“Greater demands in the U.S. for billing and regulation-related documentation contribute to the excess time burden of EHR systems compared with other countries. A high volume of clinical alerts and other distractions in the EHR, as well as various other inefficiencies (such as locked computer screens and repetitive sign-in requirements), encumber physicians as they navigate the EHR.

As a result, physicians can spend half of their total EHR time on clerical and administrative tasks, and another quarter on inbox management. Only half of a doctor’s day remains for direct clinical interactions with patients. Physicians spend about one-fourth of EHR time outside the clinical session.

The essential lesson from this EHR evidence is that the time burden it imposes on physicians is substantial in the U.S., occupying hours that could otherwise be spent building truly meaningful relationships with patients (not “meaningful use” metrics!) and providing quality care.’

James G. Kahn is a health policy professor. Thrisha Gogineni is a student intern.

They share their stories and discuss the KevinMD article, “How much time do physicians spend in the EHR?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/follow. Today on the show, we have James G. Kahn and Thrisha Gogineni. James is a health policy professor. Thrisha is a student intern, and they co-wrote the KevinMD article “How much time do physicians spend in the EHR?” James and Thrisha, welcome to the show.

James G. Kahn: Thanks for having us.

Kevin Pho: All right, so I’d like to briefly ask you both to share your stories and journeys to where you are today. James, why don’t you go first?

James G. Kahn: Sure. So I am an emeritus health policy professor. I’ve been doing research about health economics for about 30 years, and I’ve long been interested in the interaction, in the United States, of how we pay for health care and what that means for the clinical experience. One aspect of that is how we use the electronic health record. So I had been familiar with a little bit of research on the physician burden of using the EHR, but I also realized no one had assembled all the data, and that was our mission.

Kevin Pho: Wonderful. James, I know we’re going to talk more about this, and of course the EHR is such a big part of health care costs and, as a primary care physician myself, such a big part of my life. During all your research, what’s the one thing that has really surprised you in general regarding the EHR as it intersects with health policy?

James G. Kahn: What surprises me is how little control physicians have had in designing an EHR that is optimized for clinical care. The decisions about the adoption and design of the EHR have been made basically by the business side of health care, and I think that has resulted in an experience for people like you delivering care that is suboptimal.

Kevin Pho: And Thrisha, you’re a student intern. You co-wrote this article with Professor Kahn. How did you get interested in this topic?

Thrisha Gogineni: So I’m a sophomore high school student, and I reached out to Dr. Kahn for a research opportunity, as I was interested in health technology and health policy. Dr. Kahn introduced me to the EHR and asked me to research physician time in the EHR.

Kevin Pho: Wonderful. And what’s the biggest thing that you’ve come away with when working with Dr. Kahn?

Thrisha Gogineni: I’ve learned so much about the EHR, and that physicians were spending a lot of time on the EHR irrespective of different EHR software.

Kevin Pho: James, let me ask you to summarize this article, “How much time do physicians spend in the EHR?” I’m certainly interested in hearing the data. So for those of you who get a chance to read it, what should my audience come away with?

James G. Kahn: Well, we searched in the usual way, in PubMed and Google. We found 10 articles and 11 data points, and basically what we found is that the median amount of time that doctors spend on the EHR each day is 4.5 hours. So that’s more than half the workday is spent in the EHR. When studies have looked at where that happened, most of it happens at work, but actually about a third happened after hours. So physicians either have to focus on the EHR during work or basically take it home with them, and that’s what we found.

Kevin Pho: And James, what are some of the reasons? I can certainly tell you from my own personal experience, but what does the data show in terms of some of the reasons why physicians spend so much time in the EHR system?

James G. Kahn: Well, there are two big parts to it, we think. One is documentation of detail that is necessary to optimize billing, so very precise and nuanced diagnostic codes beyond what you’d need for clinical management, and also information about procedures that are being delivered. In addition, as you know, there are these meaningful use metrics, which are necessary for getting certain kinds of funding, and these need to be documented. And some of it is simply inefficiency of the interface. Again, the doctors weren’t designing the way this works.

I have a colleague who’s a gastroenterologist who talks about the fact that when he used to write up the summary orders after a colonoscopy, it would take him 30 seconds, and the nurses knew what to do. With the EHR, it takes him 10 minutes. He has to navigate to all different parts of it, and even still, not everything’s covered. So it’s a series of requirements which are not well aligned with the clinical flow.

Kevin Pho: So I remember reading a study that said something like, for every hour we spend with patients, we spend another two hours or something like that on the EHR. So what are the implications of so much time on the computer, and how does that affect direct patient care?

James G. Kahn: Well, it cuts into the direct care, not only quantitatively, in the amount of time, but also qualitatively, and we’re seeing big jumps in physician burnout at this point. I do want to quote my wife, who published an article about her experience as a patient with the EHR, and the best quote from that article was, “The EHR kidnapped my doctor.” Basically, once doctors are forced to focus on all of these maneuvers within the EHR, the prior focus on the patient gets lost, and no one likes that. The doctors don’t like it. Patients don’t like it.

Kevin Pho: So we have this problem here where physicians are spending hours on the EHR, the majority of their time. Do you see a lot of movement from them in terms of decreasing the time it takes a physician to chart?

James G. Kahn: There isn’t much movement in the United States. I think one of the things that’s interesting about our review is that we found a couple of studies that compared EHR time in the U.S. versus in other wealthy countries, and the EHR time here is two to three times greater. So I think a big piece of this is the complexity of our billing system. We have to deal with many different payers and very complex rules about how to optimize payment.

And so one of the things that I’m passionate about is reforming how we pay for health care. I’m a researcher and an educator about single-payer health care. There’s a lot of support in the physician community. Most surveys show that about 60 percent of physicians and of the general population support single-payer. But as you and your listeners know, there’s still a growing role for insurers and other for-profit entities, and so we have a big challenge ahead of us. But I think the only solution, which is what all other countries have done, is to unify and simplify health insurance. So how do we get from here to there?

Kevin Pho: So I think we’ve had this topic on many times, and I’m sure you’ve had this conversation with many of your colleagues in terms of what an ideal health care system would be, single-payer being one. I know that a lot of countries, of course, in Europe don’t necessarily have a single-payer system. They have that hybrid between the private and public insurers, and they do fine as well. Is single-payer really the only option, or could any type of nationalized system also be an option as well?

James G. Kahn: Excellent question. So it is true that quite a few countries rely on private insurers, but private insurers in those countries look nothing like private insurers here. Take the Netherlands, for example, or Switzerland. The private insurers are not for profit, and they are highly regulated. They all sell exactly the same products. Contrast that with the approach we have here, where the insurers are generally for-profit and make big profits, and they have a whole array of products to try to entice people into this product or that product. That’s a formula for confusion and inefficiency.

If we could have a single coverage plan, like all the other countries have, marketed by insurers that are not for profit and follow very strict rules, that could work here. The question would be, would this country accept that kind of regulation? I think when it comes down to it, as long as we have everyone covered with exactly the same insurance and no profit interceding, then we can have a really good system.

How do we get there? Well, I am neither a political tactician nor a political scientist, so all I can say is that, in my very amateurish view of history, big changes come in unexpected ways. The civil rights movement was largely unexpected, as one example. And I can hope that one day we will realize as a society that we’re wasting too much money, and honestly too many lives, on a system that really doesn’t work.

Kevin Pho: All right, let’s get back to the study here. Thrisha, did you find that there were a lot of studies, when you were doing this research, that examined this in the past?

Thrisha Gogineni: Yeah, we found a bunch of studies on the EHR and about the different times the physicians spent on the EHR.

Kevin Pho: And how did you determine which studies to include in your own study?

Thrisha Gogineni: So we used studies such as log files, web tracking systems, observations, and metadata, and each of them had the different times the physicians spent on the EHR.

James G. Kahn: More generally, any study that had a reasonable method to quantify the time was fair game, and that’s how we reduced all of the studies down to the 10 studies that did take a quantitative approach.

Kevin Pho: Thrisha is a student intern. James is a health policy professor. They both co-wrote the KevinMD article “How much time do physicians spend in the EHR?” So James, what are some of your take-home messages that you want to leave with the KevinMD audience?

James G. Kahn: Again, I think we as a physician community ought to be pushing for the EHR to focus on supporting clinical care, to make our lives and our jobs better, to make it easier to provide high-quality care, and the patients will appreciate that. And again, I do think that how we pay for health care is a critical element of returning the focus back from the money to the patient.

Kevin Pho: And James, short of nationalizing or wholesale changes in our health care system, do you offer any hope to practicing clinicians like myself who have to spend increasing time on EHR systems?

James G. Kahn: The people that I’ve spoken with, both the clinicians who are educated about this issue and the IT specialists who design these systems, talk about very small nudges, like, “Oh, we finally got that button that sends a report moved to a different page.” It’s very, very incremental. I don’t see any big changes in that way. I think physicians should continue to educate the IT folks that it is really the clinical experience that we should be improving. But Kevin, you’ve heard me say this before: I’m a believer that a big change will bring all sorts of benefits, and so I’m not optimistic about the little tweaks resolving any of these problems.

Kevin Pho: And Thrisha, just let me ask you. On my podcast, I talk to physicians all the time. I talk to policy professors like Dr. Kahn all the time. But you’re someone who’s just starting to research our health care system. So what’s the biggest thing that you’ve come away with?

Thrisha Gogineni: I would want to streamline the EHR to where the physicians’ time can be reduced to one to two hours.

James G. Kahn: Absolutely. I just want to mention one other thing that Thrisha and I are working on, which is that we’re starting to do qualitative interviews with physicians to get a deeper understanding, beyond the numbers, of what’s going on with that. Thrisha has done some great interviews, and we’ll be expanding that. If any of your listeners want to talk about their EHR experience, we’d welcome talking with them.

And I do a blog myself. It’s called Health Justice Monitor, and if any of the listener audience is interested in health reform issues, or in getting in touch with us and talking about their qualitative experience with the EHR, I would welcome them contacting Health Justice Monitor, and then we’ll get in touch with them, and maybe Thrisha will interview them.

Kevin Pho: Wonderful. And Thrisha, I can say that I think you and I want the same thing. I’m a practicing physician, and I certainly want to spend less time in the EHR as well. And James, I’m sure you’ll get plenty of physician narratives about their experiences with the EHR. So both of you, thank you so much for sharing your time and insight, and thanks again for being on the show.

James G. Kahn: Thanks so much for having us.