Electronic Health Records Are A Scapegoat For Deeper Problems
Originally published in Forbes.
We crave simple explanations for complicated problems. In healthcare, clinicians often lash out at their electronic health records.
It’s understandable. For every eight hours of scheduled patient care, we average almost six hours using the EHR, nearly half occurring outside clinical hours. Repeatedly scanning, toggling, clicking, and typing zaps our energy, steals our attention, wears us out, and contributes to burnout.
Yet, while EHRs are far from perfect, they’ve become the scapegoat for too many challenges. This narrative is overly simplistic and distracting. Let me explain why.
EHRs Are A Mixed Bag
EHRs make some tasks easier and others harder. For example, they empower us with information yet overwhelm us with junk and nonsense. Clinical notes are now legible and easy to retrieve but often bloated with unnecessary, duplicative, and, at times, unintelligible content.
Similarly, EHRs bring us closer to our patients while pushing us further apart. Portals make it easy for us to communicate between visits, yet obtrusive screens and keyboards in the exam room interfere with human connection.
EHRs make us more productive in some ways yet less productive in others. For instance, it is easier to prescribe medications and communicate test results electronically, but EHRs force us to process countless alerts and notifications.
EHRs Do Not Work In Isolation
EHRs, healthcare workers, and work streams combine to form socio-technical systems. Rather than reflexively blaming the EHR for practice challenges, we must also consider other system components.
When adopting EHRs, many organizations digitized old, paper-based workflows, forcing clinicians and nurses to develop workarounds and perform unnecessary tasks. Organizations that redesigned their work and reconfigured their teams have done better. For example, primary care providers working on high-functioning teams spend up to 14 fewer minutes using the EHR for each visit.
How organizations configure their EHRs also affects clinicians’ experiences. For instance, emergency medicine physicians at one health system must click 14 times to order Tylenol—that’s a lot. Yet, those at another health system using the same EHR must click 61 times!
Finally, over 85% of clinicians in some organizations are satisfied with their EHRs. These entities have positive cultures and EHR governance groups that hunt for solutions rather than automatically denying enhancement requests.
Digital Transitions Are Challenging For All Industries
Digitization’s growing pains are not unique to healthcare. As software continues “eating the world,” knowledge workers across industries are challenged by digital tools that overload them with information, increase multitasking, quicken the pace of work, and make them feel “always on." These workers routinely rate their enterprise software (e.g., Concur, Teams, and Workday) poorly and, like clinicians, frequently work at night and on weekends.
Healthcare Is Increasingly Complex
So, if EHRs are not the core problem, why does clinical practice feel so hard? To paraphrase James Carville, “It’s the complexity, stupid.”
For one, our patients have increasingly complex health needs. More than 40% of American adults have at least two chronic conditions, one-third take at least three medications, and one-fifth suffer from mental illness.
Clinical pathways and protocols are also increasingly complex. A primary care physician would need to work 27 hours daily to provide guideline-recommended preventive, chronic disease, and acute care to a 2,500-patient panel.
The US healthcare system is the most administratively complex in the world, with various regulatory and billing requirements and medico-legal concerns. This helps explain why the average US clinician spends as much time in the EHR as a non-US clinician in the 99th percentile of EHR work.
The point is that non-technical factors explain much of the perceived EHR burden. As UCSF’s A Jay Holmgren told me, “The EHR is a conduit for this work, but not the cause of the work.”
Complexity Impacts Usability
Many clinicians rightfully complain that their EHRs are not as usable as software like Gmail or Spotify. Yet, consumer technologies are designed to meet the needs of single users and remove their decision-making abilities.
Conversely, EHRs must be complex enough to match healthcare’s complex adaptive systems and allow expert staff autonomy to make decisions. Furthermore, some EHRs like Epic use a monolithic architecture that integrates various features to guarantee high reliability. In these cases, the lack of modularity is a feature, not a bug.
Importantly, not all time in the EHR is wasted! We too easily forget that using the EHR is far more than just pointing, clicking, and typing. When using EHRs, we synthesize information, think critically, communicate with colleagues, and perform various tasks that long pre-date EHRs. Contrary to popular belief, we spend as much time with patients today as we have over the past six decades.
We Must Avoid The Trap Of Technological Solutionism
None of this is to say that EHRs are perfect—they aren’t, and we deserve more usable technology. However, EHRs are too easy of a scapegoat because they are so front and center.
Blaming EHRs for clinical practice challenges leaves us hoping for silver-bullet solutions like artificial intelligence. But, as the artist Laurie Anderson explained, “If you think technology will solve your problems, you don’t understand technology—and you don’t understand your problems.”
Healthcare’s problems are primarily social, behavioral, and economic, not technical. Most EHR-related challenges reflect these deeper issues. So, rather than continually bemoaning our EHRs, let’s focus on redesigning our care systems, streamlining our work, rightsizing our teams, and clarifying what matters most.