By Cindy Foster

University of New Mexico Studies Physician Burnout Related to Electronic Records

It was supposed to make things get better but it didn't.

When the Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law in 2009, the promise was that an electronic record technology would streamline paperwork, reduce waste and lead to more cost-effective health care.

Instead, 10 years later, physicians find the length time devoted to medical record-keeping has essentially doubled: they now are spending two minutes at the computer for every minute spent with patients and their typical workdays are apt to end with laptops out at home as they wearily climb into bed.

Now, University of New Mexico Health Sciences Center researchers are examining the toll in stress and burnout that maintaining Electronic Health Records (EHR) are inflicting on the medical profession.

"We are losing the equivalent of seven graduating classes of physicians yearly to burnout and, as they leave the profession, they point their finger at the time now required for them to document their work and how it has led to the loss of quality time spent with patients and families," says Philip Kroth, MD, director of Biomedical Informatics Research, Training and Scholarship at UNM's Health Sciences Library and Informatics Center and professor in the School of Medicine.

"In many ways, physicians are finding that the goals of a traditional medical record have been hijacked," he says. " And, while there is a great deal of research interest in physician burnout, we believe we are the first investigators who have been able to measure and correlate these impacts."

For the research project, UNM collaborated with Stanford University, the University of Minnesota, Hennepin County Medical Center, and the Centura Health System in Colorado and Texas to survey 282 clinicians on EHR design and use factors associated with stress and burnout. The survey also included validated measures of stress, burnout, and the likelihood to leave the practice of medicine.

The survey was informed by a prior focus group study that identified that identified the design and use factors of EHRs that physicians felt were most responsible for physician stress and burnout. The survey measured how strongly the respondents feel the previously identified EHR design and use factors contributed to stress and burnout The unique feature of this research is that the survey also included previously validated questions to measure the stress and burnout of the respondents at the same time. This allowed the investigators to correlate what EHR design and use features were most highly associated with respondents with high measured stress and burnout.

The research showed that statistically, about 13 percent of the physician self-reported levels of stress and burnout were directly related to EHRs. Kroth says this is far is from the complete story. Clinical process design and the clincal culture - both of which are highly impacted by the electronic health record - contribute to approximately 40% of total clinician stress.

"Our electronic medical chart notes have grown until they are 10 times longer than physician notes in the European Union," he says.

A medical record used to be a few lines to document a patient's history, Kroth says."Until I was 18, my entire pediatric medical record was one page long," he remembers.

But that was before the decade-long, $25-billion push by the U.S. government to drive institutions to adopt EHRs, he says.

Now, added to that patient history, the EHR has become a place for documenting against potential medical malpractice, collecting additional information for quality assurance initiatives s, and to support billing processes. Increasingly, it is also becoming part of governmental policy oversight processes.

"Years ago the medical record primarily served one purpose -for the benefit of the patient to support patient continuity. Today there are at least four more," he says.

"It seems as though everyone wants to add another checkbox or drop-down to the record, but no one is looking at the sum total of how all these additional data entry requirements are adding up or whether they actually benefit the patient or the healthcare system. In many ways, it isn't even valid to compare the old paper charts with today's EHRs that require so much more information to be included."

The case for EHRs was not completely negative.

"People in the focus groups liked having the ability to access and update patient medical records at home - but disliked how that access makes it easy to spend hours to update them," he says.

Doctors were asked to evaluate how issues such as excessive data entry, inability to navigate the system quickly and barriers to integrating notes into external systems affected their workday.

"Physicians are being asked to do more and more - sometimes to the detriment of the physician-patient relationship," Kroth contends. "With electronic notes what should be face-to-face time with the patient is instead has turned into face-to-screen to face time."

What used to take seconds to update can now takes minutes. Add to that, the daily avalanche of emails, texts and pages, and the time spent with technological gadgets has significantly eroded into face time with patients.

In the end, an argument can be made that all that data collecting is having a negative impact on patient care - something that Kroth's research strongly supports.

"Many of these government data quality projects are well meaning but they often create unintended consequences. What are we really accomplishing?" Kroth says.

"Now, you may go to see a doctor because your ankle hurts, but we as physicians are going to be dinged if we do not do things like screen you for diabetes during that visit," he says. "But, as the patient, you aren't interested in that. You just want something done because your foot hurts."

Many of the identified EHR design and use factors that interfere with patient care can be remedied. For instance, the pain from poor posture developed while sitting in front of a computer.

"Many hospitals and clinics are retrofitted for the technology on a piecemeal basis to where each clinic ends up with different chair and table heights," Kroth says. It is actually an area where ergonomic changes could bring big benefits.

There is also a growing awareness that the system itself should be able to become smarter.

"Why can't the system sense the difference between a 75-year-old living in a nursing home with end-stage dementia versus a 75-year-old who is still working and golfing four days a week?" he asks. Yet to date, the EHR record for both patients appear identical.

While physicians are leaving the profession in record numbers, no one has been able to show where the vast amount of information being accrued into medical records is benefitting patients, he says.

"If you thought all this data entry was meaningful and making some sort of positive patient impact then it would be a completely different story," he says, "but to date there has been no research showing an overall reduction in mortality, improvement in quality of life or reduced hospital admissions."

The American Medical Informatics Association recently called for a long-term strategy from the US Department of Health and Human Services to decouple clinical documentation from billing, and regulatory and administrative compliance requirements, which should be good news for physicians overwhelmed by all their electronic data demands.

"We went to school to see patients, but now, for every minute we have with a patient, we are spending two additional minutes on the computer," Kroth says. "It often takes a 60-hour week just to keep up with documentation, and that is tough on personal relationships and families."