Clinician EHR Demands Detract from Patient-Provider Relationship

Family practice clinicians spend more time documenting on the EHR than they do directly with their patients, underscoring a lapse in the patient-provider relationship, shows a study published in Family Medicine.

EHRs have long received mixed reviews because of their usability and patient care challenges. Although the EHR has the potential to improve care, clinical decisions, and treatment efficiency, it can also serve as a barrier to effective patient-provider relationships.

“Heavy EHR use in primary care is associated with increased time pressure, increased physician stress, and decreased job satisfaction,” the researchers explained.

Separate studies have indicated that clinicians who spend more time looking at their computer screens than at the patient yield lower patient satisfaction scores. Most providers have admitted that patient-provider communication is the most important factor in a healthcare interaction.

But EHRs currently pose too many documentation and reporting demands to allow providers to truly fulfill patient-centered care goals. An assessment of nearly 1,000 family practice appointments across Texas revealed that providers spend more time charting than they do communicating directly with their patients.

The research team looked at total visit time, pre-visit chart time, face-to-face time, out-of-hours EHR work, and total EHR work time.

Average length of visit totaled to about 36 minutes and did not include resident precepting time. Three of those minutes were spent on pre-visit EHR coding, two minutes of EHR use during the visit, 7.5 minutes of non-face time during the visit, and about seven minutes of EHR work outside of each office visit.

Sixteen and a half minutes were spent on direct patient-provider communication, a minority of the office visit, the researchers noted.

There were some limitations to the study, the researchers conceded. Physicians do other work aside from that related to the EHR and direct patient care, but that work was not included in their study, for example.

“We did not attempt to capture physician work devoted to other patients not seen that day,” the researchers explained. “A recent estimate was that 13 percent of a family physician’s time is spent coordinating care among different physicians and other health care providers, such as physical therapists and home health agencies. Other studies found that 39 to 45 percent of a family physician’s time is spent out of the exam room, and total work time not directly involved with a patient clinic visit consumed between 20 and 50 percent of a primary care physician’s time that is not compensated.”

The researchers also noted that time spent on the EHR and the clinical encounter differed between patient demographics. Notably, patients with many comorbidities saw longer visit times.

Additionally, patient visits with both a resident and an attending made a difference in visit length.

“An important independent predictor of total visit time and non-face time was whether a resident checked out the patient with an attending, even though precepting time was removed from the reported times,” the researchers said. “This could reflect that we should have attributed more time to precepting, that patient visits that were checked out to attendings were more complex than average and required more thought and time, or that the attending changed some of the residents’ assessments and plans.”

These results are similar to other studies investigating clinician EHR use and patient face-time. A 2016 study from the American Medical Association (AMA) found that for every hour clinicians spend with a patient, they spend two hours on EHR documentation. Providers spend 27 percent of their work time on direct patient interactions, and about 49 percent on EHR documentation.

While in an ideal world providers would see less rigorous health IT demands, that is not the reality. Healthcare professionals instead need to reconcile EHR use with the patient interaction. Seamlessly integrating the EHR into the care encounter may help providers accomplish their documentation work will maintaining a positive patient-provider relationship.

Many medical professionals recommend addressing EHR use during the patient encounter. Providers should explain how and why they use the EHR, and even share what the screen looks like with their patients. Although this does not reduce provider screen time, it may enhance patient relationships by letting patients in on the technology.

Clinicians also recommend their colleagues dedicate a certain amount of time to technology-free communication with their patients at the start of a care encounter. This helps establish a connection and eases the transition when the provider does need to use the EHR.

The EHR is likely a mainstay in medical care. As providers continue to integrate it into their clinical practices, they must not get caught up exclusively in the usability issues with the EHR. Providers must also focus on making the EHR a workable tool for the patient-provider relationship.