Impact on Time
I do not type, and I don’t like [the template-based note program] at all. I don’t like copying and pasting. To me, it just seems like an abomination. I’m kind of old school that way, so I chose the Dragon method of dictating so that I can put templates in [the EHR] and then dictate like I used to, and so a nice note comes out instead of a nine-page progress note under [template-based note program]. That has its own problems in that Dragon is not fully developed. It’s not entirely teachable, so I spend a lot of time selecting and teaching, and there are certain [words] that I must have selected and taught [the EHR] or Dragon how to say it 50 or 60 times, and it still won’t get it right and it will print things in there later that just are astonishing. … And, unfortunately, there’s a lag period behind your dictation, so you can’t really watch what you’re dictating because then you get discombobulated, and you have to also dictate all the syntax and all the commas and everything else, so then the only other option is, after dictation, to go through the whole note and … then correcting everything and typing. Or trying to retrain just makes the dictation in the [the EHR] system very burdensome and very long, so that’s mostly how it’s cut back on my productivity and my time.
Interviewer: “Relative to dictating prior to [the EHR] and the Dragon system, how much more time does it take you to dictate a typical note?”
At least twice as long. … Now in the nursing home, it takes much longer, because I have to take this whole system there, log out, log in, log into their system and go through all those things just to get in, and then with each on- and off-premises charge, there are several clicks and selections to take, and if the computer is over there—if the signals are not good, it can be very, very slow. It can take me a half an hour to set up. [Before the EHR was installed,] I saw a patient in the nursing home, and then I would dictate right away using a handheld Dictaphone, and I could do the dictation in five minutes. Now it takes me at least 15 to dictate just the dictation portion of a nursing home patient. … This last weekend I worked five hours, and that was six nursing home patients it took me five hours to see. [Before the EHR], I could have seen six patients in two hours with everything—driving out there, dictation, and coming back. … It’s been stressful. I think it’s, the overall effect, has been to add more stress.
—primary care physician
All of the [EHRs] that I’ve seen have actually been very time-consuming for physicians. Physicians have to order everything themselves, which is time-consuming, and do all the data entry themselves, which is time consuming. [EHRs] at this point in the development are not time savers for physicians. They’re big time sinks. Everyone agrees, everyone I talk to in every practice.
—primary care physician
Another described data entry spilling into his home life and commented on the accuracy of transcription software:
Every screen’s got 50 different things, you know, that are changing. It slows me down. So, I do a lot of my charting at night. … But, the problem is I’m spending more hours doing it than I would have before. We have Dragon, which you have to be careful of, because I just [dictated] a “Patient’s prostate is bothering him” and it turned out “Patient’s prostitute is bothering him.” You really have to read that carefully, because I can end up going to court with that stuff.
—primary care physician
The first place we started seeing [an EHR], if you will, was in operating rooms [during] the perioperative time, … where the nurse would be recording. She used to fill out a form by hand. Now it’s in the computer, and everybody was like “Oh my gosh, it’s taking three times as long to populate all the fields that you have to populate.” … The joke early on, like on an appendix or a gallbladder or something that went really fast and easy, is: “We’re done, and the nurse is over there still trying to get in the pre-op data.” She has now spent 90 percent of her time at a screen, having to enter data that takes her away from circulating.
—general surgeon
Clinical Workflow Impact
For me, the most frustrating part is the extra time it takes. So if you have ten patients to round on, rounding on them isn’t hard; it’s all the order entry. … Like the other day, I discharged a patient, and I went through every step, at least I thought I did. I did everything I thought I was supposed to do, and about an hour later, I got a call from the nurse saying, “I can’t discharge the patient. It won’t let me finish my part.” It turns out there was one button that I missed clicking, so she and I were on the phone, both on the computer looking at this patient’s chart, trying to figure out why it wouldn’t work. And it’s just so time-consuming.
—pediatrician
It’s hard to find certain items in the computer system. [The physicians] have to click-clickclick- click. They count their clicks. … It’s not laid out how their workflow is, and I think it’s just sometimes when you’re in [the EHR] you go from page to page to page and then you forget where you started. And so you kind of get lost in the route. It’s hard adjusting to, you know, sitting in a room with a patient and having to put things in a screen while still engaging the patient.
—manager of primary care practice
Our particular [EHR] is buggy. There’s no great way for me—say, you’re my patient—I can’t get your results back to you with a letter that explains what I’m thinking about, necessarily. It’s like, come on, why can’t we do that, you know? … I’m a diabetes educator, and I can’t electronically send prescriptions for test strips and syringes and pen needles …you know, paper and pencil of my medical trade. That’s what I work in, and so that’s just silly. There’s no reason why the drug database that we use can’t do that, and sometimes the fixes are really slow in coming. … I’d been sending tickets in for months and years now: “Can we do this? Can we do this?” “Nope, sorry, you can’t.” … And I’m the “superuser” here. I’m the person who knows supposedly the most about this machine, and I have a lot of questions, and I wonder, if I can’t do it, someone like [physician colleague], who’s, like, opposed to it, who thinks it’s too many clicks and too complicated and gets in the way of her relationship with her patient, what is she doing with it, you know?
—nurse practitioner
Patient Engagement
[The EHR has] impacted my life incredibly, because I am not facile enough with a keyboard to be able to talk to somebody and type at the same time, and it’s too important for me to be able to communicate with my patients and see how they’re reacting to [what I’m saying]. I mean, you know, I can’t tell how depressed they are while I’m doing this and looking at a computer screen and they’re sitting behind me. So I don’t do my notes while I’m in the room, although that’s the goal—that the physicians are supposed to be able to do their notes as they’re talking to the patient. I’m sure people who are more facile with this technology probably can do that. I can’t, so I finish my day and then I have several hours’ worth of typing ahead of me, which is a real drag.
—primary care physician
I find [the EHR] inefficient in that I used to write the note [on paper] while I was in the room with the patient, and I would say, “I’m going to write while I’m here, is that okay with you?” And people will generally appreciate that. I can’t type and not look at the screen, just not a thing I can do. And I don’t like the idea of having technology there, same reason I don’t have it at my dinner table. And so, in that regard, it makes me less efficient, because I can’t just leave the room and have things already written and a plan already in my mind and write three sentences and be finished with the note. Instead, I interact with the patient, touch the patient, look at the patient in the eyes and then I come out of the room and interact with the computer.
—hospitalist
Lack of Interoperability
We still get things faxed, and so we get the paper. Then the paper we have to … scan it into the system. So it hasn’t really saved us completely from paper. I’ve been in the system now two years, about, and still we have papers. We still have to scan, every day we have to do this. And plus the systems that you work with, not all of them talk to each other, as you know. … So also when the labs come, you know we have only one lab now that talks to us. So if people do labs different places then it comes in the form of [a] fax. … And also, we don’t have, yet, radiologist systems that talk to us. So it’s always again, it’s a fax, same thing scanned in.
—primary care physician
One physician wondered why interoperability was not a regulatory requirement:
The hospitals have a different EHR, and they don’t communicate, which was the big problem, I think, in [health reform—] … it did not mandate [interoperable] electronic records. The best thing they should have done was to pick a couple organizations and [say]: “You’re going to [create] electronic medical records, and you need to all communicate easily.” That way we can get stuff from the hospital and everything else. … That’s, I think, the big problem: Everyone’s going to electronic medical records, [but] there’s not an easy way for everything to communicate. And I think that was kind of the purpose behind it, that people could have their history and it’d be portable and they could go from place to place and everyone would be able to see what’s been done and not duplicate it and be up to date on what was going on with that patient.
—general surgeon
The biggest limitations come from our lack of good interfaces and the fact that the hospital has way too many different computer systems. So for instance, our scheduling system, which is from 1994—oh, my God, makes me want to cry—doesn’t interface perfectly with [our EHR]. And so when a patient cancels [an appointment], you can’t always tell they’ve canceled on your [EHR] schedule. We order everything electronically, and then our secretaries print it out and transfer it to another system. So there are operational problems that I think are not related to the system itself being inadequate, but our [information technology] infrastructure at the hospital [is also] inadequate. … For instance, all the labs we order come back to [our EHR], all the radiology we order comes back to [our EHR]. The colonoscopies do not, because that will be another system. Because, of course, [gastroenterology] is functioning in their own little silo, and we’d need to build another interface to our system.
—primary care physician
Alert Fatigue
I think the most important challenge [with the EHR] is physician satisfaction. Since we switched to the EMR, you know, everything comes in that box. It’s like just ding, ding, ding, ding. When you go away for a week and you come back, there is just so much [email] volume to go through, and that’s a big dissatisfier with physicians. … The culprit is the [EHR], the computer. … Everything that happens to the patient is there; they keep sending [it]. Every podiatry visit, every nutritionist visit, every specialist visit, whatever they did, keeps coming, and it’s in multiple places. … Faxes come, they send you an ER report, the x-ray, and the CAT scan. And the moment you click it, you own it. And you make sure there’s nothing wrong there, … because if you missed it, you’re in trouble, okay? And this goes on every day. So the volume of the stuff you have to go through is out of control. … My point is there’s an overload of information which is not necessary, … if you go and see the podiatrist, nutritionist, their notes will be in the [EHR], it’s not going anywhere. It’s there. But why do you have to send it to me [via EHR-generated email as well]? … By end of the day, if I clear my desk, [and] I go home, there’ll be another 10, 15 labs or something sitting [in my inbox]. And then by morning it becomes 30. [If] you don’t clear 30 today, tomorrow it’ll be 60. That’s how it multiplies. … So you’re like, run, run, run, and the older you get, how fast can you run? Mentally, I mean, not physically. So that’s what happens. So it’s had its own, you know, stress. That’s one of the reasons why you saw that the satisfaction [decreased].
—primary care physician
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