The Real Cause of Burnout in the EHR Era?

Written by Clay Smith

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This opinion piece suggests that it may not only be the clunky EHR that is to blame for physician burnout.  Rather, meaningless government documentation requirements pack our notes with useless information that we must include nonetheless in order to get paid.

Why does this matter?
Burnout among physicians has reached unprecedented levels, especially among emergency physicians.  One of the things that has also changed during this time period of increasing burnout is the use of electronic health records.  Authors state, "The highly trained U.S. physician, however, has become a data-entry clerk, required to document not only diagnoses, physician orders, and patient visit notes but also an increasing amount of low-value administrative data."  But is it the EHR or something else that may be driving burnout?

Blame the government
The authors are physicians and have worked to support Epic EHR software optimization around the world.  At first, I was very skeptical, but they made an interesting observation.  As they have implemented the Epic EHR in other countries, they found, "a significantly different interpretation of the EHR abroad: Physicians were more likely to report satisfaction with its use and cite it as a tool that improved efficiency."  They back up that assertion with evidence that physician notes in the US are four times longer than in Canada, the United Kingdom, Australia, the Netherlands, Denmark, the United Arab Emirates, and Singapore.  Notes in these countries document only important information to communicate what is clinically relevant (what a concept!), as opposed to the US in which the note must contain often irrelevant elements demanded by government payers.  They mention this is a relic from the fee-for-service model.  The bad news is that as Medicare moves to value-based care, the, "Administrative tasks could grow even further as value-based payments increasingly demand documentation of comorbid conditions, quality process metrics, and clinical outcomes."  Many blame the EHR vendors, which seems reasonable to me.  They make the point that hospitals demand these features in the US.  However, I am an Epic user, and it seems as though they are in league with mouse manufacturers; our EHR seems to optimize number of mouse clicks, not efficiency.  Regardless, they have a fair point that the vendors must include these government-required features.

So what is the answer?  A colleague of mine is moving to Australia.  That's one option, but then I remember that every living thing there is venomous or has some other way to kill, maim, or eat you on land or at sea.  The only real option for us who want to remain in the US is reform.  What if we focused on meaningful notes, not meaningful use?  What if we rewarded brevity and clarity in communication, not unreasonable notes with a comprehensive review of systems for strep throat?  Burnout is not a simple problem, and it won't have a simple solution.  These authors argue that government requirements for meaningless documentation bloat our notes and create the very inefficiency the EHR was designed to solve.  True, but I'm not letting the vendors off the hook so easily.  EHR vendors need to trim all the fat and optimize speed and efficiency, not number of clicks.  Most importantly, if you're experiencing burnout, ask for help.  I have been there.  Heck, I still dabble in burnout periodically.  If you want some great reads on the subject, see Another Spoonful section below.

Source
Downing NL, Bates DW, Longhurst CA. Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause?. Ann Intern Med. [Epub ahead of print 8 May 2018] doi: 10.7326/M18-0139

Another Spoonful

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