Melbourne’s Royal Children’s Hospital has configured its Epic electronic medical record to ensure clinical notes are kept short and to the point, has turned off many of its alerts and is not using voice recognition in an attempt to keep documentation to a minimum and hopefully avoid the problem of EMR-linked physician burnout that is plaguing the US health system.
While clinician burnout is a concerning feature of the local health system, it has not yet been tied to the overwork problem facing the US, where the federal government has announced it will introduce a “patients over paperwork” initiative and revise the E/M codes that it uses for medical billing for the first time since 1996.
University of California San Diego Health CIO Chris Longhurst told the Health Informatics Conference in Sydney last week that his own organisation had introduced a “home for dinner” initiative to ensure doctors were not spending hours after work doing their clinical documentation.
He quoted a former Stanford University colleague, Cutting for Stone author Abraham Verghese, who wrote in the New York Times recently that technology could turn doctors into clerical workers.
However, Dr Verghese also wrote that the electronic health record was only part of the issue. “Other factors include rapid patient turnover, decreased autonomy, merging hospital systems, an ageing population, the increasing medical complexity of patients,” he wrote.
But even if the EHR is not the sole cause of the problem of doctor burnout, he wrote, “it has become the symbol”.
Back in Australia, RCH chief medical information officer Mike South told the conference that while we also have a problem with doctor burnout – and a serious problem with clinician suicide – the link to EMRs had not been made. “Not yet,” Professor South said.
However, he said he feared that we may move down the US path, where clinical notes in the EMR seem to be written for billing, administrative or legal purposes rather than clinical ones.
As Dr Longhurst admitted – and wrote about in an article in the Annals of Internal Medicine recently using data from UC San Diego’s EMR vendor, Epic – US doctors have a tendency to write very long notes, on average four times longer than Australian doctors.
“We write novels when we see patients,” Dr Longhurst said. “The longest international [Epic] client writes notes shorter than the shortest US client.”
Both UC San Diego and RCH use an Epic EMR, but RCH clinicians had much higher satisfaction ratings with it and much lower time spent writing and reading notes. In a recent survey, just 15 per cent of UCSD users were satisfied with the system while another 20 per cent were indifferent, Dr Longhurst said.
“Our net user satisfaction on the scale of minus 100 to plus 100, is only 27 per cent. We can do better.”
Having worked with Professor South and the RCH team, including program director Jackie McLeod, on the Epic implementation in his former role at Stanford Children’s Health, Dr Longhurst said he was intrigued by the difference in satisfaction rating.
He described the Royal Children’s roll-out as a “phenomenal implementation” and best practice from across the world. “And the same thing again when we talked to their teams and staff and physicians. They say yes, it has been great. And so I was really kind of intrigued by this difference. Same software, different implementation, different outcome.”
Even within the University of California health system, community and affiliate physician practices were writing notes that were 30 per cent shorter than faculty doctors.
To try to solve the problem, UC San Diego has rolled out voice recognition tools and is doing pre-charting, as well as retraining as part of the home for dinner initiative.
The move by the Centre for Medicare Services (CMS) about the patients over paperwork initiative and the revision of the E/M codes will also help, he said. But what he would like to see is a move towards how things are done in Australia.
Professor South said he believed one of the essential differences was that US doctor wrote notes for billing purposes, while in Australia clinical notes were for clinical purposes.
“We need to remind ourselves what is the documentation for,” he said. “In my world it is for clinical care. Nobody else looks at my outpatient note apart from me the next time I see the patient, and my clinician colleagues who want to know what I am up to, and our patients. Nobody from compliance or revenue or legal ever looks at my note.
“In the US it seems to be the other way around. It seems like the note is primarily about something non-clinical. And the clinical care is often secondary with lots of non-clinicians reviewing the notes for different reasons. All of these are drivers to document more.”
RCH has configured the clinical note writing tools in the Epic EMR to only allow bullet points, removing any conjunctions or joining words. The rule is not to write narrative notes and short notes are actively encouraged.
The hospital prefers not to use transcription tools or voice recognition as it is difficult to dictate by bullet point, so users find themselves using long sentences, he said.
“It is not just documentation. Even things like ordering; we order a whole lot less. Our nurses just do things out of common sense and protocol. So we don’t have to order them to educate the asthmatic patient that they’ve got asthma for example.
“Epic has an inbuilt email-like system called In basket. Our doctors complain like hell that they get six messages a day about different things. The median is 32 messages a day in the US.”
Professor South said that as shown in Dr Longhurst’s recent paper, there was a very strong tendency to blame the tool, rather than what health systems expect doctors to do with that tool.
“I might sound a bit smug that we’ve got this right and the US have obviously screwed it up, but it is not the case,” he said. “I am actually terrified that we might go down the same pathway. That our compliance and revenue and legal and other people like that, get it into their heads.
“My message is hands off our notes, they are for clinical purposes. And the US, pretty simple: they need to go back to the drawing board on this, I think.
“We are all trying to deliver value in all of these areas. The technologies that we are developing and using, do have the potential to save patients’ lives. But that should not occur at the cost of burnt-out doctor and nurses losing their lives to suicide.”
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Excellent article Kate. I learned a lot. It just goes to show that no advance comes without unintended or unexpected consequences – often context-based. Thanks! Greg