Why do US doctors hate their computers?

Advancing Practice Science With Electronic Health Record Use Data

Christine Sinsky, MD

The study by Holmgren et al points to a portion of the answer, presenting data on the differences in physician time costs between US and non-US clients of the same electronic health record (EHR) vendor.

Are American physicians less tolerant of innovation? Less technologically savvy? More prone to complaint? Are the EHRs in other countries better than in the US?
Using data representing nearly the entire user base of a single EHR vendor (Epic Systems), this comparison found that physicians and advanced practice clinicians in the US spent approximately 50% more time on the EHR, twice the time on order entry, and almost 3 times on in-basket work; managed triple the number of messages; and used more documentation templates and copy-paste than their non-US colleagues.2 Perhaps most striking, only the farthest outliers for time on EHR in the non-US sample, at the 99th percentile, spent the same amount of time as a US clinician at the median.

By comparing time allocation within the same EHR platform across different countries, Holmgren et al2 raised the possibility that responsibility for the greater time costs for US physicians may not reside exclusively with the vendors and may, in fact, be associated with the social, regulatory, and payment context into which the EHRs have been implemented.

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Assessment of Electronic Health Record Use Between US and Non-US Health Systems

Question  Does the use of the electronic health record (EHR) differ between clinicians in the US and those in other countries?

Findings  In this cross-sectional study of the EHR metadata of 371 health systems in the US and abroad, US clinicians vs non-US clinicians were found to spend more time per day actively using the EHR, receive more system-generated messages, write a higher proportion of automatically generated note text, and spend more time using the EHR after hours.

Meaning  Findings from this study suggest that US clinicians compared with non-US clinicians had a higher EHR burden, which could be alleviated by minimizing EHR uncertainties and consolidating documentation requirements.

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Digitization promises to make medical care easier and more efficient. But are screens coming between doctors and patients?

Atul Gawande is a surgeon, a public-health researcher, and the chairman of the health-care venture Haven. His four books include “Being Mortal” and “The Checklist Manifesto.”

Difficulties with computers in the workplace are not unique to medicine. Matt Spencer is a British anthropologist who studies scientists instead of civilizations. After spending eighteen months embedded with a group of researchers studying uid dynamics at Imperial College London, he made a set of observations about the painful evolution of humans’ relationship with software in a 2015 paper entitled “Brittleness and Bureaucracy.”

The I.B.M. software engineer Frederick Brooks, in his classic 1975 book, “The Mythical Man-Month,” called this final state the Tar Pit. There is, he said, a predictable progression from a cool program (built, say, by a few nerds for a few of their nerd friends) to a bigger, less cool program product (to deliver the same function to more people, with different computer systems and different levels of ability) to an even bigger, very uncool program system (for even more people, with many different needs in many kinds of work).

Human beings do not only rebel. We also create. We force at least a certain amount of mutation, even when systems resist. Consider that, in recent years, one of the fastest-growing occupations in health care has been medical-scribe work, a field that hardly existed before electronic medical records. Medical scribes are trained assistants who work alongside physicians to take computer-related tasks off their hands. This fix is, admittedly, a little ridiculous. We replaced paper with computers because paper was inefficient. Now computers have become inefficient, so we’re hiring more humans. And it sort of works.

We are already seeing the next mutation. During the past year, Massachusetts General Hospital has been trying out a “virtual scribe” service, in which India-based doctors do the documentation based on digitally recorded patient visits. Compared with “live scribing,” this system is purportedly more accurate—since the scribes tend to be fully credentialled doctors, not aspiring med students—for the same price or cheaper. IKS Health, which provides the service, currently has four hundred physicians on staff in Mumbai giving support to thousands of patient visits a day in clinics across the United States. 

If the software companies provided an “application programming interface,” or A.P.I., staff could pick and choose apps according to their needs: an internist could download an app to batch patients’ prescription refills; a pediatric nurse could download one to set up a growth chart.

Electronic-medical-record companies have fought against opening up their systems this way because of the loss of control (and potential revenue) doing so would entail. In the past couple of years, though, many have begun to bend. Even Epic has launched its “App Orchard.” It’s still in the early stages.

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