Last month, 15,000 nurses went on strike in Minnesota in the largest strike by private sector nurses in US history. They were protesting understaffing and overwork at a time when provider burnout has reached epidemic proportions – around 63% of doctors and 80% of nurses are now reporting symptoms of burnout. Meanwhile, health care continues to struggle with overwhelming cost pressures. We still spend more money for worse results than any other developed country. As a surgical resident, I’ve heard too many structural explanations for cost and burnout issues that overlook one specific, fixable culprit: our electronic medical records (EMRs) are still hopelessly broken.
In 2022, software is suffocating American medicine.
The HITECH Act of 2009 launched the modern era of EMR with federal incentives for EMR use. Unfortunately, the legislation has also favored established businesses over smaller competitors due to its many requirements and short timelines. Today, many top hospitals use EMRs from one of two vendors, Epic Systems or Cerner Corporation (now part of Oracle). Epic alone has medical records on 250 million people, while Cerner won a $16 billion contract to submit its EMR to the Veterans Health Administration. These companies had combined revenue of nearly $10 billion in 2021, with both seeing double-digit year-over-year growth.
Despite bloated funding, I haven’t experienced any significant upgrades to Epic or Cerner EMR systems in the last 8 years. I find the interfaces comically inelegant. I often watch screens with more than 30 tabs, and when I click on one, the system stutters and delays before displaying a result. This flawed user experience slows providers down significantly. In a study of a North Carolina orthopedic clinic, adopting Epic’s EMR increased physician documentation time by 230% and increased labor costs per visit by 25%. For family physicians, it’s worse: many spend 6 hours a day on the EMR. Nurses often spend more time tracking records in the EMR than on any other task. Multiply that by the entire healthcare system and the idea that an extra MRI here and there is causing our cost crisis seems laughable. Every day the expensive work of doctors and nurses is wasted on unnecessary clicks and scrolls.
Compounding the day-to-day slowdown, time away from patients and increased staff workloads lead to the combination of exhaustion, cynicism and reduced efficiency known as burnout. professional. More than 8,000 nurses surveyed last year gave their EMR an average “F” rating for usability, and usability was directly correlated with symptoms of burnout. Among physicians who reported using an EMR, 70% reported EMR-related stress, with “high” use doubling the risk of burnout. Why is burnout important? Because burnout breeds more burnout, along with rising costs and deteriorating care. Conservative estimates suggest that reduced clinical hours and physician turnover due to burnout cost us $4.6 billion a year. Quality of care deteriorates when nurses report symptoms of burnout, regardless of practice environment. Burned-out providers sometimes leave the workforce altogether, worsening staff-to-patient ratios and inducing further burnout in a vicious cycle. Largely because some clumsy and extremely slow software consumes a lot of our time.
The ineffectiveness of current EMRs is sometimes attributed to poor training. The Veterans Health Administration delayed implementation of Cerner’s EMR because providers were proving difficult to train. It’s wrong. Well-designed software for data entry and retrieval should be intuitive enough to require no specific training. No one needs training to figure out how to filter through millions of Airbnb listings for homes, Kayak flights, or Yelp for local businesses. You can find what you want, check availability, and even submit a review, all in seconds. The information I need as a doctor is not more complicated. I need to see a targeted list of patients and then a neat grid of their numerical information. I have to cycle through text entries and scroll through images, then start typing at a blinking cursor. That’s it. It should happen instantly, without me having to think about it.
Instead, it takes 3 minutes to order an x-ray, 60 seconds to extract the image, 5 minutes to find background facts, and 90 seconds to load an MRI. After that, there are 2 minutes left to see the patient. What is needed is not “training”, but rather design thinking and approaching the problem from first principles. What do doctors need? What do nurses need? How would they like to see the information presented? How might they want to enter information?
Take the example of another well-known software company, Google. Google has tested what users want, and has come back again and again to a one-word answer: speed. As little as 400 milliseconds of delay in search speed leads to lower search volume, while four out of five users click when a video freezes while loading. For Google, “speed is not only a characteristic, it is the functionality.” Google engineers work with a fixed “budget” for the total time (say 1 second) that it’s acceptable to require users to complete a single step. EMR creators should take the same approach: measure the duration of each action and the speed Simplify the interface Store data more efficiently Anyway.
To fix EMRs, one suggestion has been to put money on the line by fining hospitals for the burden of EMRs in the same way that fines are imposed for infections or pressure sores. It would be a welcome change, but embracing health policy that undermines vested interests is incredibly difficult, and it cannot be the only strategy. While advocating for legislation, we must also build the EMR of the future. We need an explosion of the kinds of quick and easy tools that technology innovators are now adept at creating. To achieve this, professional societies and hospital groups should fund some sort of EMR X award to drive innovation. Projects should be categorized by speed, ease of use, and interoperability – all of which today’s EMR companies have failed over the past decade. Simply focusing on politics will keep the real solution, a better product, in the realm of abstraction. Instead, build it first and show doctors, nurses, and patients what’s possible.
Dane Brodke, MD, MPH, is the Chief Resident Physician for Orthopedic Surgery at the University of California, Los Angeles.
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