By Christina Frangou

Ask any surgeon how much time they spend on their hospital’s electronic health record and the answer is likely to be the same: too much.

For the first time, researchers have looked at how many hours per day that general surgeons spend dealing with their hospital’s EHR. The number is an average of 1.95 hours every day of the week, with some surgeons regularly spending nearly five hours daily. The heaviest EHR use by surgeons occurred on clinic days, and the lightest was on Saturdays.

All surgeons took EHR work home with them, with a measurable increase in remote use occurring on nights and weekends.

“We hope to raise more awareness about how our time is spent as we care for patients,” said Morgan Cox, MD, a general surgery resident at Duke University Medical Center, in Durham, N.C. She presented the study findings at the 2019 Clinical Congress of the American College of Surgeons.

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Dr. Cox and her colleagues studied 20 female and 31 male surgeons working in the Department of Surgery at the center between 2016 and 2017. They did not capture EHR use at Veterans Affairs hospitals or physician logins from portable devices, so the study underestimates overall EHR use.

Investigators tracked surgeon login and logout time stamps from the Epic EHR (Epic Systems) and compared them with time schedules from the department. Results showed the following:

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Even though the study is the first to look specifically at EHR use by practicing surgeons, the results are not surprising. Physicians across specialties say they spend hours each day, even after work hours, on the records. A 2017 study found that family physicians spent nearly six hours in an 11.4-hour workday—more than half their working time—dealing with documentation (Ann Fam Med 2017;15[5]:419-426).

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Physicians say they are frustrated that the time dedicated to the EHR often feels like time wasted because of poorly designed technology that prioritizes billing over patient care or physician time.

Doctors voiced their dissatisfaction loudly in a survey of 30,000 physicians, published in November in Mayo Clinical Proceedings (pii: S0025-6196[19]30836-5. doi: 10.1016/j.mayocp.2019.09.024). They gave EHRs an overall grade of F for usability.

“That is not shocking to me, but it should be a cause of alarm. Why are we accepting something in health care with F-level performance?” said Lillian Erdahl, MD, a clinical assistant professor of surgery at the University of Iowa Carver College of Medicine, in Iowa City. She was not affiliated with the study.

Dr. Erdahl and other surgeons pointed out many design flaws in EHRs, including frequent alerts that are not relevant to a patient’s care, leading to “alert fatigue”; inaccuracies in patient histories that are repeated by using the copy-and-paste function throughout a chart; and crucial information that is locked behind dozens of clicks.

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These frustrations exacerbate physician stress levels and burnout, research has shown. In the same survey where physicians gave EHRs a failing grade, investigators found a strong dose–response relationship between EHR usability and burnout.

Another study, published this summer, looked at physicians in a multispecialty practice and found that doctors who received a higher number of in-basket messages by the EHR were more likely to experience burnout and had an increased intention to reduce their clinical workload (Health Aff [Millwood] 2019;38[7]:1073-1078).

In an essay in The New York Times last fall, Emily Silverman, MD, an internal medicine physician in San Francisco and the host of the podcast “The Nocturnists,” wrote of the Epic record system: “We are met with relentless reminders of tasks we haven’t completed, supplications to correct our documentation for billers, and daily, jaundiced reminders.” She quotes the message frequently delivered by Epic: “You are currently deficient.”

The rapid adoption of EHRs in the United States occurred despite the technology and not because of it.

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Today, EHR systems are present in more than 95% of hospitals, up from about 9% in 2008. This uptake was spurred by policy changes, such as the American Recovery and Reinvestment Act, which poured $49 billion into adoption of EHRs, and the monetary penalties instituted in 2015 via the Medicare EHR Incentive Program.

But the shortcomings in the technology have never been addressed. In an article in Nature this fall, John Halamka, MD, the executive director of the Health Technology Exploration Center at Beth Israel Lahey Health, in Boston, who was part of the working group that helped develop regulations for EHRs, was quoted as saying: “Our trajectory of getting from 20% adoption to 90% adoption was very good,” but the usability of the resulting systems was “not so wonderful.”

Dr. Erdahl said change needs to happen quickly. Physicians and other health care workers are burning out, leaving their practices, and taking their own lives at alarming rates. “This is a crisis in our practice, and resources must be put in place to address it.”

Health care organizations need to commit more time, money and personnel to reducing the burdens on physicians, she said. Efforts are underway to improve technology to support EHRs. In December, Amazon introduced a virtual medical scribe, Amazon Transcribe Medical, which can transcribe doctor–patient interactions and upload the text straight into the medical record. At the time of publication, no details were available on how Amazon will ensure its tool is HIPAA-compliant and accurate. Nuance Communications Inc., together with Microsoft, and Google also are working on developing their own “digital scribes.”

Some institutions have hired medical scribes to follow physicians and type during interactions with patients. A 2018 study found that physicians who worked with medical scribes reported a reduced physician EHR documentation burden, improved work efficiency, and improved visit interactions (JAMA Intern Med 2018;178[11]:1467-1472).

“Whatever they are, changes cannot come soon enough,” Dr. Erdahl said.

Other research has shown that EHR use may disproportionately affect female physicians. They spend more time on it, according to a report in November in the digital journal NEJM Catalyst Innovations in Care Delivery. In an analysis of 1,336 physicians, female physicians spent more time on EHRs after work hours and on days off (including weekdays and weekends), documented longer notes (with greater use of the copy/paste function), and addressed a higher percentage of patient contacts within 24 hours (https://catalyst.nejm.org/ ambulatory-ehr-patterns-physician-gender/).