By Jami Starr, MD
Dr. Starr will complete her graduate certificate in Health Policy & Law in spring 2017.
The concept of electronic medical recordkeeping was first introduced in the late 1960’s but it did not really become established until this century. Electronic Health Records (EHRs) are expected to provide a number of benefits, including: ability to track data over time, monitoring use of interventions (i.e. vaccinations), and identifying patients in need of preventive screening. Data are forthcoming as to how effectively EHRs meet these goals. What is clear, however, is that it is third party payers profit from EHRs as a result of improvements in claims processing.
The use of EHRs carries implicit hazards with respect to confidentiality. It seems no cyber security system today is impenetrable. We have witnessed multiple breaches in the past few years involving government agencies, major retail chains, and financial institutions. If a hospital database were hacked, not only would pertinent demographics be exposed (social security numbers, insurance policies, etc.) but also personal information about diagnoses, socioeconomic circumstances, and the like. While this is a risk with paper medical records as well, the rapid and potentially widespread dissemination of information though a computer data system is far more menacing in scope. In most clinical settings where EHRs are employed, paper charts have been eliminated and patients do not have an option as to how personal data are maintained. Vulnerability has been increased de facto by reliance upon this new medium.
Aside from the issues related to cyber security, there are start-up costs related to productivity, burnout and physician-patient relationships. While head-to-head comparisonsof paper versus electronic documentation have not been widely performed, in a study on the cost-effectiveness of EHRs in primary care, Wang et al found that internal medicine clinics suffered a 20%, 10% and 5% decrease in productivity in the first three months of implementation, respectively, which translated into over $11,000 lost per provider in the first year.2 Other studies have reported similar income reductions. Revenue is further impacted by the huge costs related to initiation and maintenance of these systems.
Beyond financial costs, there are additional affronts on physician time and labor. In a recent article in the Annals of Internal Medicine, Dr. Christine Sinsky highlights the fact that EHRs demand up to 1-2 hours of additional after-hours burden for physicians, mostly in completing documentation. From the physician standpoint, this change in work flow is a trigger for job dissatisfaction. In 2014, Shanafelt et al conducted a multi-specialty national study that revealed a higher risk for professional burnout (as measured using a standardized questionnaire) among physicians using EHRs.This impact has not improved with time. A 2017 Labor Force Survey among obstetricians and gynecologists revealed that the majority of respondents felt less optimistic about providing good care and complained of increased professional stress levels. Among the top reasons for unhappiness was electronic medical (and burdensome) technology.
The downside is perhaps even greater regarding the physician-patient relationship. Sinsky et al also found that over 1/3 of the time spent in the examination room was devoted to EHR tasks rather than talking directly to or examining the patient. This exacerbates the time crunch created by current financial pressures to reduce appointment duration. As a band-aid, the burden of typing is sometimes circumvented by ‘scribes,’ who are engaged to allow a provider to avoid the keyboard. Recently, I had the opportunity to visit my primary care physician for an annual exam and was asked if I minded having a scribe in the room. Mostly out of curiosity, I consented. I must admit that I soon forgot she was present, and the time spent with my physician was more ‘face-to-face’ than usual. That said, it is conceivable that I would have been more inhibited had I needed to relate an embarrassing symptom or highly personal anecdote.
A related, but subtler, effect on the physician-patient dyad is that of intra-system transparency. For example, it may be very helpful for me, as an obstetrician, to access the note from the pulmonologist about Mrs. Smith’s asthma. This may, in fact, improve care, as I am able to track medication changes and exam findings and communicate promptly with another provider. Is it, however, necessary for me to read a detailed synopsis of her visit with her psychiatrist? While it may be important for me to know that Mrs. Smith is on an antidepressant (and as such I might inquire as to her mood), I don’t believe it is necessary for me to be privy to the details of her discussion with my colleague. For me to obtain medical records from another institution, a patient has to sign consent. It is unknown, however, if patients fully comprehend the degree to which their records are accessible to all providers within a health care network, and how they might react if they knew.
It is unlikely that we will return to the days of clipboards and hefty paper-filled patient charts. EHR technology provides unquestionable advantages to health care systems in being able to track data trends and outcomes. Equally positive is the elimination of duplicate tests and medication errors. In order to mitigate the inherent liabilities, however, it behooves us to be creative once again. On a broad scale, there is a global urgency for protection of electronic data. More specifically in the field of health care, there is a need to address the unintended consequences of EHRs, such that all users of the system are well served by the process. Initiatives to enhance patient safety and reduce physician burden are imperative. EHR technology is here to stay; protecting it from misuse, while optimizing its operability is a nonpartisan, and important, priority.