Last month, an interesting study was published in JAMA Internal Medicine titled “Assessment of Electronic Health Record Use Between US and Non-US Health Systems.” Researchers focused exclusively on the ambulatory setting and employed clinician activity logs in the electronic health record (EHR) to identify and examine any differences between U.S. and non-U.S. usage. Were there differences? You betcha! I think some of the findings were completely predictable, but others not so much.
One of the main problems in identifying differences between how doctors and nurses use the EHR is...the EHR itself. In the U.S. alone, there are over 900 certified EHRs, each with a unique take on how they do what they do. How could one possibly compare time spent in Vendor A’s EHR versus Vendor B’s? Heck, they might have completely different concepts for how a progress note is written or lab results are displayed. The investigators came up with a good plan to mitigate this issue: only study clinics and offices using the same vendor. In this case, they studied the EHR from Epic Systems Corp. in Verona, WI. While it may seem that studying only Epic-using clinicians would solve all standardization problems, it wasn’t that easy. Like many large EHRs, Epic comes with plentiful configuration options. Hence, the truism holds that once you’ve seen one Epic implementation...you’ve seen one Epic implementation. That said, basic data and user log activity are similar enough that apples can be compared to apples. 
They studied 348 U.S.-based health systems and 23 based outside the United States (not surprisingly, there are many more Epic installs inside the U.S. than outside). Some of the interesting data include:
- U.S. clinicians spent ~90 minutes actively using the EHR every day compared with ~59 minutes outside the U.S.
- Clinicians in the U.S. created more notes that were generated from automated sources compared with non-U.S. clinicians (translation: more note bloat).
- U.S. clinicians received more messages per day compared with those outside the U.S. (~34 vs. ~13).
- After hours EHR time (aka “pajama time”) was omnipresent, but higher for U.S. clinicians (~27 minutes) than those outside the U.S. (~19 minutes).
I was particularly taken aback by the differences between the number and type of messages that American clinicians received versus their international counterparts. It’s not just that U.S. clinicians received 2.5 times more messages, but the content of the messages was quite different. American physicians received an abundance of system-generated messages, patient secure messages, and even result messages. This is likely explained by differences in government policy, legal exposure, billing requirements, and quality mandates among the countries, yet it’s still startling.
What can clinical IT leaders do to reduce EHR-associated burden among American physicians besides moving them to a different country with a better climate or more interesting food? Plenty! The Office of the National Coordinator for Health Information Technology released their report “Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs” last year. This report thoughtfully breaks down various issues and suggests possible solutions. Some solutions depend on the federal government to change regulatory requirements, while others focus on what EHR vendors can do to make their software better. Naturally, there are some possible fixes that those of us who configure and lead EHRs can leverage.
There are ways to level the playing field between U.S.-based and non-U.S.-based clinicians. Teach your physicians about the updated ambulatory evaluation and management (E/M) guidelines that went into effect on Jan. 1 and modify your documentation templates to support streamlined, less-cluttered progress notes. Create a strong team-based culture with everyone working at the top of their license and organized, formal protocols delegating appropriate work to non-physicians when possible. To the extent possible, automate billing based on orders and discrete documentation so that physicians don’t need to handle this themselves. Ensure that quality metrics are calculated in a standard way as part of the normal clinical workflow so that care team members don’t spend unnecessary time re-documenting. Simplify physician workflows. Configure the technology so that the EHR works for the doctor and not vice-versa (i.e., forcing clinicians to enter an order for “ear canal cleaning”); in other words, get rid of stupid stuff.
Clearly, the data don’t lie: in the U.S., many of our EHR problems are self-inflicted. We should learn from our international colleagues and emulate them when we can, while lobbying for common sense changes to regulations and rules as necessary. Speaking of international colleagues, Nordic's own Tasman Global is based in Europe and is well aware of the wrinkles of EHR implementation outside of North America. Tasman’s Steve Lewis will do his own assessment of this JAMA article; keep a look out for that in a few weeks.
Is your organization experiencing any of the EHR-associated issues covered above? Let's talk. We'll discuss a solution that works best for your clinicians and operational teams.
