Feature | Death by a Thousand Clicks

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I have been in clinical practice for 3.5 years since completing my interventional cardiology fellowship in 2015. Thus far, I have remained in the same job at a medical school in Tennessee, employed as faculty and mostly working at an outlying hospital as a community cardiologist. In those 3.5 years of practice, I had to learn four different electronic medical records (EMRs).

Let me repeat that again: I have no changed jobs. In the past 3.5 years, I have not changed practices and I have had to learn four separate EMR systems.

Physician burnout is real.

The control that the EMR has on our lives as physicians is certainly contributing to this factor. I enjoyed having to reduce my clinical capacity for the additional training that I attended mostly on nights and weekend to limit the interruption of clinical care. Just one more click.

Since I work for Vanderbilt, our clinic and inpatient software was upgraded to EPIC about a year ago from an internal proprietary software, which worked well but was running out of support services and terribly needed a complete overhaul for the newer operating systems. The hospital decided to purchase EPIC and implemented their own version of the system.

Since I also cover an outside hospital for most of my time, I learned another EMR (Meditech) when I first started. As time progressed, the hospital decided to purchase Cerner for another rollout and transition of their EMR. In my Cerner rollout, I cannot order anything on a patient until I make a patient status order (bed request and inpatient certification). Just one more click.

Rolling out a new EMR can be stressful on the hospital system, patient and physician. In my brief experience, it takes three to four months to truly adjust through this stressful process. My undergraduate degree is in industrial and systems engineering. Process improvement, throughput and efficiency are things I learned in college, as well as how to apply these principles to different fields of work.

It has been more helpful than I ever imagined with the reengineering of the patient-doctor interaction, and EMR launch at the heart of this debate. I thought this would make me more resilient than most. To make things easier, we have order sets with plenty of predetermined hard stops that require extra engagement and clicks to proceed and over-ride alerts. Just one more click.

When harnessed appropriately, technology can be incredibly fluid and improve your day- to-day activity. I can do a majority of my banking without stepping foot into a bank, make dinner reservations without calling the restaurant directly and navigate to new locations using a map on my cell phone.

However, I cannot for the life of me understand why our EMR systems are so slow to adopt this integrated and adaptive technology available at our fingertips. Instead we toil away as someone reminds us that it is just "one more click" to place that order, mail the note to a referring colleague or bill for the level of service.

While I agree it is "just one click," those clicks quickly add up and multiple when you see over 20 patients a day. My throughput and efficiency is now stifled. Just one more click.

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I watched my colleagues at different locations struggle one day as I took it upon myself to evaluate if there was anything I could do to improve my ability to see patients. There was the prototypical "older" physician who remembers the "good old days" when paper charts ruled and they could see 30 – 40 patients in a full day of clinic with no problem. Now these doctors barely see 20 patients a day, and they are spending plenty of time at home on the computer charting, ordering, documenting and billing well into the night.

There is the middle age physician who prides herself on being tech savvy. They have the latest smart phone with app integration to their smart watch and are tweeting on the regular to their colleagues. They are still unable to create a workaround to improve their efficiency and looking to exit clinical medicine at a rapid pace.

Finally, there are the young doctors, who trained in the generation of EMRs and do not know any better. They have already submitted defeat without even understanding how it used to be, because this is all they know and agree unknowingly to the EMR trainer when they say, "Just one more click."

Unfortunately, physician burnout is real with no real solution in sight at this point. I just cannot wait for the next EMR rollout. When my parents tell me to be careful when working around the house on home improvement projects or working on cars, I jokingly tell them not to worry because my hands are insured.

The biggest risk to my hands is probably carpal tunnel syndrome with all these clicks. I have successfully transitioned from a cardiologist to a clickologist. Death by one thousand clicks.

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This article was authored by Amit Nilam Keswani, MD, FACC, assistant professor of medicine at Vanderbilt University Medical Center in Nashville, TN.

Keywords: Clinician Well-Being; Work Life Balance; Burnout;