by wayne persky
Founder and President of the Microscopic Colitis Foundation
*Note that this article is so long that it is being published in two parts. This is part one.
Burnout among medical professionals is an increasing problem, while patient dissatisfaction is growing. Doctors and nurses are understaffed, and overworked at most institutions. They're increasingly frustrated by how their job description has changed over the past couple of decades. Patients are losing faith in the healthcare system because of increasing wait times for appointments, and dissatisfaction with the way their appointments (and often their treatments) are handled. Is a crisis looming? You be the judge.
The primary problem appears to be the EMR.
In a previous article, we considered some of the problems with the electronic medical record (EMR) system, and how it has negatively impacted the experiences of most patients when interacting with the healthcare system. Many patients resent the way that clinicians devote more time to the computer monitor and data entry during an appointment, than they share with the patient. But that's not the clinician's fault. Both clinicians and patients alike (in the U.S., at least) are victims (or captives, however you prefer to view it), of the comprehensive healthcare reform law enacted on March 23, 2010, known as Obamacare.
This healthcare reform has resulted in drastic changes.
The legislation required that, as of January 1, 2014, all public and private healthcare providers and associated medical professionals must adopt and maintain an EMR system in order to qualify for full reimbursement from Medicare and Medicaid. And failure to comply with the requirements of the EMR system results in reimbursement penalties by Medicare. Needless to say, as thin as operating margins are at most healthcare facilities these days, precious few facilities could continue to operate competitively if their Medicare reimbursements were consistently penalized, so for all practical purposes, EMR compliance is mandatory.
But EMR has become the elephant in the room.
Unfortunately, as the system has evolved, it has effectively destroyed the traditional doctor-patient relationship of the past, simply because in use, it has proven to be extremely time intensive. It places so many demands on a clinician's time, that the lion's share of a patient's appointment time is spent by the clinician's efforts to satisfy the requirements of the EMR system, while only being able to interact with the patient occasionally, for brief intervals. If the clinician doesn't enter the data into a patient's record during an appointment, then at the end of the day, it would take hours to enter all the data, and there is no way that clinicians would remember to enter all of the patients' information correctly, so that's not an option.
Why is EMR a poster child for the Law of Unintended Consequences?
The initial concept for EMR was based on the best of intentions. It was supposed to simplify record-keeping and communications, and provide new features that are beneficial to both patients and clinicians. Normally, when computer systems are proposed, they are developed as intended, and they continue to improve, and offer new, and beneficial features, as they evolve. So what happened to EMR? After a decade of evolution, the EMR system (actually systems) has evolved into a time hogging, poorly organized, expensive fiasco, arguably despised by both patients and clinicians.
The AMA's official position regarding the EMR system states that:
The American Medical Association (AMA) supports the use of electronic medical records (EMRs) as a way to improve patient care, enhance efficiency, and reduce healthcare costs. The AMA believes that EMRs have the potential to improve patient safety, facilitate coordination of care, and enable better communication among healthcare providers. However, the AMA also recognizes the challenges and barriers associated with implementing and using EMRs effectively, such as interoperability issues and the potential for increased physician burden. The AMA advocates for policies and practices that address these concerns and promote the successful adoption and use of EMRs in healthcare settings.
EMR systems are not cheap.
Published research (the Health Affairs study) shows that EMR implementation costs for a typical multi-physician practice is about $162,000, and first year maintenance costs are about $85,500 (Green, 2023, March 23).1 Studies show that EMR implementation for hospitals varies widely, with some facilities paying less than $5 million, and others more than $20 million. On a nationwide basis, the cost of EMR implementation is tremendous. The federal government initially set aside $27 billion for promoting EMR, and estimates that it spent $12,000-$16,000 per physician in technical support, just to get them up and running. In view of the results, one has to wonder how effectively that money was spent.
Before EMR came along, the patient was the focus of the appointment.
Now that the EMR system dominates the patient's visit, the computer has become the focus of the appointment. This, in essence, probably describes the gist of the problem from the viewpoint of most patients. Patients don't like to wait several months for an appointment with their doctor, just so they can share most of that relatively short appointment time with an attention-demanding, time-hogging computer that demands seemingly endless (and often redundant) information from the clinician, regarding the patient. Patients usually sign up for appointments because they want the doctor's advice regarding a health issue. So it shouldn't be surprising that most patients are upset because of the ways that their appointments have deteriorated.
Why haven't appointment times been increased?
Ideally, patient appointments would have been lengthened in order to accommodate the additional time requirements imposed by the EMR system. But alas, to add insult to injury, the time reserved for most appointments has grown shorter, rather than longer, primarily due to an attempt to make up for time lost because of decreased physician efficiency. Recognizing that this short changes both the physician and the patient, does not require a medical degree. And in the end, it's debatable who suffers the greatest loss. The patient loses quality of care, and the physician loses the luxury of adequate time in which to deliver quality care. Both come away from the appointment feeling unsatisfied (or cheated).
How do most doctors and nurses view this dilemma?
Similar to the way most patients view this issue, apparently — with intense dissatisfaction. Because of fears that their position at their place of employment might be affected, medical professionals who are currently employed are unlikely to feel comfortable critiquing the system, and because of that, their responses would be unlikely to be completely candid. Consequently, I haven't bothered to try to reach out to any of them.
Fortunately, one of our board members is a retired physician.
Our newest member of the Board of Directors of the Microscopic Colitis Foundation is a retired physician, so she can speak freely. Sharyl Magnuson, MD. has an extensive background in healthcare service that can be reviewed on the Microscopic Colitis Foundation website by selecting "About Us/Board Of Directors", on the main menu. And because she is dedicated, as we are, to trying to convince her colleagues to reconsider the way that they view microscopic colitis, and prescribe treatments for the disease, she has kindly agreed to share her honest opinion regarding the EMR, and how it has affected the practice of medicine, from a clinician's viewpoint.
Doctor Magnuson not only verified the EMR issues mentioned above, but she also pointed out numerous additional problems.
- Because of the shortage of physicians, Nurse Practitioners (NPs) and Physician Assistants (PAs) are providing more primary care services. They are able to provide high quality healthcare, but their training doesn't prepare them to manage the very complex medical patient seen regularly in most primary care offices today. For that, they need physician oversight, which is often unavailable.
- Medicare now treats all physicians as though they are about to commit fraud every time they make an EMR data entry (which is many times each day). Another, even bigger problem with the system is that insurance claims require excessive documentation, much of which is useless. Constant repetition of these issues is surely contributing to physician burnout.
- Primary care physicians are required to work longer hours to treat fewer patients.
- The previous freedom, and valuable ability of physicians to think for themselves when assessing a patient's symptoms, has been usurped by the EMR. This implies that the EMR is in charge of our healthcare, whereas previously, our physicians were in charge of our healthcare. How can this be a good thing?
- Young physicians search for positions with controlled hours, and when they discover that such positions do not exist, they typically decide to leave primary care as soon as they pay off their education loans.
- Fewer young physicians are going into primary care. Consequently, more primary care positions are being filled by foreign doctors. These healthcare professionals are highly qualified, but unfortunately, the visa system, under which they are allowed to remain in the U.S., takes advantage of them, so that in many cases, they are treated almost as indentured servants.
She shares valuable insight into how EMR affected her own medical practice.
In her own words, Doctor Magnuson eloquently describes her experiences with EMR:
I loved being a Family Doc when I was young, I found it very satisfying. The EMR sucked all of the joy out of my career.
This article will be continued in part two.
References
1. Green, J. (2023, March 23). How much EHR cost and how to set your budget. EHR in Practice. Retrieved from https://www.ehrinpractice.com/ehr-cost-and-budget-guide.html
