Death By 1,000 Mouse Clicks: Electronic Medical Records And Physician Burn Out

Physicians are being sucked into the vortex of their electronic medical records.

I’m on our hospital’s electronic medical record physician advisory committee and so I have access to data about how physicians use the EMR that is not available to the average physician. I was astounded by the amount of time I spend in the EMR and my data is not unique.

I’ve been using our EMR for 9 years and I’m pretty good with it – I close my encounters promptly and at the end of the day, I’ve managed all of my messages, phone calls, and test results. I see patients three half-days a week in the clinic (total 12 hours) and cover our inpatient pulmonary/critical care service 1 weekend a month. Nevertheless, I spend a huge percentage of my time in our EMR.

My average encounter length is 7,369 characters – although most of those characters are automatically imported from templates and the after visit summary, it still results in a lot of typing. For progress notes alone (fewer characters than the entire encounter), as a percentage, 20% of the content of my notes is copy/paste, 15% is manually typed in, and 65% is imported via templates/SmartTools.

I spend 32% of my time generating notes & letters, 24% doing clinical review, 16% managing my inbasket, 11% entering orders, 9% in the visit navigator, 4% in the schedule & patient list, and 4% doing other EMR windows. Granted, the EMR is open a lot when I am doing other activities (in fact, it is open while I am writing this post) so these percentages can be a bit misleading. However, our EMR automatically logs us out after 15 minutes of no use.

I use the EMR a lot of the day. Currently, we are not able to track the total hours per week we are in the EMR (but we are trying to get that data and if so, it will result in a new blog post!), but we can see our EMR activity as a percentage of use and my results are pretty alarming. The graph below shows my own use activity for a 3-week period in January 2017 and this is pretty representative of my use activity in other months.

My EMR use starts to ramp up about 7:00 AM and then tapers off around 7:00 PM with a second peak of inbasket management after dinner around 9:00 PM. To examine use in a different way, we can look at the percentage of time I was in the EMR while seeing patients in the office (scheduled time) versus times when I was supposed to be doing other things.

If you analyze this data, what you see is that I spend about 2/3 of my total daily EMR time when I am seeing patients and 1/3 of my total daily EMR time when I am not seeing patients. Another way of looking at this is that I spend 2 extra hours doing EMR work for every 4 hours spent in the clinic. And compared to my peers, I’m very efficient. For me, I’m pretty much done with the EMR by 10:00 PM but many of my peers are still in the EMR at 1:00 or 2:00 AM. I’m particularly fortunate because I work with a great group of nurses in the office who really streamline my EMR use.

The literature on physician use of EMRs is surprisingly sparse. A 2013 study in The American Journal of Emergency Medicine showed that during a 10-hour shift, the average ER physician spends 44%of their time doing data entry, 28% of time in direct patient care, 12% of time reviewing test results and records, 13% of time in discussion with colleagues, and 3% of time doing other things. The average ER physician had 4,000 mouse clicks per shift.

An often-referenced 2016 study in the Annals of Internal Medicine looked at 57 physicians during ambulatory care (family medicine, internal medicine, cardiology, and orthopedics) and found that they spent 49% of their time in EMR & desk work, 33% of time in direct patient care, 1% doing administrative tasks, and 19% doing other activities (including personal breaks, travel time, etc.).

A 2013 study by the RAND corporation commissioned by the American Medical Association identified 9 reasons that physicians disliked their EMR:

  1. Time-consuming data entry
  2. User interfaces that did not match clinical workflow
  3. Interference with face-to-face care
  4. Insufficient health information exchange
  5. Information overload
  6. Mismatch between meaningful-use criteria and clinical practice
  7. High cost of acquiring and maintaining the EMR
  8. Requirement of physicians to perform lower skilled work
  9. Template-based notes degraded the quality of clinical documentation

A 2015 study in the Mayo Clinic Proceedings found that of the 6,375 physicians surveyed, those that used EMRs had a higher burnout rate (57%) than those that did not use EMRs (44%). Physicians who used EMRs also reported lower satisfaction with the amount of time spent on clerical tasks.

In a previous post, I satirically outlined the strategy hospitals can use to ensure that their physicians get burned out. Electronic medical records are clearly one of the factors contributing to burnout and it is incumbent on us to devise ways to improve physicians’ interface with the EMR to make the EMR work for the physician rather than the physician work for the EMR.

April 26, 2017