Is the electronic health record causing burn out in primary care doctors?

Nigel Masters is a retired General Medical Practitioner and a GP notes summariser.

Primary care is undergoing a seismic restructuring such that the nature of the job has changed beyond recognition. In part this has been caused by the advance of the electronic health record (EHR) which has tethered the primary care doctor to the computer screen.

In most surgeries one screen for each consultation room is not enough and two are becoming normal. Instead of seeing or talking to patients we are navigating a constructed health record environment which can be rigid, slow and impersonal. Compared to colleagues in hospital specialities we are spending more and more time facing this record rather than our patients.^1,2

Let us take an example of what this tethering means. In a four doctor practice two may stay at home all week dealing with computer / patient administrative work, while two at the surgery see or talk to real patients. The following week the roles are reversed. This work pattern is becoming primary care’s version of the Deliveroo dark kitchens.³ This disengagement from the physical practice is made possible by the EHR in the cloud, but causes the primary care team to dispense with regular in person meetings. But in the practice incidental encounters can provide positive support and care for everyone at the primary care coalface.

The EHR demands full concentration to read and digest the electronic workflows and take appropriate action. As a result family doctors have been morphed into hospital physicians with generalist, diabetic, cardiac and respiratory outpatient clinics with information overload to micro-manage. Patients have become a virtual administrative task rather than people or families as their bodies are imaged, tested and slotted (“sliced and diced”) into technical procedure clinics all often provided by different poorly co-ordinated NHS services. There are no pictures of patients and minimal personal details easily visible on the electronic record adding to the sense of alienation from the patient when ordering tests or responding to laboratory test results.

Vast numbers of laboratory results are delivered daily to the practice which require action and comment. Artificial intelligence cannot easily deal with the subtle interpretation needed, and deal with paradoxical thinking. For example, some patients can have a laboratory result that is normal which could be abnormal in its proper context, and most abnormal tests are often totally satisfactory.

And then there is that rare abnormal result that surprises the patient and clinician. Such nuanced reflection also applies to incoming diagnostic imaging reports which need careful assessment. This is what information overload looks like, and it explains why many GPs wish to retire early or reduce their working week. The EHR works incessantly with machine like efficiency presenting yet more information work for the harried physicians.

The EHR was initially viewed by family doctors as a benign useful tool for managing the increasing number of repeat prescriptions for the growing elderly population. Subtle changes in preventative medicine meant that Big Pharma could now add preventative drugs to the list of treatment medications. The drug delivery software would provide drug information and warnings of drug allergy but of course could not predict the unpredictable nature of adverse effects of such industrial polypharmacy.

So, who could screen the computer for everyone’s risk other than the primary prescriber or a dedicated pharmacist? This is a complex and difficult task with a huge number of drugs with potential interactions and indications. Although Deprescribing is a fashionable policy it becomes impossible without continuity and face to face time to explore the shared health agenda between patient and prescriber.

As a retired general practitioner observing the changes in practice, I conclude that the EHR has changed family medical practice for the worse by reducing patient contact and increasing workload. This data dragon does breathe fire and it will rapidly burn out general practitioners if it fails to be reigned in.

References

1. Overhage J. Marc. Physician Time spent using Electronic Health Records during outpatient encounters. https://www.acpjournals.org/doi/10.7326/m18-3684#

2. Rotenstein L. Holmgren J, Downing L. et al. Differences in Total and After-hours Electronic Health Record Time across Ambulatory Specialities. JAMA intern Med https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2777845

3.https://www.theguardian.com/global-development/2021/apr/25/deliveroo-tech-delivery-restaurant-service-dark-kitchens

 

Featured photo by Shahadat Rahman on Unsplash