Emergency department (ED) physicians, who do some of the fastest-paced work in the medical profession, find it difficult to use electronic health records (EHRs) without losing productivity, finds a recent study in the American Journal of Emergency Medicine.
According to the small-scale study of one ED, physicians spent 44% of their time entering data in their EHR. They spent 28% of their time in direct patient care, 12% reviewing test results and records, 13% in discussion with colleagues, and 3% on other activities.
The number of mouse clicks required for common charting functions and certain patient encounters ranged from six for ordering an aspirin to 227 for charting the ED stay of a patient with right-upper quadrant abdominal pain. During a typical 10-hour shift, a doctor clicked up to 4,000 times if he or she saw an average of 2.5 patients per hour.
"Emergency department physicians spend significantly more time entering data into electronic medical records than on any other activity, including direct patient care," the researchers pointed out. "Factors such as operating system speed, server/mainframe responsiveness, typing skills, user-friendliness of system, interruptions, extent of training, opportunity to delegate tasks, and various environmental attributes can influence data entry time. Efficient use of the [EHR] system will increase physician productivity and hospital revenue."
Robert G. Hill Jr., MD, lead author of the study and an emergency room (ER) physician in St. Luke's University Health Network in Allentown, Penn., told InformationWeek Healthcare that the EHR he and his colleagues use is an extension of the hospital system's EHR. "It's a mainframe product for the hospital, but it's not designed for the ER. The ER product is kind of an afterthought," he said.
While there are other applications specially designed for ED use, he added, they wouldn't interface as well with the hospital information system as the "cumbersome" module he and his peers are forced to use.
This EHR, he said, "tends to produce a disjointed and difficult-to-read record." If another physician hands off a patient to him at the beginning of his shift, he said, he may find it difficult to grasp the essential facts in the record. "Even though I work with it every day, the record can become voluminous and kind of difficult to navigate. I can do it, but somebody who is not that used to it would struggle with it and maybe not find important information buried under irrelevant things."
Data entry is even more challenging. Hill said he finds the point-and-click templates difficult and avoids them when he can. "That's how dysfunctional the software is. It leads you down paths you don't want to go and doesn't create a flowing narrative that's the essence of the patient contact."
Hill can dictate portions of the record, using a speech-recognition program. "It helps some," and gets better as it "learns" the speaker's vocal patterns; but it does make mistakes and must be edited, he said. The study did not find that use of speech recognition increased the EHR users' productivity.
Besides slowing the ED doctors down, the EHR also tires them out, he added. "There's a fatigue factor. We counted 4,000 mouse clicks aimed at a small [point-and-click] box in a 10-hour shift. That's a lot of typing, and battling templates is mentally fatiguing as well."
Asked how the EHR affected patient care overall, Hill replied, "We can access records more easily, and that's helpful. But our study shows we spend 44% of our time in data entry, which takes away from seeing more patients. We're the most highly paid and highly trained providers in the ED, and we spend a lot of our time doing data entry, and that's not good. It's a waste of resources."
Hill acknowledged that there are better ED products on the market. Those would fit the ED workflow better, he said, but they still use the same type of point-and-click templates. Moreover, much of what they prompt physicians to do is based on the documentation required by insurance plans to support claims. "The software prompts you to do those things, so it's useful in that regard. But producing a good, defensible, logical record is difficult."
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