april 18, 2014 philip j. kroth, md, ms [email protected] provider stress and electronic health...
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April 18, 2014
Philip J. Kroth, MD, [email protected]
Provider Stress and Electronic Health
Records
This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 United States License.
Conflicts of interest
• None
Overview
• Actual impact of EHRs?• What is known about physician stress
and impact on clinical care• Technostress• Possible solutions
EHR Impact
Historical Perspective
• Government report
Historical Perspective
• Government report • Document management & Digital
access
http://www.louvre.fr/en
Historical Perspective
• Government report • Document management & Digital
access• Computerized Decision Support
April 2012
CDSS Impact on Mortality
• 7/148 RCTs had mortality as an outcome
• 6/7 had combinable data:
CDSS Impact on Morbidity
• 22/148 RCTs had morbidity as an outcome
• Morbidity: reduction in readmissions, CAD event rates, surgical site infections
• 16/22 had combinable data
CDSS Impact on Morbidity
CDSS Impact on Length of Stay
• 6/148 RCTs had length of stay as outcome
• 5/6 had combinable data:
CDSS Impact on Process Measures
Other Meta-analyses that Showed a Significant CDSS Effect
• Recommended treatment ordered/prescribed (67 RCTs) (another process measure)
Other Meta-analyses that DID NOTShow a Significant CDSS Effect
• Adverse Events (5 RCTs)• Cost (22 RCTs)• Cost-effectiveness (6 RCTs)• Health-related quality of life (6 RCTs)
Overall Conclusions
• 29 (19.6%) RCTs assessed the impact of CDSSs on clinical outcomes
• 22 (14.9%) RCTs assessed costs• “Strong evidence shows that CDSSs/KMSs
are effective in improving health care process measures across diverse settings using both commercially and locally developed systems..”
• “Evidence for the effectiveness of CDSSs on clinical outcomes and costs and KMSs on any outcomes is minimal..”
Physician stress and impact on clinical care
Physician Stress*
• 53% of physicians report time pressure during office visits
• 48% said their workplace is “chaotic• 78% noted low control over their work• 27% reported burnout
*Linzer M, Manwell LB, Williams ES, Bobula JA, Brown RL, Varkey AB, et al. Working conditions in primary care: physician reactions and care quality. Ann Intern Med. 2009 Jul 7;151(1):28-36, W6-9.
Intern time devoted to HICT*
• 12% direct patient care• 64% indirect patient care• 40% with “computer use”
*Block L, Habicht R, Wu AW, Desai SV, Wang K, Silva KN, et al. In the Wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J Gen Intern Med. 2013 Apr 18
Chaotic environment*
• Amount of data accessed and used by clinicians per medical decision is increasing exponentially
• Amount of face time physicians have with patients is not expanding to accommodate this increased information processing load
*Stead W, editor. Beyond expert-based practice. IOM Annual meeting summary: Evidence-based medicine and the changing nature of healthcare; 2007; Washington, DC: The National Academies Press 2008: Institute of Medicine.
Dr. Christine Sinksy, Director, American Board of Internal Medicine*
“Frantic multi‐tasking during an appointment is now the norm, pulling the doctor’s attention away from the patient.. Studies in our practice reveal that it takes an average of 3 seconds of physician time to schedule a future appointment, lab, and X-ray using a paper order set and 2 minutes to do this same work through computerized order entry. It takes 23 seconds to enter a family history on paper and 2 minutes and 14 seconds to enter that same information in structured text. This time adds up and can quickly consume much of the 15‐minute visit. I have shadowed primary care physicians across the country and have observed this same pressure in almost every setting.
*Sinsky CA. If not for the pause. SGIM Forum. 2013;36(5):1-2
Technostress
Technostress*
1. Techno‐overload2. Techno‐invasion3. Techno‐complexity4. Techno‐insecurity5. Techno‐uncertainty
*Tarafdar M, Tu Q, Ragu-Nathan B, Ragu-Nathan T. The impact of technostress on role stress and productivity. Journal of information management. 2007;24(1):301-28.
Techno‐overload
• Work faster• Multi-tasking• Example: See more patients because
of provision of HICT
Techno‐invasion
• HICT invades personal life• Example: Ubiquity of HICT allows
physicians to practice from anywhere at any time
Techno‐complexity
• HICT makes users feel incompetent• Example: number of things HICT
users can do is rising at an increasing rate (e.g., e-prescribing, digital medical imaging, EHR access)
Techno‐insecurity
• Job security of users is threatened by fast changing HICT that can provide new ways to practice medicine
• Example: Radiologists may feel threatened by teleradiology services
Techno‐uncertainty
• AKA “Version Stress”• HICT upgrades and bug fixes impose
a continual requirement to change work processes
• Example: new versions of Microsoft Word or Windows force us to relearn how to do the same functions again and again
Yerkes-Dodson Law shows therelationship between stress (arousal) &
performance (1908)
Why does Decision Support work?
Time
Performance &Attention
1.5 hrs
Time-Performance CurveFor Monitoring a Continuous Process
A possible solution
From Aircraft Crashes Record Office (ACRO)
Quiet Dark
Metaphor
Na+
K+
Cl-
CO2+
BUN
CrGlu
A possible solution – radically redesign HICT
• Reduce information chaos• Vastly reduce the variability and
standardize the EHR user interface across vendors and institutions
• Create a version of the Aviation Safety Reporting System (ASRS) for HICT
April 18, 2014
Philip J. Kroth, MD, [email protected]
Provider Stress and Electronic Health
Records
This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 United States License.