“One More Click,” Dr. Bianca Roberts’ president’s message in the November/December issue of SSV Medicine, details the woe the electronic health record (EHR) has foisted on the daily lives of clinicians caring for patients. As the lead physician for EHR implementation for several years in Sutter Medical Group, it is my experience that there are three reasons why this robust clinical tool has become such a burden in the everyday care of patients: business strategy, misguided training, and financial incentives.
The business strategy failure of EHR vendors is that they didn’t — and don’t — listen to their average customer, the busy clinician. “Superusers” are the primary source of feedback used to build and program the application, but these are clinicians with unusual technical savvy. Clinicians in the trenches have complained bitterly for years about the complexity of the application and its use, while vendors continue to believe that superuser feedback is sufficient.
Superuser feedback became the inspiration for development. As a result, the voice of the struggling average clinician working in the clinic was drowned out by the demands of these superusers for more and better data management. This required, of course, data entry. Who was tasked with that data entry? Clinicians. Clicks and keystrokes be damned.
An example of how a viable software application should be built is Intuit. Their financial management products — Quicken for home use, QuickBooks for small business, and the tax application TurboTax — are rock stars when it comes to usability and popularity. How did they get there? They listened to their average customers.
While customer company bookkeepers and accountants pressed for more complex and elegant functionality, Intuit deferred to the busy personal and small business user who consistently demanded that the application focus on ease of use. Their developers focused on what tasks were essential to the outcome required, and the most efficient way to complete those tasks. Fewer clicks, less typing. It meant that data not essential to the goal was not entered. The time of their average user was the most important factor in determining design.
The EHR vendors have failed in this miserably, despite personal appeals from people like me who bore the brunt of the complaint and frustration of their colleagues. The vendors didn’t listen to their users.
Unfortunately, the horse has left the barn on this one and busy clinicians have no time to mount up and chase after that horse. It will take a huge effort to change the strategic thinking of the vendor, and to quell the superuser demand for more complexity in data management.
Misguided training is the second major factor in the rise of the EHR. This is a failure of customer organizations (medical groups, medical foundations, hospitals, and integrated systems) to take seriously the task of proper clinician training.
The training that was lacking was not about improving typing skills, or data mining ability, or note documentation. It was none of these.
The lack of training that still is a black eye to these organizations is a failure to teach and train clinicians and staff how to use the computer in the exam room to invite patients into the documentation of their care, a review of their health and how they are progressing.
The EHR should be a tool that a clinician and patient use together, as partners, arms around each other’s shoulders, as data relevant to the patient and their health is entered and reviewed. It should result in the creation of a relationship that is more trusting and transparent, a bond that deepens as clinician and patient jointly use the tool of the EHR to pursue their shared goal of improved health and better lives.
This requires an investment of time and training. It costs money. In my experience, when financial hardship struck, the go-to-cost-to-eliminate was training. Not just in the EHR but almost always including the EHR.
Throwing a clinician into the heat of the clinical encounter without the skills to understand how to integrate the EHR with the patient experience remains an act of cruelty to everyone concerned. The good news is this one can be fixed if organizations take the responsibility seriously and invest in it properly.
Financial incentives are the last and strongest foundational reason for the burden of the EHR, as pointed out in “One More Click.” At some point in time the vendor ceased focusing on clinical excellence as the most important outcome and began to focus on revenue capture. This was in response to the clamor of the paying customers for ways to finance the huge expense of the application and its maintenance, and the never-ending pursuit of profit. Health care organizations’ focus on finance, especially when the EHR vendor adapted and grew the inpatient business, attracted the programming resources of the vendor.
While the focus on revenue seems like something that might benefit the clinician, it in fact became the nemesis. The clinician became the point of entry for coding and capture. And all that data entry resource was free to the health care organization. The medical record itself became focused on how much money a note was worth, not on how much better the care would be. Physicians were trained on how to write a note for revenue capture, not for succinctness and clinical utility. The result is volumes of useless redundant information in the clinical portion of the application, copy-and-pasted from past years, lacking assessment of accuracy or relevance to the care of the patient.
In the age of capitated care, a major financial goal became patient enrollment. To attract patients, new services were created in the EHR. Direct messaging to clinicians, accompanied by the lack of workflows to manage this messaging and the give-away of medical advice without compensation to the data entry slave, dispirits and wears down the energy of caring clinicians. The clinician’s time outside of the exam room is not spent on journal review, attending CME or time with their family. It is spent on the never-ending uncompensated task of pleasing patients for the sake of enrollment.
This too, I fear, is a fire that will never be controlled. As chair of a compensation committee and leader of EHR implementation, I could always find the explanation for behavior could be found by following the dollar. So we pay physicians better if they enter long notes that don’t provide clinical relevance, in order to capture revenue, and then fail to pay them for the busy work of maintaining a positive clinician-patient relationship.
The solution to this one will take a redesign and implementation of the health care system in America — which, sadly, is not coming any time soon.
Email Thomas R. Atkins, MD
Claire Unis, MD, contributed to this article.
