascribe this difference to the structure of US healthcare and express concern over the ongoing transition to a value-based system, which in their opinion will not solve the administrative burden. They remark that strategies to reduce physician data entry have grown rapidly – such as the use of medical scribes.
It’s worth mentioning that between 1997 and 2012 the number of healthcare support and health information technology occupations grew more than any other employment groups (4) - EHRs have made the growing US health IT workforce necessary (5). Although such measures could increase physician satisfaction, they increase costs and provide a short-term answer to an issue that may be solved as the technology is further developed.
Moving towards the Merit-based Incentive Payment System (MIPS), the overall burden of this transition – for CMS and providers – should be considered, and its goal reassessed.
Policymakers seeking to strengthen MIPS and pursue value-based programs in general, should be aware of the status quo and try to refocus these resources towards the end users – physicians and other healthcare professionals. These are resources we should be meaningfully using.


1. Goldschmidt PG. HIT and MIS: implications of health information technology and medical information systems. Communications of the ACM. 2005 Oct 1;48(10):68.
2. Office of the National Coordinator for Health Information Technology. “Hospitals Participating in the CMS EHR Incentive Programs,” Health IT Quick-Stat #44, #45 and #50.
3. Downing NL, Bates DW, Longhurst CA. Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause? Annals of Internal Medicine [Internet]. 2018 May 8 [cited 2018 May 11]; Available from: http://annals.org/article.aspx?doi=10.7326/M18-0139
4. Glied S, Ma S, Solis-Roman C. Where The Money Goes: The Evolving Expenses Of The US Health Care System. Health Affairs. 2016 Jul 1;35(7):1197–203.
5. Skinner J, Chandra A. Health Care Employment Growth and the Future of US Cost Containment. JAMA. 2018 May 8;319(18):1861.

Much of the narrative on the flaws of the electronic environment for physician documentation focus on user factors and interfaces. While there is much to be desired in current EHR designs, Downing et al. hits on a fundamental flaw in clinical documentation in the United States--the regulatory requirements associated with each patient encounter [1]. We could design a more efficient and user friendly EHR, but without addressing the current standards of content of each clinic note, time-wasting regulatory data entry will persist. Is it really necessary to conduct a full Review of Systems to get credit for management of a complex patient? The epidemic of "note bloat" seen in many EHR's where meaningful clinical information is buried in pages of meaningless data is certainly not the formula for efficient delivery of care.

With CMS's Quality Payment Program (QPP) and the Merit-Based Incentive Payment System (MIPS) that it created, targeted low complexity visits are now muddied by the mandate to report on metrics such as tobacco use screening, influenza vaccination status, breast cancer screening, colonoscopy screening, and medication review--just to name a few out of the 275 quality measures available for reporting--irrespective of how relevant the measures are to each specialty [2]. Many of these metrics merely require attestation, but even this takes time away from meaningful patient care, and accelerating physician burnout [3].

It was quite timely then, that a letter from CMS Administrator Seema Verma, released on July 17, 2018 admitted that "Washington is to blame for much of the frustrations with the current system," proposing a dramatic overhaul of the current Evaluation and Management (E&M) documentation requirements [4]. This is a startling but welcome admission by a largest 3rd party payor that what is deemed to be the essential elements in the clinic note that is tied to reimbursement, is not improving quality of care, but rather contributing to burnout. The letter concludes by shedding light on an initiative called MyHealthData as a potential solution for interoperability (something the HITECH Act failed to do) and redesigning the incentives in the MIPS program [4].

Finally, there is a call for proposals and input from stakeholders [4]. Current policies had little, if any, input from physicians and specialty societies. It is hoped that CMS's new, more streamlined documentation requirements will usher in a new era of shorter, meaningful notes containing the information clinicians need to take care of patients. Other 3rd party payors are watching and will likely follow.

1. Downing NL, Bates DW, Longhurst CA. Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause? Annals of Internal Medicine. 2018 July 3; Available from: http://annals.org/article.aspx?doi=10.7326/M18-0139.

2. Quality Payment Program Year 2 Final Rule at https://www.cms.gov/Medicare/Quality-Payment-Program/resource-library/QPP-Year-2-Final-Rule-Fact-Sheet.pdf

3. Luh JY. MACRA Regulatory Burdens and the Threat of Physician Burnout. Mayo Clin Proc. 2016 Nov;91(11):1671-1672.

4. Verma, S. "A Letter to Doctors from CMS Administrator Seema Verma." July 17, 2018 at https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2018-07-17-eNews-SE.html, accessed 7/22/2018.

Disclosures: Advisory Board Member, Crux Quality Solutions

We appreciate the interest that Drs. Girard, Toscano and Kapoor showed in our article and thank them for their insightful comments. Dr. Girard cites the results of the prospective study comparing physician attitudes and emotions from Australia and the U.S. (1). We agree that these findings that show similar qualitative experiences between U.S. and Australia trainees and strengthen the argument that differences between clinical documentation reflect systemic differences such as regulatory requirements. Anecdotal stories of US physicians who have practiced in abroad suggest similar conclusions (2). Additional research into differences between clinician experience in other countries would be helpful to define what policies may mediate provider burnout.

 

Dr. Toscano discusses the federal investment that has led to widespread EHR adoption and the resultant increase in health IT workforce and the implications of the Merit-based Incentive Payment System (MIPS). We agree that programs like MIPS should be assessed for unintended consequences. MIPS may create a shift in the incentive for clinicians to document for reimbursement without reducing or even increasing the overall documentation burden. For example, many have noted the low-value documentation generated by Meaningful Use such as incentives to send patients a secure electronic message, regardless of content. To risk adjust for patient acuity, MIPS may similarly create financial incentives which could result in an “arms-race” to document comorbid conditions. The employment growth in IT consultants may well continue if organizations continue to see a potential return-on-investment under new payment models (3).

Dr. Kapoor makes valid arguments about the need for EHR vendors to prioritize usability. However, the incentives created by the American medical reimbursement system have led to the EHRs that dominate the market – they excel in meeting compliance requirements necessary for quality and billing purposes, not usability. Usability has not been prioritized by EHR vendors because the reimbursement environment has not sufficiently incentivized health organizations to demand it.

With recent recognition of the human and financial cost of physician burnout, we hope organizations and policy-makers will investigate root causes and invest in creating sustainable work for its clinicians (4). Actions such as the recent proposal by Centers for Medicare and Medicaid Services (CMS) designed to modernize documentation requirements are a step in the right direction but continued attention and representation by physician leaders is critical to create a landscape that will allow doctors to focus on patients, not documentation.

Sincerely,

N. Lance Downing, MD

David W. Bates, MD, MSc

Christopher A. Longhurst MD, MS

References

1. Gordon GH, Girard DE, Hickam DH.  Comparison of mood changes and satisfaction among first-year medical residents in three programs.  J Med Educ. 1987; 62:428-430.
2. Dewitt DE, A Tale of Two Countries: How I Saw More Patients With More Joy in Internal Medicine Practice. Ann Intern Med. 2017 May 2;166(9):669-670
3. Skinner J, Chandra A. Health Care Employment Growth and the Future of US Cost Containment. JAMA. 2018 May 8;319(18):1861.
4. Sinsky, Christine A., and Michael R. Privitera. 2018. “Creating a ‘Manageable Cockpit’ for Clinicians: A Shared Responsibility.” JAMA Internal Medicine 178 (6): 741–42.