EPtalk by Dr. Jayne 5/18/23

A colleague clued me in about an article that was published in JAMA Network Open last week, “Perspectives on the Intersection of Electronic Health Records and Health Care Team Communication, Function, and Well-being.” The associated qualitative study looked at the habits of more than 70 attending and resident physicians and found that the EHR dominated most inter-office communication.

Although it can be helpful for management of patient-related tasks, they found that communicating through the EHR limited the “rich communication and social connection required for building relationships and navigating conflict.” The authors suggest that “the technology shifts attention away from the human needs of the care team, and interventions to cultivate interpersonal interactions and team function are necessary to complement the efficiency benefits of health information technology.”

Digging into the study design, I found it interesting that the participants in the qualitative interviews were separated in time, with a significant event in the middle with the emergence of the COVID-19 pandemic. The first of the two cohorts was interviewed from March to October 2017 with the other being interviewed from February to April 2022. The authors called this out as a limitation of the study. They also noted that the first study focused on EHR-related distressing events and their role in physician emotions and actions, where the second study focused on EHR use and “daily EHR irritants.”

I would propose that in a post-pandemic world, even the smallest of daily annoyances is felt much more acutely than it might have been in 2017. This is exacerbated by the staffing and financial pressures that have been magnified since the pandemic’s start in 2020. I’d be interested to know what the relative level of staffing was during the two cohorts’ interview periods, since a significantly understaffed practice will yield different sentiments than one that is running with adequate staffing. Interestingly, information on respondent demographics wasn’t collected.

The authors also note that communicating through the EHR was felt to negatively affect team function and team well-being, namely by “promoting disagreement and introducing areas of conflict into team relationships related to medical-legal pressures, role confusion, and undefined norms around EHR-related communication.” There was specific discussion of physicians being expected to manage EHR-related messages across multiple platforms such as in-basket, email, and text.

One interviewee compared this to driving a car before stoplights were developed. “Some of my colleagues text; some of them send it in… email; some of them send it as Epic provider-to-provider messages. What a mess… there’s no sort of manners and rules. Right? Sort of like… before they developed stoplights, and there were starting to be more and more cars. Right? Man, this is nuts. It’s like, ‘Who’s going first. Who’s talking to who?’” I feel that frustration, especially when you look at the fact that different platforms might offer different subsets of functionality that can be confusing.

In some of my experiences with startups, we ran into this with differences in what IOS versus Android platforms would support, and even with IOS, on what might work on iPhone but not on iPad. This is magnified when you’re dealing with a full-feature EHR that people are trying to use from disparate platforms. You can also throw in some desktop support requirements and the Apple Watch and it’s a doozy.

I tend to only perform “real work” on a laptop or desktop, so I can’t imagine the cognitive overhead that people who try to manage on different platforms are experiencing as they try to remember which device will allow them to do what. Especially with portable devices, people are also trying to use EHR-based communication while doing other things, such as attending events with family, which adds a layer of distraction to what might already be some fairly brief communications.

Others in the study noted that “now that I can place an order from anywhere, everyone assumes I can place an order from anywhere, and expects me to do so anywhere, anytime.” In my experience, this blurring of personal and professional time adds to clinician burnout and resentment towards the workplace.

I was saddened to read the part of the article where they discussed the EHR being used to air disagreements, including clinicians who “would document petty, kind of nasty comments in the EHR about residents.” Others noted that concerns about potential litigation may “put people under the bus” in the EHR with documentation about who was paged and when, and whether the response from the contacted clinician was to their satisfaction. There were also the expected comments that delivery of care to the patient has “completely been subsumed in documentation requirements.”

The authors noted that there is a need for greater understanding of optimal EHR use and that “the development and improvement of local work culture is critical and may have a greater influence on physician burnout than EHR improvements alone.” They go on to suggest that “organizations support physicians in implementing small, structured peer-group discussions to enhance team function and individual well-being.” I’m a big fan of the concept of self-organizing teams and the latter comment resonated with me. People need to be able to talk about how they like to be communicated with, and any additional needs they have in processing information, but may not be likely to address these needs unless it’s clear that the workplace is supportive of accommodating them.

I received quite a bit of reader mail about my recent Curbside Consult that talked about May being graduation season. Many readers have graduates in their families and it sounds like there is an even split between those going into technology-related fields and those pursuing careers in the arts and humanities. A couple sent pictures of their graduates and it was great to see the proud parents and the excited faces of the graduates in the photos. One correspondent noted that her daughter is headed to work for Epic, with another sending a child to a public health organization. They’re looking forward to seeing what their children think about the industry after seeing it from another side. I’m sure new entrants to the healthcare field have an entirely different idea of what it will be like than many of us did 10 or even 20 years ago.

What did you think healthcare IT would be like when you first started in the industry? Has it met your expectations or crushed your dreams? Leave a comment or email me.

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