Electronic Medical Records and Upper Extremity Symptoms: Pain With the Gain? FREE

Upper extremity musculoskeletal symptoms (UEMSs) lead workplace injuries nationwide,¹ incur the longest absence among service sector workplace injuries (28 days median, exceeding fractures and amputations),^2- 3 and can foster multiple spells of lost work time, so that work loss per episode underestimates the impact of UEMSs (by approximately 32% at 5 years).⁴ Numerous studies link computer use to UEMSs.^3,5- 8 However, to our knowledge, whether such symptoms affect physicians practicing at facilities using integrated electronic medical records (EMRs) has not been assessed. We evaluated the prevalence of UEMSs attributed to computer workstation use in 2 medical facilities with different EMR systems.

A cross-sectional survey assessed work-related computer use and symptoms in primary care clinics at 2 academically affiliated centers in San Diego, California, with distinct EMRs. The US Department of Veterans Affairs (VA) San Diego Healthcare System group converted to the VA CPRS/VISTA EMR⁹ 8 years prior to the survey, and the University of California, San Diego (UCSD) Medical group practice adopted the EpicCare EMR 1 year prior to the survey. Both systems require extensive physician keyboarding and/or mouse clicks. Fifty-nine physicians (87% of those targeted) completed the 20-minute survey. A visual analog scale (VAS) assessed UEMSs attributed to computer use (scale, 0-100), validated against the QuickDash measure of UEMSs, not specific to computer use.¹⁰ Demographic variables reported to predict UEMSs (age, sex, and body mass index [BMI] components [weight and height])¹¹ and computer use (EMR-using clinical sessions per week and hours per week of computer use) were elicited, as were institution, years of computer use, and years of EMR use. Bivariable relations of dichotomized VAS scores to categorical variables were assessed by χ² analysis. Multivariable regression evaluated prediction of UEMSs (continuous VAS) by computer variables, adjusted for UEM predictors of age, sex, and BMI.¹¹ A 2-sided α level of .05 was used to indicate statistical significance. This project was approved by the UCSD Human Research Protection Program & San Diego VA Research Compliance office.

Moderate or severe reported UEMSs attributed to computer use were common: 48% (29 of 59) reported VAS scores of 25 or higher. Mean (SD) VAS was 29 (25) (range, 0-100). The correlation of VAS to QuickDASH was 0.61 (P < .001), supporting convergent and construct validity for VAS.

Electronic medical record–using clinic sessions per week (defined as half-days in clinic) ranged from 1 to 9. A total of 18 clinicians (30%) had 5 or fewer clinic sessions per week, 8 of whom (44%) worked full time.

On bivariable analyses, higher VAS scores related to more EMR-using clinic sessions per week (P = .02) and more computer hours per week (P = .04).Other variables individually, including sex, age, and BMI, as well as institution and years of EMR use and employment, bore no significant relation to dichotomized VAS in this sample, suggesting a more powerful relationship of EMR-using clinic sessions or computer hours than other potential UEMS predictors.

The prediction of UEMSs by computer hours per week and particularly by EMR-using clinic sessions per week was preserved or strengthened in analysis adjusted for age, sex, and BMI (computer hours per week: β = 13.9, SE = 6.48 [P = .04]; EMR-using clinic sessions per week: β = 4.30, SE = 1.56 [P = .008]) (Figure).

High prevalence of UEMSs attributed to EMR use was reported among physicians at 2 facilities with integrated EMRs. Economic and personal losses arise irrespective of employment type, but “costs” from UEMS disability are arguably amplified for physicians by the investment years of education required to practice medicine.

Our findings parallel those for nonphysician computer users: indeed, UEMSs are an emerging concern in professional occupations.¹² More than half of computer users reported musculoskeletal symptoms during the first year after starting a job.⁵ One review found that the most consistent predictor was hours keying.³ However, mouse use may more strongly predict UEMS development.^6,13 The apparently stronger association to UEMSs of EMR-using clinic sessions per week (vs computer hours per week) might be speculated to reflect relatively high mousing requirements of EMR systems during patient-relevant activities and/or reduced discretionary (nonclinic) computer use among those with UEMSs. Future studies may evaluate whether modifications of EMR systems to minimize mouse use reduce the risk of clinic session–associated UEMSs.

The generalizability of findings must await replication in other settings; however, findings were consistent across 2 physician groups with distinct EMRs. Our findings may underreflect the true impact, since prior injury and work modification were not captured and reduced clinic sessions engendered by UEMSs may produce strong bias to the null. (We are aware that at least 4 physicians received surgery, had clinic reductions, and/or used specialized voice/foot pedal–operated workstations because of UEMSs.)

Ergonomics have received little attention in discussions of EMR implementation. (“Transitioning to an EMR System Without Pain”¹⁴ refers to protection against figurative rather than literal discomfort.) This is perhaps ironic because health care institutions are in the business of understanding risk factors for, and promoting prophylaxis against, illness and injury.

To our knowledge, ours is the first assessment of this issue for physicians. If high rates of UEMSs among physicians using EMRs are replicated and extend to other settings, the impact of physician symptoms and disability on health-related quality of life, work time lost, patient care continuity, and costs for health care institutions warrant assessment. Proactive attention to ergonomics may be merited, as integrated EMRs are increasingly adopted at health care institutions.

These findings are timely, given the current efforts, extending to the presidential level, to hasten nationalized implementation of EMRs.^15- 16

Correspondence: Dr Golomb, Department of Medicine, University of California, San Diego, 9500 Gilman Dr, MC 0995, La Jolla, CA 92093-0995 (bgolomb@ucsd.edu).

Author Contributions:Study concept and design: Yaghmai and Ramsdell. Acquisition of data: Yaghmai and Ramsdell. Analysis and interpretation of data: Golomb, Yaghmai, Renvall, and Ramsdell. Drafting of the manuscript: Golomb and Renvall. Critical revision of the manuscript for important intellectual content: Yaghmai, Ramsdell. Statistical analysis: Golomb, Yaghmai, and Renvall. Administrative, technical, and material support: Golomb and Ramsdell. Study supervision: Ramsdell.

Financial Disclosure: None reported.

Previous Presentations: A poster of this study was presented at the Society of General Internal Medicine annual meeting, April 25-28, 2007; Toronto, Ontario, Canada.

Additional Contributions: Sabrina Koperski provided excellent editorial and administrative assistance. We thank the physicians who kindly took the time to complete the survey.