Physicians spend 16 minutes using EHR for each patient encounter

Physicians spend, on average, 16 minutes and 14 seconds using an EHR for each patient encounter, with 11% of that time occurring after hours, according to a study published in the Annals of Internal Medicine.

“The time physicians have to spend on indirect patient care tasks creates time pressure on direct patient care — interview, physical exam, discussion — adds to the physician's cognitive load and can be difficult to integrate into the time we have face to face with the patient,” J. Marc Overhage, MD, Ph.D., a health care information technology executive at Cerner Corporation, told Healio Primary Care.

Approximately 100 million patient encounters with 155,000 physicians were included in analyses.
 The average time spent actively using an EHR each month was 16 minutes and 14 seconds per encounter across all specialties, with 11% of that time accounting for work completed after hours.

Chart review consumed 33% of this time (5 minutes, 22 seconds), followed by documentation at 24% (3 minutes, 51 seconds) and ordering at 17% (2 minutes, 42 seconds).

Among primary care physicians, the mean active time using an EHR per encounter was 19 minutes and 48 seconds. Physicians in internal medicine spent an average of 18 minutes and 19 seconds using the EHR per encounter, and those in family medicine used it for an average of 15 minutes and 52 seconds per encounter.

Overhage said the findings provide important information on the amount of time that physicians invest using EHRs, which is often overlooked by patients and policymakers.

“It is, of course, important to maximize the efficiency with which physicians can care for patients,” he said. “The health care system also needs to be thoughtful about the tasks we ask physicians to do and which tasks other members of the care team, including the patient, can perform as well or better in order to free physicians to focus on their unique contributions.”

The situation is even worse for trainees

Residents Spend 5 Hours on Electronic Charts per Day

Trainees are hard-pressed to meet the demands of patients, attending physicians and study time. The facts in this story are disturbing because it takes away protected time for study, research, and collaboration.

To address resident satisfaction and thus improve motivation to provide patient-centered quality care, reducing the time residents spend on clinical documentation should be a priority," write Lu Chen, a medical student at the Department of Medicine, New York Methodist Hospital, Brooklyn, and colleagues.

Their study appeared in an article published in the February issue of the Journal of Graduate Medical Education.

Whereas some evidence suggests EHRs can improve the quality of care, the amount of time physicians spend on the records is emerging as an important issue. For example, switching from paper charts to electronic ones reduced productivity among residents by 30% at a hospital in Moreno Valley, California, researchers reported previously.

With that in mind, Chen and colleagues set out to document the time first-year residents spent on EHRs at a 691-bed university-affiliated community teaching hospital.

They tracked the amount of time each of the 41 residents was logged into the EHR system. A tracking system tallied the residents' active use, defined as more than three mouse clicks, 1700 "mouse miles," or 15 keystrokes per minute.

The residents took part in ambulatory, emergency, and inpatient care, including general medical floors, intensive care units, and step-down units. The researchers recorded their EHR usage for May, July, and October 2014 and January 2015.

Over the course of 4 months, the residents spent 18,322 hours to review 33,733 electronic patient record encounters (EPREs), defined as an active EHR usage for one patient's chart each day.

This worked out to 40 (±11) minutes per EPRE for July and 30 (±5) minutes in January.

In other words, in January, after becoming familiar with the system, the residents spent 5 hours charting for a maximum of 10 patients per day.

The decrease of 18% spent on EHRs from July to January was statistically significant (P < .001).The researchers noted a reduction in time in all four categories of EHR activity: 2 minutes for chart review, 2 minutes for orders, 3 minutes for documentation, and 2 minutes for all other activities

"Although increased familiarity reduced time spent on clinical documentation, a significant portion of an intern’s day is still consumed by clinical computer work," the authors write. "Our data correlate well with national survey data, showing that [internal medicine] residents spent more than 4 hours per day on clinical documentation. Furthermore, a nationwide survey revealed that residents’ perceptions of the time devoted to documentation were generally negative; residents felt that clinical documentation took time away from education, patient care, and more importantly, motivation to provide high-quality care."

Physicians spend 16 minutes using EHR for each patient encounter: 

Where is the Patient in the EHR ?

The Missing Link.

Health reform is outpacing information technology, and a disconnect has occurred. Recently a patient discussed a difficult diagnosis that defied diagnosis. She had breast cancer removed over 8 years prior to her developing shortness of breath, fatigue and other symptoms that affected her normal activities.  She noticed her gradual recovery from breast cancer had taken a reverse course.  She saw a number of cardiac specialists, other providers, did internet searches and analyzed what was occurring.   She consulted many sources of information to no avail.

All her tests and examinations were within normal limits, and she left each visit hearing that "all is normal" She was well off financially and had invested in many consumer devices such as a Fitbit, Apple Watch, and a KardiaMobile monitor. or KardiaMobile6L FDA-cleared, clinical grade personal EKG monitor. KardiaMobile captures a medical-grade EKG in 30 seconds anywhere, anytime.FDA approved) (compatible with iPhone and Android This device attached to a smartphone and could display an EKG. The KardiaMobile6L produces a full six lead EKG which can be interpreted by a physician. Omron provides many remote BP monitors that record measurements, as well as EKG in one unit.

Alivecor EKG sensor

Omron BP and EKG Sensor and Recorder

These and other devices are now on the consumer market and can be purchased online.
Our cancer patient used all these devices including a number of blood pressure cuff which she calibrated against her physician's office manometer.

For each physician encounter, she would bring the record with her, but there was no means to enter the data into her own electronic health record from home. When another physician looked at her EHR there was no record of her home monitoring. EHR vendors are quickly adding this feature to their systems.

She discussed her symptoms with a friend who told her about a friend who had identical symptoms and was diagnosed with dysautonomia.  She then discussed this with her physician, who reviewed the data and her history again, agreeing that was the most likely diagnosis. The patient devised her own dietary modification, adding salt to her diet when she excercised.  Her symptoms abated.

The takeaway here is that the patient owned her diagnosis and made a considerable effort. Her collaboration with her doctor is the near-perfect example of patient-centered medicine

A number of manufacturers have designed smartwatches to measure BP and/or EKG

Omron Watch 

Looking For a Smartwatch or Fitness Tracker? These Are the Best You Can Buy

Smartwatches are a compromise at best, for the time being.  The addition of vital sign monitoring to a watch that tells time, messages, facebooks, weather reports, internet access, and phone capability is a stretch.

You want the best of the best and don’t mind paying for it.

Our pick: Apple Watch Series 5 ($400-$1,500)

Yes, yes, we know it’s not exciting that the Apple Watch is the best smartwatch out there. The Series 5 didn’t update much in terms of hardware—the biggest change was the addition of an always-on display powered by an LTPO screen. That said, Apple beefed up its health-tracking software. Now you can view 90-day trends, track reproductive health, and monitor environmental noise levels straight from your wrist. Plus, it’s still FDA-approved for ECG readings. 

More advanced features, like LTE connectivity and NFC payments, still work without a hitch. The only downside is battery life is still pretty short at an estimated 18-hours. However, in testing, we found the Series 5’s battery isn’t likely to run out on you before you make it home.

There is a multitude of EHR vendors designed for specific practice types from enterprise systems for large entities, universities, Mayo Clinic, VAH, and others, while smaller systems are designed for small groups or individual practices. 

You may want to consult with your physician or the IT department of the large enterprise at which you receive care.  Things change rapidly, try before you buy 

Business and Payors rapidly adopting Telehealth Virtual Visits

What is driving the adoption of telemedicine?

     1. Reduced costs
     2. Accessibility
     3. Provided as a benefit with minimal cost model (Walmart  $ 4.00 virtual visit)
     4. Little time lost from work for a routine health problem.
     5. Payors recognize lower costs and are reimbursing for telehealthcare without restrictions, and no longer limited to rural areas.
     6. Employer realizes benefits as an added value to employer-based health insurance.
     7. Standard of care rapidly shifting to this as a primary access route.

Almost all large employers plan to offer telehealth in 2018, but will employees use it?
UnitedHealth doubles down on telemedicine with an app in employer-sponsored plans

The country's largest private payer is rolling out a new virtual care app for the more than 27 million Americans covered in its employer-sponsored health plans.
The new UnitedHealthcare app gives users access to a practitioner via a mobile device or computer. Beneficiaries can use it to schedule and conduct a virtual visit with a doctor. Physicians can diagnose a range of conditions during the visit and prescribe and send medications to local pharmacies for pickup.
The app will be free for the majority of people enrolled in the Minnetonka, Minnesota-based payer's employer-sponsored plans, but consumers may have to pay additional out-of-pocket costs for telemedicine services depending on their plan and state requirements.

Walmart, Doctor on Demand roll out telehealth initiative for employees
AMA: How to make telehealth an ordinary component of healthcare
AMA blog on 3 must-haves for Telemedicine
Why a Philadelphia landlord says offering telehealth to tenants is a 'no-brainer'
106 hospitals, health systems that launched telehealth services in 2019
Cigna taps telehealth provider for virtual mental health visits
VA, Walmart launch telehealth pilot program to deliver medical services in rural areas
VA performed 2.6M virtual care visits in 2019

CMS, ONC Propose New Regulations to Transform the Future of Interoperability and Patient Access | Healthcare Innovation

The two rules—separate but very related—outline new provisions around requiring interoperable activities while giving patients easier access to their electronic health data

Federal health officials are pulling an array of levers that fall under the core aim to improve interoperability and patient access to data.

The two proposed rules—one from CMS (the Centers for Medicare & Medicaid Services) and one from ONC (the Office of the National Coordinator for Health IT) are separate, but at the same aligned as the two agencies within HHS (the Department of Health & Human Services) look to further advance the nation’s healthcare interoperability progress. The two rules represent great significance for health IT stakeholders, who will now be more under the microscope than ever before as it relates to their efforts in making sure that health information is seamlessly moving—while not restricting such efforts.

The ONC rule, titled “21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT," is 724 pages in length, and according to federal health IT officials, is designed to increase innovation and competition by giving patients and their healthcare providers secure access to health information and new tools, allowing for more choice in care and treatment. It calls on the healthcare industry to adopt standardized application programming interfaces (APIs), which will help allow individuals to securely and easily access structured electronic health information (EHI) using smartphone applications, officials attested.

In the ONC proposed rule, a provision also exists requiring that patients can electronically access all of their digital health data (structured and/or unstructured) at no cost. What’s more, the rule implements the information blocking provisions of the 2016 Cures Act, which defined information blocking as interfering with, preventing, or materially discouraging access, exchange, or use of electronic health information.

The new ONC rule proposes seven exceptions to the definition of information blocking. As it outlines, there are four specific healthcare “actors” regulated by the information blocking provision: providers, certified health IT developers, HIEs (health information exchanges) and HINs (health information networks). The seven proposed exceptions include:

1. Preventing harm;
2. Promoting the privacy of EHI;
3. Promoting the security of EHI;
4. Recovering the costs reasonably incurred;
5. Responding to requests that are infeasible;
6. Licensing of interoperability elements on reasonable and non-discriminatory terms; and
Maintaining and improving health IT performance

ONC fact sheet on the seven exceptions (further details) Additionally teeth are provided for violations by ONC’s Office of Technology, noting that the first three actors listed—developers, HIEs and HINs—are subject to up to a $1 million fine per information blocking violation, if they are found to be bad actors. Providers are not subjected to a monetary fine, Posnack noted, adding that exceptions will be reviewed by ONC and the OIG (Office of Inspector General).

Some of the standards will be changed, ONC is calling for the removal of the CCDS (Common Clinical Data Set) definition and its references from the 2015 Edition and replacing it with the USCDI standard. “This will increase the minimum baseline of data classes that must be commonly available for interoperable exchange,”

CMS Rule Focuses on Patient Access

CMS’ rule, “Interoperability and Patient Access Proposed Rule,” while separate from ONC’s, is quite aligned with it in several ways—such as requiring FHIR for APIs. Building on the Blue Button 2.0 API that allows Medicare beneficiaries to electronically access their health data through an app, CMS is now proposing to require Medicare Advantage (MA) organizations, state Medicaid and CHIP fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and QHP (qualified health plan) issuers in FFEs (federally-facilitated exchanges) to implement, test, and monitor an openly-published FHIR-based APIs to make patient claims and other health information available to patients through third-party applications and developers.

CMS is also proposing to require MA organizations, Medicaid managed care plans, CHIP managed care entities, and QHP issuers in the FFEs to support the electronic exchange of data for transitions of care as patients move between these plan types. This data includes information about diagnoses, procedures, tests, and providers seen and provide insights into a beneficiary’s health and healthcare utilization.

In yet another push on health plans, CMS is proposing that payers in CMS programs be able to participate in a trusted exchange network that would allow them to join any health information network they choose and be able to participate in the nationwide exchange of data.  "We propose requiring MA organizations (including MA-PD plans), Medicaid managed care plans, CHIP managed care entities, and QHP issuers in the FFEs to participate in trust networks to improve interoperability," CMS said.

“We have proposed that by 2020, all health plans doing business in Medicare, Medicaid, and through the federal health insurance exchanges, allow their patients to obtain their data through an API. This will allow patients to be true partners in their healthcare,” said CMS Administrator Seema Verma

And in regard to information blocking, CMS said it would make public the names of clinicians and hospitals that submitted "no" to three attestation statements committing them to data sharing. “Making this information publicly available may motivate clinicians, hospitals, and CAHs to refrain from information blocking,” CMS said.

“We’re also putting an end to information blocking,” Verma boldly stated on the press call. “The days of holding patients’ data hostage are over. We propose to publicly identify hospitals, doctors, and others who engage in information blocking. Simply put, we’re exposing the bad actors who keep their patients from their data.”

These Orwellian tactics are not voluntary, and CMS intends to enforce this rule using 'shame' and negative publicity.  It also assumes that these measures improve the quality of care without any prior studies or documentation for this extension of interoperability.  (show me the references)



Massive Rule Drops at HIMSS19: CMS, ONC Propose New Regulations to Transform the Future of Interoperability and Patient Access | Healthcare Innovation: