How Electronic Patient Records Can Slow Doctor Productivity

Electronic health records are sweeping through the medical field, but some doctors report a disturbing side effect. Instead of becoming more efficient, some practices are becoming less so. Robert Huckman's research explains why.
by Dina Gerdeman

Digital record-keeping is slowly but inevitably replacing paper records everywhere from the pilot's cockpit to the registry of motor vehicles. But if implemented without proper consideration of how work gets done, the results can make productivity worse, not better.

That's one of the lessons from a new study of physician offices transitioning to electronic health records (EHRs) used in managing patient care. In general, larger offices in the study that employed EHRs recorded productivity gains, but certain types of smaller practices lost productivity.

“You should be aware of the subtle way that you might be changing existing communication patterns among staff”

One likely reason for the decline: processing electronic records can change the way staff members communicate with one another, clogging up what had been a well-oiled machine.

"When you adopt EHRs, you should be aware of the subtle way that you might be changing existing communication patterns among staff," says Harvard Business School Professor Robert S. Huckman, who recently cowrote The Impact of Electronic Health Record Use on Physician Productivity with University of Michigan Assistant Professor Julia Adler-Milstein.

The Digital Doctor

In recent years, many physicians have put away pen-and-paper and taken up the keyboard or tablet to maintain patient health records. One motivation was the 2009 Health Information Technology for Economic and Clinical Health Act, which allows for $27 billion in incentives for health care providers who demonstrate "meaningful use" of digital records. The legislation came from the belief that EHRs used in certain ways—such as medication order entry that would alert a clinician about drug-to-drug interactions—could ultimately make patient care safer, more effective, and more efficient.

Entering patient data into a computer can cost doctors valuable patient time.
Photo: iStockPhoto

However, several studies indicated that when physicians spent extra time entering data themselves, it cut down time spent with patients and stretched out their workday—hardly what was intended. So many practices realized that it made sense for clinicians—mostly physicians, but also nurse practitioners and physician assistants—to delegate some EHR-related tasks to clinical support staff, including registered nurses, licensed practical nurses, and medical assistants.

Huckman, the Albert J. Weatherhead III Professor of Business Administration and faculty cochair of the HBS Healthcare Initiative, set out with Adler-Milstein to discover what happens to productivity when doctors delegated their data entry. Did it free up their time and increase office productivity? After all, delegating these tasks can cost physicians extra coordination time, plus doctors still need to review and authorize orders in an EHR before they are submitted.

The study examined the relationship between physician productivity, the degree of digital health records use, and the delegation of EHR tasks. And it explored whether these relationships differed by practice size.

Huckman and Adler-Milstein researched monthly EHR task-log data between 2006 and 2009 from more than 40 primary care and internal medicine practices throughout the United States. Practices had a range of one to 14 clinicians, with an average of four. All the practices had used digital records for a minimum of six months, with an average of 17 months. All practices in the sample employed at least one clinical support staff member, allowing clinicians to delegate EHR tasks.

Productivity Increases

Overall, the findings suggest that increased use of electronic health records and greater delegation were independently associated with higher levels of production. That is, practices that increased the number of tasks performed using EHR saw an increase in clinician productivity, and practices that increased the extent to which EHR tasks were performed by clinical support staff, as opposed to clinicians, saw an independent increase in productivity as well.

“We rely on physicians' penmanship in making some pretty important decisions”

But there was one important caveat: Increasing both EHR use and delegation gave large practices with four or more clinicians a productivity boost, while the same dual increase led to a productivity loss among small practices with high levels of delegation.

Bigger practices may benefit more from EHRs by allowing a larger group to communicate more effectively, Huckman hypothesizes. In smaller practices, where informal but highly effective relationships may exist, introducing an EHR system might generate formal processes that, at a certain level, become counterproductive.

"In large practices, where staff might be less likely to interact face to face, putting such a system in place might serve to make communication richer and bring people closer. But in a small practice, where face-to-face contact is more common and effective, introducing an EHR might make communication more sterile, leading to either a smaller gain—or even decline—in productivity."

There may be other explanations for the differences among practice sizes. For example, large practices may devote more time to training and workflow protocols that improve productivity.

The Wrong Lesson

The research results should not dissuade practices, large or small, from using EHRs, Huckman says. Electronic records have many benefits. In particular, patient data can be shared relatively easily between providers within a given practice, and some of the errors that result from illegible penmanship might be avoided.

"We rely on physicians' penmanship in making some pretty important decisions," Huckman says. "That has been a challenge at times. We could still get it wrong with an electronic health record, but the chances are lower."

And mistakes can be detected much more quickly. If a prescribing physician puts an extra zero on the end of a dosing order that puts it out of the normal range, an EHR system may instantly detect the error. With hand-written prescriptions, the error could easily make it all the way to the pharmacist, who would check on it with the physician. "That requires more time and resources to get to the right answer," Huckman says.

Though interoperability—the ability to transfer information across EHR systems—remains a long-run goal that most systems are still working to achieve, Huckman believes electronic records can still help reduce expensive redundant care.

"If a physician can go into an electronic record and find out if her patient has already had a lab test or X-ray in the recent past, and can access the results of that study, she may be less inclined to repeat it," he says. "This reduction in duplication can lead to lower costs without harming quality."

Productivity losses are not inevitable, and not every small practice will experience a detrimental effect. Rather, Huckman says small practices should simply be mindful of the potential for EHRs to interfere with work coordination and they should pay close attention to how they might affect existing communication within the office to avoid productivity losses.

For example, in a small practice without an EHR, the staff might be able to engage in regular, face-to-face meetings about challenging cases. Once an EHR is adopted, however, some might perceive such meetings to be less critical, as the information shared at those times could now be exchanged via summary reports from the EHR system.

"But it is possible that the exchange of information in those meetings is not replicated by even the most detailed summary report coming out of an EHR," Huckman says. "My guess is that the size of many larger organizations allows for fewer natural opportunities for this regular person-to-person contact. So when an EHR is introduced and allows for information exchange through summary reports, it's a great innovation because it allows them to share information they were not routinely sharing before."

Lessons For Business

Aside from the implications for physicians, the research should also be interesting to any business that adopts new information technology as a way of categorizing and accessing information in an attempt to streamline a process that already exists.

Adopting these systems can have significant implications for how individuals in firms interact with one another, and that has to be accounted for when analyzing productivity implications from increased information technology.

"We often look at systems on the basis of their technical capability, the fact that they can store this many records or process that many requests in this period of time. But when we ask how that technology can improve productivity, we have to consider that the true capability of the system depends on the context in which it is adopted."

About the Author

Dina Gerdeman is a senior writer for Harvard Business School Working Knowledge

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    • Sawad thotathil
    • VP, NEIS
    Interesting article. I believe there needs to be careful management of delegating task and communication
    • Kathryn Roy
    • Managing Partner, Precision Thinking
    EHR might take a lesson from the introduction of CRM for salesforces. Initially, the automation was geared to giving overseers more visibility into what was going on and relaying context when someone new took over an account. Large companies customized CRM to make front-line people more productive which increased their efficiency and ability to make quota. Vendors started building those capabilities into the systems, which made them available to smaller companies. Hopefully, the same will happen with EHR. It may be worth investigating whether it already is happening.
    • Tiny Montgomery
    • Hopeless, Dis
    There is nothing like being in a doctor's office and having a nurse take information down on an iPad, very slowly, and hold up his/her hand to shush you when you try to explain why you are there. I don't know any doctors who like electronic clinical records. This was Uncle Sam's idea, not the doctors'. They are less secure, less intuitive, and less useful than papyri would be. The focus is on the computer, and the endless piles of regulations for what must and must not be entered, rather than on the patient and treatment. This is another Ginormous Government boondoggle; the real objective is to gather enormous amounts of information about individuals for sale or use by government insiders. Do I believe that all the HIPAA regulations in the universe will actually maintain the confidentiality of patient information? Not a chance, because the federal government plans to use them, and that is the end of any chance of confidentiality. I
    t's all of a piece with NSA surveillance -- "all of your information are belong to me now."
    • Paul Lepley
    • Retired, MBA '71
    I'm glad I get my healthcare with an HMO that has used EHR for many years! The pluses are overwhelming (virtually no screw-ups between doctors). For two years I tried a PPO, and I'm so happy to be back with the HMO. My wife and sister-in-law insist on carrying around all their records in order to coordinate care among doctors. Although they think they can select better doctors, I haven't seen much improvement among the doctors EHR coordination -- too many different systems. Perhaps in another 5 years the different systems will "really talk" to one another.
    • Kapil Kumar Sopory
    • Company Secretary, SMEC(India) Private Limited
    EHR is a handy and useful tool as it can be easily stored and referred to in future, need arising. Maintaining manual records is more clumsy and costlly as it needs more staff and much more storage space. It is also time consuming to retrieve the manual records.
    Hence EHR is ideal and in fact essential for large health service providers. For very small outlets, manual systems may work.
    Medicine shops also have started using laptops in a big way to store information of medicines so that no time is lost to trace out any item as also to know whether or not it is in stock.
    • William Laurence
    • Family Physician
    It would be interesting to see how much time could be regained if we could do away with mandates from Accreditation Organizations that just take up time and clutter the medical record, but don't improve care. Such items as religious and cultural barriers to care (I'll worry about that on the rare instances it occurs), pain scales (most times irrelevant and inaccurate), medication reconciliation on everybody (Some of my patients bring in their own list of meds which is cleaner and less confusing than the list that my EMR produces), etc. Another impact of the huge amount of mandated items on the EMRs is that when a patient has to pay for a copy of their record, it now is 4 to5 times longer than the prior paper note medical record. Do away with the mandated items, allow me as a professional to determine what is relevant to be charted, and we will all save time and clutter.
    • Suzanne Gordon
    • retired CIO, SAS
    If you have ever taken someone to an emergency room you will find that the nurses spend more time entering everything that happens into the computer than they do working with the patient. Something is very wrong.
    • Asha
    • Owner/Founder, HD67space, Gaming
    Common sense dictates that an optimal point exists, different in each interaction and play of x and y, defined in it's own unique creative f(x,y), where x and y represent humans and computers; and some wise ancients have advised that it is better to make our functions a little less efficient and a lot more communal, authentic and fun. This leads to a long-term sustainable, secure and peaceful environment. Without peace of mind first, there is no peace possible in the world.
    • Pia Koch
    • Business Anthropologist, Registered Nurse, (relevant)
    Quite a few years ago I experienced working with bed-side electronic journals/recording on a neuro-surgical unit. Lots of observations etc.
    Bed-side access worked very well for me. You are in immediate proximity to the patient. Perfect.
    • Kim
    • Leadership Development Consultant, Advocate Health Care System
    I wonder if they controlled for clinicians' attitudes and skill levels related to computers. Even when providers delegate to support staff, they are still required to enter some information themselves. Those who "hunt and peck" at the keyboards can become frustrated more quickly. They may be more likely to claim a loss in productivity.
    • J.Michael-Val
    • EHR Developer
    While some interesting information, we cannot call this a new study. The data is from 2006-2009 long before any EHR, used by physicians for reimbursement under the Meaningful Use Program, was required to be, or a had a pathway for becoming certified. Back when this survey was taken the Ambulatory world was cluttered with homegrown EMRs that while meaning good, were not that usable. Usability is a requirement for certification now and many off the shelf EMR's compete on this basis. Before anything "new" is published, let's get more current data.
    • Tom Broge
    • Managing Director, Venture Technical Resources
    OMG! Nobody that has been to a doctor's office can rationally defend EHRs! It is pure insanity to pretend that digitizing a person's health has helped patients or doctors. The only beneficiaries are ancillary players -- the larger staffs now required by doctors, insurance companies, software providers, the government (as the largest insurance company), and statisticians. Healthcare has suffered, as a result, and doctors do a poorer job for their patients.

    I do distinguish, however, digitized health records from the use of electronics in a doctor's office. The use of electronics has certainly been beneficial; however, attempting to force practitioners to 'code' a patient's circumstances (as opposed to the way medicine works and as doctors have always worked -- namely, short notes to remind the doctor of his thinking and ongoing evaluation and analysis) wastes enormous time and resources with no tangible return for patient or doctor. In fact, since notes can't be coded, the usual result is that a doctor has to ask the patient for information he would otherwise not need.

    As in any other business, forcing the players into unproductive activities creates tremendous inefficiencies. It is no wonder American healthcare is in crisis, with government-sponsored solutions just creating worse outcomes -- although ones that statisticians can now merrily track.