Years ago, when he used paper charts, Dr. Steven Reid would ask his patients about their children or their vacations and then jot notes down in their records. “Those kind of things could really facilitate a good doctor-patient relationship,” says Reid.

Today’s electronic medical records don’t encourage those personal touches, however.

Instead, most EHRs make physicians navigate through inflexible templates that require them to click on boxes. The exhaustive lists cover everything from patient demographics to family history, medications, health problems, vital signs and smoking status.

Most doctors have to log in after hours to finish checking all the boxes, approve prescription refills, review lab results and respond to patient messages. One study looking at 142 family practitioners in Wisconsin found the care providers spent more than half of their 11-hour workdays doing desktop medicine, with nearly 90 minutes spent outside of normal work hours.

Research and physician surveys cite EHRs and “click fatigue” as a cause of doctor burnout. Reid believes EHRs are part of a “toxic environment” that contributes to physician suicides. Doctors kill themselves at a rate of 40 per 100,000 a year — a rate higher than California prison inmates and military veterans. “It’s worse than dentists, lawyers, stockbrokers or air-traffic controllers,” says Reid, who retired from his Gainesville neurosurgery practice last year and started a non-profit called Doctor Lifeline to focus on the problem. He says he knew four physicians who killed themselves.

Systems engineered more for coding and billing than clinical care also can contribute to a phenomenon known as “moral injury” — physicians feel torn between where they think the EHR system is leading versus what they feel is in the patient’s best interest.

“To get a routine payment, you have to include a review of systems, past medical history” and many other things, explains informatics expert Hoyt. To justify a higher level of reimbursement and save time, providers often overuse an EHR’s copy-and-paste functions, duplicating information from previous progress notes in new ones. The practice leads to “note bloat” — voluminous patient notes that can obscure pertinent medical information or cause incorrect information to be repeated in the medical record. Copying and pasting in EHRs can also compromise a provider’s defense of a malpractice claim should one arise.

Meanwhile, some doctors are taking their vendors to court. Dr. Ben Cohen, a New York City ophthalmologist, claims the EHR software his retinal surgery practice purchased for $100,000 from Nextech Systems in Tampa in 2016 is “defective” and wants his money back. A complaint he filed in Hillsborough County court alleges the software couldn’t handle the surgical center’s billing needs, didn’t allow his anesthesiologists to make notes in the way they needed to, and that it was “less efficient” and required “more screen touches” than the surgical center’s “old, hybrid paper and electronic practice management software.”

Cohen said he asked Nextech to “come back and fix this thing or take it back,” but the company didn’t, so he sued them. “It’s a screw job,” he says. Nextech did not respond to requests for comment.

There’s evidence that poorly designed EHRs can be hazardous to patients. A 2018 study by Pew Charitable Trusts and several health care systems examined 9,000 safety events involving pediatric patients at three facilities and found that 36% of the events occurred in part because of the software. The majority of the mistakes involved improper dosages of medication. And a 2019 investigative report on EHRs by Kaiser Health News and Fortune noted that the health analytics firm Quantros recorded 18,000 EHR-related safety events between 2007 and 2018. Three percent of those incidents led to harm, including seven patient deaths, the report said.

Doctors Co., a physician-owned medical malpractice insurer, says the number of malpractice claims tied to EHRs has more than tripled from about seven per year in 2010 to 23 in 2017 and 2018. Nearly 60% of EHR-related events in medical malpractice claims occur in outpatient settings, according to a 2019 study in the Journal of Patient Safety.

Remedies

Training and customized software can improve the usability of EHR systems, and some providers are hiring scribes — clerical assistants who sit in on patient exams and enter data in the computer. Before Obamacare and the HITECH Act, scribes were mostly seen in hospital emergency departments. Today, they’re common in other areas of the hospital, outpatient surgical centers and doctors’ offices, says Fabio Giraldo, regional president of HealthChannels, which owns the Fort Lauderdale business ScribeAmerica.

AdventHealth’s Central Florida division, which operates 20 hospitals in the Orlando metro area, recently examined whether scribes could help free nurses up from electronic paperwork demands. The pilot program improved staff responsiveness by 12% and improved lab turnaround time by 13%. Nearly three-quarters of those nurses said they were able to spend more time with their patients.

But scribes are not for everyone. Some physicians and hospitals can’t afford them — they earn an average of $32,523 annually in Florida, according to salary.com — and others worry they’ll misinterpret things and introduce errors into the chart.

Technology can help, but it also has drawbacks. Doctors at Mayo Clinic, for instance, can use speech-recognition technology to dictate notes into the patient’s electronic record. But speech recognition software has an error rate of about 7.4 errors per 100 words, research shows, and generally requires review by a transcriptionist to verify accuracy.

Informatics expert Hoyt suspects EHR software may improve as the “meaningful use” incentive programs come to a close. “Now that the EHR vendors are not creating EHRs just to please the government, which is what they did for the first 10 years, maybe now they’ll try harder to make the EHR more usable and innovative,” he says.

Read more in Florida Trend's April issue.
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