Electronic health record (EHR) vendors should imbed metrics into their systems to measure how EHRs affect clinicians' work, experts write in a commentary published online October 10 in the Annals of Internal Medicine.
Yumi T. DiAngi, MD, a fellow in clinical informatics at Stanford University School of Medicine in Palo Alto, California, and colleagues propose six areas metrics should cover and recommended the creation of a "national council of clinicians" to design measures and create guidelines to address privacy and other issues.
"The EHR, which was intended to improve patient care, has had the ironic and unintended consequence of impairing practice efficiency, largely because of poor design, a focus on regulatory reporting, and the burden placed on clinicians by data entry," they write. EHRs have also led to high levels of burnout as physicians' satisfaction in their work has declined, they note.
To gain insight into the stresses that have produced this burnout, the coauthors suggested the establishment of EHR work metrics in these categories:
- Work after work: The number of hours a clinician spends logged onto the EHR during evenings, weekends, and vacations. The coauthors view this as a key indicator of lifestyle balance.
- Click counts: The number of clicks per day or the number of clicks needed to accomplish common workflow tasks. This measure could help improve work flow at both the local level, with changes to things such as log-in routines, and could drive vendors to make improvements in the EHRs themselves.
- Teamwork: Measures the ratio of staff-entered to physician-entered EHR tasks, such as prescriptions, visit notes, inbox messages, and orders. These metrics could show how well tasks are distributed to the appropriate team members, the authors note.
- Being present: Measures that capture how much assistance physicians receive from staff with EHR documentation, order entry, and chart review. The goal of these metrics would be to show how much personal attention physician can give patients during visits.
- Fair pay: Measures of how much uncompensated EHR work physicians currently need to do. This category includes answering patient emails, providing medication refills, and managing patient-generated health data.
- Regulatory balance: Measures of pay-for-performance-related EHR clicks and billing-related EHR documentation.
The proposed metrics "will help capture facilitators of and impediments to professional fulfillment," Dr DiAngi and colleagues write. The data might be used, they said, to help researchers identify how EHR interaction affects care delivery and patient outcomes. In addition, they said, the information could help administrators and clinicians work together to increase professional satisfaction.
In the view of the coauthors, health system leaders, along with other stakeholders such as regulators, payers, and EHR vendors, are obligated to provide clinicians with "adequate support and usable tools" to avoid physician burnout.
Why should health IT developers want to rewrite their programs to include the proposed metrics? "Health professional burnout is a public health crisis," coauthor Christine Sinsky, MD, vice president of professional satisfaction for the American Medical Association, told Medscape Medical News. "It is incumbent upon vendors to care about the well-being of the user."
If the metrics were imbedded in EHRs, the data from them could eventually be made public on a voluntary basis, Dr Sinsky said. The comparisons between the users of different EHRs might prompt design improvements to increase the usability of these systems, she suggested. Comparing the data from different instances of the same EHR might show how EHR implementation affects usability and the burden on clinicians.
Difficulties in Measuring EHR Effect
Charles Kilo, MD, who formerly led the Institute of Healthcare Improvement's practice redesign project and who now practices part time at Greenfield Health in Portland, Oregon, told Medscape Medical News that he is not sure whether the measures proposed in the commentary are a good idea. "You don't measure something unless you're going to do something about it," he said, and the suggested metrics are neither specific enough nor attributable enough to prompt positive remedies.
Some of the proposed measures, noted Dr Kilo, who until recently was chief medical officer and vice president for quality at Oregon Health & Science University in Portland, concern issues that are under a vendor's control, and others are under an institution's or a clinic's control. Even the number of clicks required to complete a particular task can be at least partly determined by a health system's IT staff, which is able to customize most EHRs, he noted. So comparing the performance of users of different EHRs would be a real challenge.
Moreover, Dr Kilo said, "It's not so easy to draw a straight line between EHRs and physician dissatisfaction, because there are many other drivers of dissatisfaction" in healthcare. Despite the benefits of EHRs, including the ability to prescribe directly from the exam room and the ability to review labs in real time, for example, "the EHR is in many ways the whipping boy for just so much dissatisfaction with what's going on in healthcare," he said.
Although he did not dispute the commentary's contention that EHRs can reduce productivity and force physicians to take work home regularly, he said that many other factors must be considered, including a physician's practice patterns and personal efficiency, the way his or her organization set up the EHR, and how the practice has organized its care teams.
Dr Kilo was intrigued by the suggestion that measuring the amount of time that physicians and other care team members spend on routine tasks might indicate how much work physicians were doing that could be delegated to other clinicians. Most organizations that have care teams cannot measure how well they are performing, he said. "An EHR could be a new tool to measure that. It's worth validating, and I'd like to see some studies validate that."
The authors and Dr Kilo have disclosed no relevant financial relationships.
Ann Intern Med. Published online October 10, 2017. Abstract
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