I didn’t become a physician to do data entry

The trouble began when I needed to open the electronic health record (EHR) system for the tenth time that day. EHRs have significantly changed the way we practice medicine. They have completely eliminated the need for storage and transport of paper charts, reduced prescription errors secondary to illegible handwritings of physicians and provided an excellent platform to maximize billing for services rendered. However, in terms of creating a smooth workflow for physicians and in facilitating meaningful face to face encounters with our patients, all EHR systems have completely failed.

Sara, the nurse for Ms. Tucker, called me saying, “Doc, Ms. Tucker is back from the cardiac catheterization lab. She is complaining of a mild headache.”

“It must be from the nitroglycerine I gave her in the lab; please give the ordered Tylenol, it will resolve soon,” I said.

“I don’t have any orders, Doc. All the orders for this patient are on hold,” she replied.

“On hold? What do you mean?” I said surprised.

“Yes. All orders go on automatic hold when a patient goes for a procedure and comes back unless you reorder. It’s the new EHR upgrade,” she said.

“OK, I will do it as soon as possible,” I said, taking in a deep breath and involuntarily rubbing my forehead.

To reorder Ms. Tucker’s medications, I needed to log into the EHR system again. I had to do it remotely, as I was at another hospital in town that used a completely different EHR system, though it was only ten minutes away. I had to enter my username and password carefully and slowly three times in response to three different prompts in addition to entering the secret code that was texted to my cell phone. After what felt like an eternity, I logged into this most sacred, highly-classified, triple-password-protected space of EHR. I wondered if the FBI have to enter their passwords thrice to log on to their everyday workspace. As I was able to log onto the EHR system without seeing the prompt “Incorrect username and or password,” anytime during my three-password entries, I regarded it as my greatest success for the day. The fact that Ms. Tucker’s procedure was uncomplicated and smooth faded in comparison to this success.

I opened Ms. Tucker’s chart. There were twenty-one tabs vertically on the left-hand corner of the screen and eighteen tabs horizontally on the top of the screen. I quickly glanced through the cluttered twenty-one vertical tabs; I clicked on the one I am looking for — “transfer medication reconciliation” in the 19th slot. A new grid showing sixteen held orders opened. I selected each of them separately and clicked on “continue.”

Select and continue.

Sixteen times two: thirty-two clicks.

I was fidgety. I was not sure of even reviewing each order. I just clicked and clicked. Final tab. Review and sign. Clicked. End of my rendezvous with EHR for today. I hoped. The age of “clerical” physicians continues, I mused.

A few weeks ago, when there was EHR system breakdown, patients were still taken care of. Nurses took verbal orders. It was unquestionably chaotic, but for me, it was bliss. I was on call for acute heart attacks that day. Ms. Copper drove her husband to the hospital with sudden-onset chest pain. Mr. Cooper had a cardiac arrest in the parking lot of our hospital. He was revived after a brief period of cardiopulmonary resuscitation and taken immediately to the cardiac catheterization lab. I opened his occluded left circumflex artery successfully, and he was transported to the intensive care unit in a stable condition. No one pestered me regarding entering orders before doing the procedure.

After the procedure, I wrote down the report and all the orders on a single plain sheet of paper in fifteen minutes. Zero clicks. I then went to meet Ms. Cooper in the family lounge. Usually, I am interrupted by messages from the nursing staff that family is waiting for me when putting orders or vice-versa that there is some problem with order entry when I am meeting with the family. This didn’t happen that day. Ms. Cooper had my undivided attention for a full twenty minutes. Her eyes filled with tears of gratitude at the end of our conversation. She hugged me and said, “Thank you for saving my husband’s life.” I didn’t have to rush to correct orders or type in my notes. The bliss, unfortunately, lasted only for twenty-four hours, and once the software was uploaded again, the usual “digital” drudgery continued.

I chose to be a physician to care for people. I value my direct face-to-face interactions with my patients. I want to hear their stories told by them in their own words. I cherish their smiles, their tears, their gratitude, their handshakes and hugs. I did not sign up for screen time with a computer, speed typing or clicking. I did not sign up to type passwords multiple times.

The leading, if not the only, cause reported for physician burnout is workflow issues related to the use of EHR systems. Instead of providing meaningful clinical documentation for easy communication among health care providers, it has evolved into this massive, cumbersome giant with so many interfaces, cluttered screens, redundancy and duplication requiring innumerable clicks, selects, templates and passwords with no added clinical value but only frustration and burnout for physicians. The software has to be re-designed for clinicians to efficiently gather data, enter orders and communicate relevant clinical information without having bloated notes and cluttered screens that are catered for easy billing and coding. Clinicians together with hospital administrators and information technology professionals should be actively involved in the development, testing and optimization of new electronic features to streamline the workflow. For me, there will be no joy in the practice of medicine until my frustrating rendezvous with EHRs end.

The names used in essay have been modified to maintain anonymity. It is a fictionalized account of true events.

Jaya Mallidi is an interventional cardiologist.

Replacing transcriptionists with physicians is a fool’s bargain

My general internal medicine practice is equidistant from the three academic institutions and a Veterans Administration facility, and thus I have patients who receive primary, secondary and tertiary care at each of these institutions.

The notes I receive back from one of these organizations are hands down the best of the four institutions. These notes are personal, concise, precise and clear. If the patient had a complicated outpatient work-up the communicating physician will send a problem-oriented summary of the patient’s symptoms, the work-up, the conclusion and the recommended next steps. There is a clinical narrative with clear communication of the patient’s unique story and the medical decision-making. Furthermore if the patient saw more than one physician, the note I receive integrates the impressions of all of the physicians.

For my patients hospitalized at this institution I especially value the discharge medication list, which is broken down into fields for continued medications, modified medications, new medications and discontinued medications. In most circumstances the patient has also received a copy of the inpatient and outpatient notes and the medication list.

From the other organizations the communication is rather more like a “ransom note,” a multi-font collection of structured text entries, pieced together with imported labs and x-ray results into a hard-to-read document, typically 6 pages of structured text, with an emphasis on billing justification and compliance language. Scanning through these lengthy documents for the “meat” of the note I struggle to find a coherent story (but I readily see what type of learner the patient is, and what part of the visit the attending was present for and other billing and compliance information.) Three different EHRs are represented. Here is a typical emergency room note:

“The patient presents with palpitations. The onset was just prior to arrival. The course/duration of symptoms is resolved. Character of symptoms skipping beats. The degree at present is none. The exacerbating factors is none. Risk factors consist of none. Prior episodes: none. Therapy today: none. Associated symptoms: near syncope”

Transcriptionists are being replaced by physicians for cost reduction, a calculus that doesn’t consider reductions in patient safety and quality, or lost physician productivity and well-being.

This “savings” in transcription costs also comes at a cost to the clinicians who subsequently read through multiple pages of low value text to find the kernel of useful information. And because the person documenting the care spent considerable time processing through the drop down boxes, less effort has been applied to the assessment and plan, often leaving the receiving physician in the dark when trying to pick up the thread of care.

I have always appreciated the care my patients receive at the first institution, not just for the care itself, but for the systematic, reliable communication I receive back about my patients. I recognize that having one physician summarize complicated care across many specialties, and having dictated notes is an expense, but it is an expense that makes a difference in the care of patients. Replacing transcriptionists with physicians is a fool’s bargain.

Christine Sinsky is an internal medicine physician who blogs at Sinsky Healthcare Innovations.