Should senior healthcare IT executives shoulder a part of the responsibility of reducing physician frustration with IT in their day-to-day practices? Richard P. Wenzel, M.D., of the Department of Internal Medicine at Virginia Commonwealth University Health in Richmond, has written a compelling “Perspective” op-ed in the January 24 New England Journal of Medicine, entitled “RVU Medicine, Technology, and Physician Loneliness.”
The op-ed focuses on the administrative burdens facing practicing physicians right now, and what Dr. Wenzel sees as some ironic results of the push to empower and better connect patients with their clinician caregivers. As Dr. Wenzel states at the outset of his op-ed, “The increasingly sharp focus in the United States on the business contours of medicine and the related use of a productivity lens for basing salaries on Medicare relative value units (RVUs) have left many health care providers disheartened. Young doctors, especially, fill the unforgiving minute with clinical efforts, keenly sensitive to substantial school debts, mortgage and car payments, day-care costs, and the modest increases made in the professional fee schedule over time. Furthermore, the administrative burdens of enhanced documentation (important for institutional billing and risk management) and various compliance-training sessions can add drudgery to a physician’s diurnal tasks. Clinicians speak of long days delivering care with less time to talk to patients and their relatives, to colleagues, and sometimes to their own family members. Many of us sense the erosion of time for reflection, for inhabiting that uplifting, quiet place where we know who we are, where we are going, and what we hold to be true.”
The core challenge, Dr. Wenzel believes, is that “the institutional goals of abbreviating hospital stays and accelerating clinic visits are… factors feeding professional loneliness. Meaningful advances in technology have also levied a significant toll in the from of separation from patients and colleagues. The advent of online patient portals has generated increasing quantities of email communications, often in lieu of face-to-face discussions. Thanks to expanding digitization, we no longer need to engage our colleagues in the laboratory or radiology suite while on rounds or to discuss recommendations with a consultant: we can see the information we need right on our own computer screen.”
Ironically, Dr. Wenzel says, the very fact that physicians can choose to type while taking a patient’s history, rather than making eye contact,” is adding to physicians’ growing dissatisfaction with how contemporary medical practice works, in practice.
Much ink has been spilled over the subject of intensifying demands for the time of physicians in practice to document their patient visits, comply with the need to support clinical outcomes improvement regimens, and make their practices more cost-effective, efficient, and with improved patient care outcomes. But this op-ed looks at things from a bit of a different angle, around the need for physicians to be able to interact with one another face to face, both for improved outcomes and for improved individual satisfaction with practice. For example, Dr. Wenzel reports, “In the mid-1980s, I spent a sabbatical at the London School of Hygiene and Tropical Medicine, where I initially failed to see value in the half-hour ritual of teatime,” he writes. “But I soon realized that it meant the entire faculty and graduate student body assembled every day at various tables in one room, where conversations flowed, ideas were exchanged, mentoring flourished, and perhaps most important, trust grew.”
Indeed, Dr. Wenzel says, “Back in the United States, when I became president of the Medical College of Virginia Physicians practice plan, my London experience inspired me to lobby for a faculty dining room and retreat center, open 24/7,with free coffee and tea, and banks of computers available for clinician documentation. Its first-floor location in the main hospital and low-cast meals encourage lunchtime exchanges among basic-science and clinical faculty who might otherwise not have occasion to meet. An important catalyst for early success was the initiation of prerounding sessions by consulting teams in an open area.” Indeed, he adds, “The resulting informal cross-talk among team members was facilitated by greater familiarity.”
In short, Dr. Wenzel contends, not only are practicing physicians feeling overwhelmed by all the computing they’re doing these days; he believes that the volume of interaction with computers is also negatively impacting their working relationships with one another; and that is a serious issue to highlight. The question is, what can be done about this? Can anything be done?
In fact, Dr. Wenzel says, “[I]nstitutions could instruct their information technology (IT) teams to work toward freeing up clinicians’ time, for example, by studying the benefits and shortcomings of centralizing clinical billing with the goal of implementing such a system. Or, since the accuracy of pharmacy technicians in medication reconciliation has shown to be similar to that of pharmacists, pilot studies of IT-assisted oversight of medication reconciliation by pharmacy technicians might examine the effects on patient safety, professional satisfaction, and institutional costs.”
The implications of all this are both broad and deep. As we all know, electronic health records were created decades ago, and developed rather narrowly, and essentially created to mimic the paper patient records of the past. EHRs were never really designed effectively from the start, in terms of optimizing physician workflow, and further, were designed by EHR vendor companies at a time when interoperability had not been recognized as the important concern it’s recognized to be now. Nor were APIs (application programming interfaces) a factor then, either.
Meanwhile, the demands on physicians to participate in quality regimens and accountable care, also didn’t exist back then. Taken together, the demands on physicians to compute are greater and more intense than ever. How to make doctors’ lives easier? There is a great conundrum involved there.
The fact is, there are a lot of tasks that physicians simply can’t be relieved of, because of the way in which are healthcare delivery and payment are set up. But are there ways in which healthcare IT leaders might be able to ease some tasks for physicians, including facilitating the participation of mid-level clinicians and staffers in certain tasks, and making clinical information systems more intuitive and easier to use on the part of physicians.
Meanwhile, despite all the frustrations, Dr. Wenzel believes that there is hope. “Traditionally,” he writes, medicine was one of the most personally rewarding professions. Many of us are still inspired by the mysterious art of making an elusive diagnosis or the ability to help patients cope with illness or injury; others are motivated by the discovery of new epidemiologic links that can benefit whole populations of ill people.” And, he concludes, “I think we need uninterrupted time to reflect, to converse, and to grapple with the downsides of the unrestrained embrace of technology. Such steps could be the beginning of a journey to reclaim our profession and recapture our must treasured relationships.”
