What Will It Take to Cure EHR Note Bloat?

I recently returned to hospital-based cardiology because I missed patient contact and the camaraderie of colleagues. What I didn’t miss was all the typing. Not a day goes by when I do not curse Epic, MEDITECH, Athenahealth, Cerner, and any and all electronic health record (EHR) platforms.

I remember how efficient my day used to be, when I could quickly dictate a note, spend more time with patients, and get home to my family. For those of us in hospital-based medicine, there is no help in sight, but help did come for my friends in office-based medicine in January 2021. However, despite changes in the Evaluation & Management (E/M) coding requirements, many doctors remain chained to their laptops typing the equivalent of War and Peace.

Reams of lab results, orders, and imaging reports are still lobbed into office notes when just a mention would suffice. This “note bloat” drives a large portion of physician burnout at a cost of hundreds of lives and $1.7 billion annually.

Some hire scribes to handle the documentation burden, but that’s like prescribing a drug to treat the side effects of another. So who should be held accountable and who can help us?

Advice From Epic’s CMO

I spoke with Sam Butler, MD, who has been Epic’s chief medical officer (CMO) and a member of their informatics team for over 17 years. I had sent him the fantasy note of my dreams: one that included the patient’s problem, their overall status, a few labs and pertinent exam findings, any relevant diagnoses, an assessment, and a treatment plan. Sounding like a Name That Tune contestant, I bragged that I could do that note in 10 minutes or less by dictating directly into a blank screen.

Instead, it takes 45 minutes to see the patient, pull in the labs, update the exam findings, formulate an assessment, and enter a plan in our current EHR system.

An EHR version of my dictated note “would not have gotten you paid before Jan of ’21,” Butler told me, “but if you were working in the office, it would suffice perfectly now.” The rules from 1995 to 1997 are gone, so he also doesn’t understand why office-based doctors continue to suffer from note bloat. “Nothing is changing [in practice],” he conceded.

According to Butler, the average U.S. note is over 6000 characters long depending on how you space it. “I did a calculation, and we are still writing the equivalent of War and Peace every 9 months. Fifty percent of our time in the EHR is spent writing notes,” he said. The remaining time is spent on chart reviewing. “But if you look at specialists all over the world, outside of the U.S., their average note length is 1200 characters long.”

Butler assigned some of the blame to ambulatory medicine coders, who tell doctors that if you don’t mention it, we won’t get paid for it. “But that’s just not true,” he said. Epic tracks user activity, making it unnecessary to pull the entire lab result into a note.

Another reason for note bloat is our own resistance to change. Butler relayed the case of a physician who insisted on including his old note within his new note despite his notes snowballing at each visit, a habit that dilutes and obscures meaningful information.

Some may believe that a shorter note won’t protect against litigation. There is no proof, however, that note length affects malpractice protection. Butler recommended that we focus on documenting the things the computer can’t tell us. The “whys” are important: how we arrived at a plan, which lab results affected it, the patient’s participation (questions asked and options considered). “The idea that notes have to be a good short story with great grammar and great flow isn’t true,” he said.

Blame the Government?

When I complained that it takes at least an hour to do a hospital consult note, Butler explained that the rules for hospital documentation have not changed because of how hospitals are paid. The diagnosis-related group (DRG) classifications mean that they have to maintain a high case-mix index. “They have to prove they have sick patients or they don’t get paid,” as Butler put it.

Butler attributes the lack of progress on this issue to Medicare and the Office of the National Collaborator for Health Information Technology (ONC). The ONC, established by President George W. Bush in 2004, comes up with the rules about DRGs.

I asked Butler if burnout or physician suicide are ever discussed. “We say these things and Medicare doesn’t always listen to us, that’s for sure,” he said. He added that KLAS, a health technology research group, is doing independent studies via their Arch collaborative looking at signs and symptoms of burnout.

One of the main frustrations in office-based medicine is having to clear out an overloaded inbox at the end of a busy shift. Many messages shouldn’t come the doctor’s way to begin with (“Can I bring my aunt with me to the next appointment?”), and the nonsense buries relevant messages (a drop in hemoglobin).

Butler told me that Epic has a physician well-being team that has targeted the inbox issue. Among their recommendation is to send notifications about overdue lab results to the lab rather than the doctor.

That will be helpful, but why it has taken so long for our vendors to find ways to help? Was it not a priority until now?

The AMA STEPS Forward

In 2015 the American Medical Association (AMA) rolled out its “STEPS Forward” initiative to address burnout with an analysis of the basic problems of dealing with the EHR. They identified that physicians spend 2 hours on EHR and desk work for every 1 hour of face time with patients and then spend another 1 to 2 hours wrestling the inbox as part of our homework.

I spoke with Christine Sinsky, MD, who is the AMA’s vice president of professional satisfaction. She identified the three main sources of frustration with the EHR. Some are related to the vendor’s EHR design, others are related to regulation at the federal level, and still others arise from decisions made at the institutional level.

The latter may result from overinterpretation of federal regulations or other local implementation decisions, she told me. As a practicing internist, she knows that “physicians were at the ‘sharp end of the stick’ when it came to experiencing those painful changes in their workflow.” In her practice, it took 32 clicks to order and record a flu shot.

She wants EHRs that come “out of the box” with streamlined processes that minimize the clicks and screen changes to perform basic actions, such as placing an order or closing a chart. We need “click parsimony,” she said.

Sinsky highlighted the Getting Rid of Stupid Stuff  toolkit, which is based on an initiative originally implemented by Melinda Ashton, MD, at Hawaii Pacific Health. Some of the suggestions include the following:

  • Changing the automatic logout time from 5 minutes to 15 minutes

  • Turning off automatic inbox notifications for copied test results ordered by another physician and for test order and scheduling confirmations

  • Allowing prescriptions for noncontrolled substances to be electronically sent in without requiring password reentry

Examples of Some Battles Won

Sinsky praised some examples of time-saving improvements made at the institutional level. She mentioned Steven Strongwater, MD, CEO of Atrius Health in the Boston area, whose team was able to decrease the inbox burden by 25%. His organization enhanced workflow by implementing wide-screen utilization to allow several windows to be opened simultaneously. They moved messages back to dashboards, and they shifted admit, discharge, and transfer notification to case managers, which eliminated about 50 million clicks a year.

I reached out to Kaiser Permanente and received an email from Ken Robinson, MD, the physician lead for Systems Solutions & Deployment at Kaiser Permanente Southern California. He explained how they improved their system after asking the hard questions.

“We learned that not all organizations require password authorization,” he said, a fact that was met with initial skepticism and even alarm by many in the organization. But they investigated the regulatory situation and found no compelling reason to keep password authorization for most order entry needs.

And so, on April 27, 2022, their EHR removed password authentication for the following:

  • Hospital/ambulatory medication orders

  • Hospital procedure orders (e.g., laboratory and imaging orders)

  • Hospital discontinue/cancel orders

 (Ambulatory settings already had no password authentication requirement for procedure orders or discontinue orders.)

There was no change in password authorization requirements for the following: 

  • Initial login to the EHR

  • Existing Electronic Prescribing of Controlled Substances (EPCS) workflow for ambulatory controlled substances

  • Oncology ordering and workflows

Hallelujah!

Shortly after the changes were made, Robinson began to get feedback:

“It’s like walking on 2 feet instead of walking on all 4s.”

 “Decreasing the password typing requirement is the best HealthConnect (EHR) upgrade ever. 

“Hallelujah!”

Dawn Clark, MD, the chief wellness officer and regional assistant medical director, had told Robinson and the other leaders to be on the lookout for opportunities to improve the lives of their physicians and staff and to be especially mindful of “both pebbles in the shoes and failing to question the statement ‘that’s how we’ve always done it.'” This change is an excellent example of that advice translated into action, said Robinson.

How Can We EHR Users Push Reform?

If we want further EHR reform, Butler of Epic advises us to push our senators and members of Congress. For more immediate effects, he recommended taking advantage of EHR training to learn how your system is set up. “Learn speech to text. It’s come a long way, and most organizations offer it.”

I have come to accept that my value as a physician is no longer measured by my physical exam skills or medical intuition. My worth is reduced to whether I can enter all the “necessary” information in the EHR before the witching hour of midnight.

I am doing my part to play this stupid game, but it came at a price. I learned how to type while chewing; I tilt my head just so to keep my drool off the keyboard. I limit bathroom visits and accept that a work shift can stretch from 8 a.m. to 1 a.m.

For others, the price was far higher, and there should be no statute of limitations on the blame that lies with the ONC and Centers for Medicare & Medicaid Services. Their over-regulation caused burnout-related medical errors and drove rates of physician suicide. But some of the blame should also go to the vendors who fell short with their algorithms.

I often wonder if any of the techno-geeks who developed our EHR platforms consider the patients and physicians who were harmed as a consequence when they walk through their fantastical campuses.

And what about our medical societies who continue to host impassioned sessions on burnout, physician suicide, and physician dropout ? We love to analyze and acknowledge these issues, but where is the progress? Their corporate apathy is why we’re in this mess. There is no good excuse for over a decade of suffering.

Meanwhile, the best we clinicians can do is to take any opportunity we get to improve our EHR’s efficiency. We should give accolades to those who are winning some battles in documentation reform. But we should remind those who are responsible for this catastrophe of their obligation to help us get back time with our patients and our loved ones. Physicians and patients deserve no less.

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