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The workforce of American physicians is one of our largest ever, with estimates varying from seven hundred to nine hundred thousand practicing physicians. It is one of our most highly skilled workforces, one of the most difficult and expensive to train, and one of the costliest to replace at an estimate of one million dollars per physician. The product involved, the very health of our nation, is critical to our society. By the standards used by any corporation, the environment in which physicians perform their jobs should be a vital consideration in maintaining the quality, efficiency, and yes, even profitability of their product, a healthy populace.
So why are we so reluctant to directly address a major problem universally acknowledged to be negatively impacting our physicians and healthcare system?
Every major survey of physicians over the past six years, including the most recent by the Physicians Foundation, has shown that roughly fifty percent of physicians have or are experiencing serious burnout. That study, as well as multiple others, has also consistently revealed that the use of the electronic medical record (EMR) is always the number one factor cited in contributing to the frustration, fatigue, and loss of autonomy accompanying the burnout problem. Burnout, in turn, leads to possible errors, decreased productivity, early retirement of critically skilled workers and in some cases, the tragedy of suicide. This occurs despite the realization by most physicians that there are positive aspects to the electronic record, particularly the easy access to the information digital records provide (at least within a network).
There are many reasons why the current user interface of virtually every EMR in wide use today is a constant source of inefficiency, waste, and frustration in physician’s daily attempts to care for their patients. While the necessity of entering twenty separate mouse clicks to order an aspirin is emblematic of many complaints, the problem runs deeper. A drastic overhaul of this interface to make it more efficient and user-friendly, leveraging current technology to actually make the point of care a more productive place to work is absolutely mandatory. Our current EMRs represent an investment of hundreds of billions of dollars and are arguably the largest, most expensive and most efficient billing machines ever created anywhere. They categorically do not make a physician's work easier. What other industry would make this kind of investment, realize that it was creating a major human resource problem and not attempt to rectify the situation?
There have been many efforts. Practices large and small have hired “scribes” to decrease the data entry workload heaped on physicians by systems hungry for data to satisfy billing algorithms, regulatory “quality mandates” and provide proof of population health initiatives. However, this has turned the medical record on its head. Once organized to succinctly focus on the key elements of a patients care, the record is now an unintelligible mass of data, organized only virtually around a priority of data reporting, billing, and regulatory checklists. Patients do not really like clerks in the exam room. Physicians are frustrated and left wondering what other business would invest in technology that created a need for them in the first place.
To their credit, hospital organizations and medical associations have attempted to approach the problem by developing multifaceted wellness initiatives intended to increase the resiliency of physicians through a variety of creative approaches. These are welcome and useful efforts. As a practicing physician recently observed, however: “When the canaries in the coal mine start dying, ones first thought is usually not to send out for tougher canaries!”
Understandably, health systems which have invested hundreds of millions of dollars in technology which captures every billable penny and literally will not allow care to proceed until every box satisfying regulators and payers has been checked, may not be eager to challenge the EMR industry to do better. It is far easier to pursue a tougher canary. I would argue that it is imperative for the health of our physicians, the quality of our medical care, and yes, even the efficiency and costs of the care we deliver together, that the current EMR interface be radically reformed. It has to be patient-centered at the point of care, not primarily designed to satisfy regulators. It has to make everyone on the healthcare team’s work easier and more efficient, not provide an obstacle to care or needlessly delay it. It should deliver the same quantum leap to the quality of our care that it has to the reports of our institutions' financial officers. While the EMR may be the only way to provide the data our social planners need to make wise system-wide improvements, surely this can be accomplished without disrupting the actual care that is delivered. Moving forward, the downstream effects of regulations requiring documentation need to be rigorously evaluated for evidence-based results before they become mandated mouse clicks.
It is time for the entire house of medicine to address the EMR itself. Our technology is capable of much better, and the promise, which electronic records held twenty years ago, is woefully unfulfilled. The need is painfully documented, and the time is now. After all, sending out for a better breed of canaries is of no help to the miners, and, at best, cruel to the canaries.
