EHRs exert different kind of drain for hospital-based physicians

Sara Berg
Senior Staff Writer
AMA Wire
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Research on how electronic health records (EHRs) affect patient-physician relationships has remained focused on outpatient settings. However, a recent study in the Journal of Innovation in Health Informatics by Rebekah Gardner, MD, Kimberly Pelland, MPH, and Rosa Baier, MPH, assesses the impact of EHRs on inpatient settings.

With limited research available on the influence of EHRs on inpatient interactions, Dr. Gardner, Pelland and Baier “undertook a qualitative analysis of a statewide physician survey across specialties to assess hospital-based physicians’ perceptions about how using an EHR affects interactions with patients.”

Initially created for billing and documentation, EHRs have now transitioned administrative tasks onto physicians, changing how they work and interact with patients. This new EHR analysis targets a larger sample size than in previous studies, incorporating both hospital and office-based physicians. More than 700 physicians responded to a 2014 Rhode Island Department of health survey question, “How does using an EHR affect your interaction with patients?”

Results showed that hospital-based physicians most often denounced how EHRs take time away from patient contact while office-based physicians expressed concerns about a decline in the quality of patient interactions. Findings from this study help to add further information to literature that previously focused on outpatient physicians and to “shape interventions to improve how EHRs are used in inpatient settings.”

“The type of relationship that an inpatient doctor has with a patient is very different than the outpatient doctor,” Dr. Gardner told AMA Wire®. “I think it’s not just about differences in how inpatient doctors use the EHR. It’s also that their relationships with individual patients are also different. They’re having different conversations.”

Dr. Gardner is an associate professor of medicine at the Warren Alpert Medical School of Brown University, senior medical scientist at Healthcentric Advisors, and a practicing internist at Rhode Island Hospital where she teaches medical students and residents.

Different emphasis for hospital-based physicians

According to Dr. Gardner’s study, most specialties perceive EHRs as negatively altering patient interactions, but inpatient physicians highlighted different reasons for their displeasure than office-based physicians. An emphasis was placed on five main themes for hospital-based physicians and their perception of EHRs.

While the themes were similar to those of office-based physicians, the order rank remained different, stating that EHRs:

  • Mean less time to spend with patients because more time is required for documentation.
  • Reduce the quality of the patient-physician interaction and relationship.
  • Have no effect on patient interaction.
  • Improve access to information, which benefits patient interactions.
  • Were negative or positive, but non-specific comments about patient interactions.

Inpatient physicians spoke about the differences in the type of relationships with patients compared to outpatient doctors, but also about the burden of documentation requirements. Having to spend more time on the computer took away from patient interaction, which increased their frustrations and often led to burnout.

In the study, an office-based physician expressed it takes “90 percent of the time that would otherwise go to the patient,” while a hospital-based respondent stated, “My nose is now burrowed deep into my computer interface, leaving markedly reduced time to make eye contact and actually interact one on one with my patient.”

Another outpatient doctor responded with, “I feel like I spend most of my visit looking at the computer screen instead of at my patient.” And an inpatient physician shared, “I don’t feel connected as I am always looking at the screen typing. The art of medicine and treating is lost in the process.”

The office-based physicians expressed more concern over a lack of quality time with patients, while the hospital-based doctors criticized the impact of less time for interactions.

In an article by Michael Hodgkins, MD, the AMA’s chief medical information officer, he describes how it was thought that EHRs would transform the practice of medicine. Instead, the incorporation of EHRs has caused physicians to spend more time on their computers and less time with their patients. As a solution, Dr. Hodgkins discusses the need to incorporate physicians’ input into the design of health information technology and AMAs efforts to work with EHR companies to address physician concerns. Dr. Hodgkins elaborated on these and other matters during a recent podcast interview.

Updating solutions for improvement

To improve patient care and EHR use, outpatient physicians can often incorporate strategies that might not be as useful within the inpatient setting because the primary issues differ. Complaints among outpatient physicians are about using the EHR in a more patient-centered way, said Dr. Gardner.

Inpatient physicians state it’s about using the EHR more quickly, more efficiently, so physicians can have more time with the patient and not just sitting at the desk for hours. For the inpatient setting, Dr. Gardner stated it’s the user interface and usability of the EHR itself—making it a much more intuitive flow.

“The typical things that are recommended in terms of using an EHR in a patient-centered way are not going to help the inpatient physicians feel better about how little time they get to spend with patients because of the documentation requirements,” she said.

Both outpatient and inpatient physicians offered different solutions for improving EHR outcomes. Hospital-based physicians “described the use of problem lists and lab results to feel more prepared for the clinical encounter,” while office-based physicians suggested facing the computer screen toward the patient and including them in the process using scribes.

Solutions that are available for outpatient physicians are likely to not work for inpatient doctors, according to Dr. Gardner’s study.

The AMA supports efforts such as Chicago health care technology incubator MATTER and the Health 2047 project that aim to give physicians a more pivotal role in determining the shape health IT innovation so that it improves care and physician workflow.

The AMA offers online CME to help you improve your practice. Explore education on “Electronic Health Record Implementation” and other content in the Practice Transformation Series.

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Comments

On the topic of physician advocacy, AMA needs to promote the idea that more documentation is not necessarily better. CMS' 95/97 Documentation Guidelines should be deemphasized as a basis for billing and reimbursement. A thorough HPI by a seasoned professional should not require a separate Review of Systems. A problem or complaint focused Physical Examination would make clinical encounters and documentation more efficient.
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Dec 12, 2017
In a first-of-its-kind survey, physicians say there are plenty of hackers and too little useful help in understanding complex HIPAA cybersecurity requirements.