INVITED COMMENTARY—Electronic Medical Records and Preserving Primary Care Physicians' Time FREE

We both hear strong complaints from primary care physicians (PCPs) about electronic medical records (EMRs) cutting their time efficiency. A long and detailed venting occurred 4 years ago when we were together at a social gathering and M.H.M. was bragging about his brother's (C.J.M.’s) involvement in the genesis of EMRs.^1- 2 Two general internists—both women—did not agree that such involvement was praiseworthy. “Think Oppenheimer and the atomic bomb,” one said wryly, “ the EMR steals sixty minutes a day from me!” The other had a 6-month-old baby and said, “He is sleeping by the time I get home,” and tears welled. There were positives. They loved its instant delivery of patient data. Computer order and prescription writing were probably okay. But note writing was a definite drag compared with paper, though they liked producing legible notes that were computer available. What vexed them the most was the EMR inbox. Compared with the paper version, it seemed to increase the number of work items, inflate the time to process each, and divert work previously done by office staff to them.

Murphy and colleagues³ provide the smoking gun for the internists' complaints of time theft. In this issue of Archives, these authors report that nearly half of one kind of inbox message was unimportant and 80% of the message text within these messages was irrelevant. In a previous study they described the spectrum of inbox messages—including study reports, confirmation of consult requests and the return of consult reports, refill requests, signature requests, and so on. Patient e-mail was not mentioned as part of this content. They also reported that processing these messages consumed on average a whopping 49 minutes of PCP time per day.⁴

To get a current estimate of the effect that EMRs have on health care providers' free time and the relative effect of different EMR functions, M.H.M. organized a pilot survey (exempted from human subject review by the University of Wisconsin and the National Institutes of Health human subjects offices) of 7 attending physicians and 2 residents from a nearby family practice clinic. Only health care providers who had experience with paper records and used their current EMR for at least 2 years were eligible. The survey was distributed on 1 day in November 2011 with no refusals. The questions and physician responses are given in the Table.

Seven respondents were woman and 2 were men. The survey results parallel the estimates the 2 general internists gave 4 years ago. No respondent reported that the EMR changed his or her average patient load (mean of 18 patients per day). The 9 PCPs reported a median of 60 min/d and a mean of 48 min/d of free time lost to the computer—numbers curiously similar to those in the study by Murphy et al.⁴ Most respondents included written critical comments. Some examples include the following:

Electronic medical record access to patient data was faster than with the paper system (no surprise). The same was true for prescription writing. Physicians had mixed opinions about the effect of EMRs on the time to write orders and notes. Their opinions were more consistently negative about the EMR's effect on message management—such as provided by the EMR inbox.

The 95% confidence intervals suggest that EMR systems consume enough extra PCP time to eat significantly into their free time, though prescription writing saves time. We suspect that PCPs in at least some other venues have the same problem because we hear these complaints from many quarters and almost all published studies report the same negative effect of EMRs on physician time.⁶ One meticulous study reported no per-patient PCP time penalty based on a time motion study limited to clinic hours but reported a marked increase in total documentation time and a large overflow of documentation work to after-clinic hours based on physician surveys.⁷ Our sample size does not let us identify the specific EMR function that explains this loss, but note writing and EMR inbox tending are our prime suspects.

Primary care physicians are already an endangered species. Fewer than 2% of medical students now plan to enter general internal medicine.⁸ Institutions and policy makers should act to reduce the EMR time penalties on PCPs to increase the field's attractiveness. Some suggestions include the following: eliminate mandates for direct physician note entry; provide alternatives, such as dictation, document scanning,⁹ and/or scribes¹⁰ for EMR note capture; make the EMR inbox smarter about when, and how, to present messages to PCPs; and train clinic support personnel to manage the same proportion of inbox messages they handled with paper systems and to think whether a message is important or just noise before pushing the so-convenient “Forward-to-PCP” button. If changes are not made to reduce or eliminate these time penalties on PCPs, there will be no PCPs left to penalize.