Electronic health records were supposed to be the miracle cure for every shortcoming in Canadian health care, an up-to-date digital file that would make care safer, more efficient and seamless. No one predicted the toll it would take on physicians.
Quite the contrary, in fact. With a world of information at their fingertips, from the patient’s history, to tracking of chronic disease measures to an instantly accessible medical library, plus treatment options, prescribing recommendations and prompts to help deliver holistic care, digital records were intended to enable doctors to deliver unparalleled care with ease.
In 2015, Canadian Family Physician published two articles that debated that idea. One, by Donna Manca, a family physician in Edmonton and director of research in the Department of Family Medicine at the University of Alberta, was firmly in favour: “Electronic medical records improve quality of care, patient outcomes, and safety through improved management, reduction in medication errors, reduction in unnecessary investigations, and improved communication [and they] improve the work lives of family physicians despite some subjective concerns about implementation costs and time.”
But Michelle Greiver, a family physician at North York General Hospital in Toronto and assistant professor at the University of Toronto, who had been “an early enthusiast,” was squarely on the other side in her article. She noted digital records often need structured or coded data (which are time consuming to enter) to do things such as automated recalls and computerized decision support. “Current [electronic medical records] are not making much of a difference,” she writes. “To enable their potential will require support for a redesign of [their] databases. We need user interfaces that make data entry for clinical decision support easy to do.”
Neither side in the debate, however, touched on an issue that’s of growing concern: the number of physicians who say electronic health records are contributing to burnout. Spok Mobile, a message app for health care, surveyed clinicians on burnout: 90 per cent said “increased and ineffective technology contributes to risk of clinician burnout,” and 95 per cent believe improving the usability of EHRs would be helpful to reduce that risk.
A 2018 review of six articles in Current Opinion in Anesthesiology said physicians feel they are spending far too much time inputting data, and quoted the head of one California medical school who said electronic records “contribute to burnout by turning physicians into unhappy data-entry clerks, and by enabling 24-h patient access without any system to provide compensation or coverage.”
The link between technology and burnout is not just based on anecdotes of people in high-pressure jobs losing it when their computers crash: some serious research has gone into the issue.
One 2018 study in the Journal of the American Medical Informatics Association began by summing up several studies’ findings on the impact of electronic health records: “EHRs contribute to burnout because of challenges in efficiently navigating the user interface, the additional time required to document in an EHR vs. a paper chart, the amount of date the physician could theoretically access during each clinical encounter and each medical decision, the increased number of clerical tasks directed to physicians, the ability to work anywhere and anytime and the impact of EHRs on the physician-patient interaction.”
Physicians have told researchers electronic health records are “an important component in burnout, and dissatisfaction with one’s EHR is associated with intent to reduce clinical work hours and leave one’s current practice.”
Other potential results of burnout include higher turnover, higher rates of substance abuse, more medical errors and more malpractice claims, the study says.
The Medical Informatics study was based on a survey sent to every physician in Rhode Island. Of the 43 per cent who responded (almost 1,800 people), 26 per cent reported burnout. About 70 per cent of physicians with electronic health records suffered from technology-induced stress, based on three measures: added frustration, time spent on the electronic record at home and insufficient time for documentation. The latter was the strongest predictor of burnout.
The problem is not insurmountable, the authors say. Pointing out three-quarters of physicians aren’t burnt out, and not all electronic health record users are stressed, the researchers recommend asking those people what keeps them calm while they work with technology. Some solutions that have been tried include scribes (to gather and enter information for physicians), team-based documentation, enhanced roles for medical assistants and better individual IT training for users would all help.
Clearly, the whole point of information technology was to give physicians tools that would enable them to take full advantage of the astonishing medical advances of the 21st century. But it’s equally clear clinicians need more delicate tools, matched to their tasks, and sorted carefully into a tool box designed with physician input, for physician’s needs. Doctors should not have to suffer for patients to benefit.