EHRs or social interactions: Can’t we have both?

Craig-JosephEveryone knows that every doctor hates their electronic health record (EHR). Have I gone a bit too far with this proposition? Perhaps. How about this: many doctors dislike many aspects of the EHR software that they use every day. That’s probably more accurate. While some physicians might say that the practice of medicine was easier/better/more enjoyable back in the paper era, I’m not sure that there are any who would give up the clear benefits that healthcare IT has brought us.  

Sure, doctors almost universally loath the plethora of mouse clicks and the documentation requirements that may – or may not – actually be required. But we would find it difficult to live without the virtually unlimited access to patient data we have at our fingertips now. I remember the hours of wasted time I spent searching through the hospital’s medical records department to find previous admission data; now it just appears. That’s a huge win. 

A recent article in JAMA Network Open shed some light on an aspect of medicine that has indeed been negatively affected by the EHR: healthcare team social interactions. Doctors and nurses don’t talk with one another like they did before we had this technology, and this change in the way we communicate has led to increased burnout and decreased well-being.  

In the pre-EHR era (aka back in the stone age with paper medical charts), if we had a question for a fellow physician, we had no other option but to call them on the phone. (In the past, we used something called a phone to talk with other humans. Imagine, how bizarre!) It was the same procedure if a nurse or other care team member needed to clarify an order or communicate an important piece of information: call the person. Did this mean that we were interrupted from time to time with issues of varying significance? Yes, yes it did. I should point out that the interruptions were much less frequent than the never-ending messages (personal texts, work texts, EHR messages from other clinicians, EHR messages from patients, etc.) that we deal with today. 

According to the JAMA researchers, the electronic health record is great at helping clinicians complete simple, uncomplicated tasks. However, “[t]he EHR was found to negatively impact team function 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. In addition, [doctors] expressed that physician EHR-related distress affects interactions within the team, eroding team well-being.” 

I am fascinated with the increase in conflicts that were identified in this study. I appreciate that as doctors and nurses spend more time in the EHR, they will naturally start communicating back-and-forth, utilizing the tools that were created for them. But I wouldn’t have predicted an increase in argumentative language that many have observed. An interviewed physician commented that “… when there's disagreement, not infrequently people take that easy way and just put a note in and explain like, oh, what they think the other party did wrong… they don't actually talk to the other party to resolve the issue.” Indeed, it is the path of least resistance to quarrel with words in the computer instead of verbally mano a mano. 

So, what can be done to remedy the situation? One mitigating factor that is referenced in the article is to establish norms around EHR communication. I would call this an EHR etiquette document. As with any discussion of etiquette, we must always speak in generalities because no two situations will be identical. Hence, it would be helpful to set out broad expectations about when clinicians should communicate in person or over the phone. I have found that these documents are better received when they have fewer words of guidance and more examples (e.g., “New onset or recurrence of cancer identified by a radiologist necessitates an immediate phone call to the responsible physician” and “Do not routinely respond with a message of thanks as it likely disturbs the workflow of the receiver.”) 

Further, a healthcare system should attempt to build-in opportunities for both planned and chance meetings of their clinical staff. This can involve something as simple as encouraging in-person attendance at Grand Rounds and other staff meetings (hint: bagels and coffee – the good kinds! – at early morning conferences do wonders, even for attendings.) Additionally, hospital executives should follow the standard human-centered design playbook by making it easy to do the right thing: consider coordinating OR and clinic schedules so that colleagues have more chances for short impromptu meetings to discuss mutual patients face-to-face.  

While technology may pull us apart, we need not let it. Steve Jobs was famously obsessed with the design of the building that was going to hold Pixar’s burgeoning staff. One of his demands was an office layout that encouraged unplanned meetings. In fact, he proposed that there would only be one set of bathrooms in the office’s central atrium, hence forcing people to accidentally run into one another. While he was ultimately talked down from that idea, Pixar (and Apple after it) benefited from this concept. Hospitals and healthcare systems can learn from these companies and free thinkers to allow their staff the necessary social interactions that we all crave... while at the same time, leveraging the technology we physicians and our patients need.  

Topics: EHR, featured, Healthcare

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