February 24, 2017 | Sumit Som, MBBS
Career Development

Sarah L. Timmapuri, MD, FACC, is the chief quality informatics officer and a practicing cardiologist at Hackensack University Medical Center in Hackensack, New Jersey. She graduated medical school from the Northwestern University Feinberg School of Medicine in Chicago, followed by residency and cardiology fellowship at UMDNJ-New Jersey Medical School and Hackensack University Medical Center. She is passionate about contemporary causes of physician burnout in the U.S., and has given talks on the implication of physician burnout on the quality health care delivery, especially as it relates to the use of the electronic health records (EHR) in daily practice.

This is the conclusion of a two-part interview series with Dr. Timmapuri on physician burnout and EHRs. View Part I here. In this section, we will focus on how the physician can make the EHR work for him/her.

The issues with EHRs have been covered extensively by news media such as The Washington Post, NPR, Time Magazine, Forbes, etc., and discussed on social media. How do you think EHRs have contributed to burnout?

The EHR today is not simply the paper chart of yesterday just typed in an electronic format. It is a whole new entity. It contains far more information than the medical record contained in the past – because it CAN. Because an electronic record has the ability to accept more information, easily and quickly, it does so. In the long run, this will be good for patient care. However, physicians have to manage this information.

In the past, physicians had a single source of truth – the patient, perhaps with a bag of medications. Now, physicians have to manage information from the patient, the bag of medications, outside pharmacies, outside institutions who have pushed information directly to the EHRs, and information from a multitude of physicians from within a clinically integrated network. This information is at our fingertips. But, it still takes time for us to digest that information, curate it, and then use it in our decision-making. The health care system has not accounted for this tremendous increase in the complexity of health care. Physicians are expected to do this within an outdated model of efficiency defined by the number of patients seen per hour. Physicians know that data management is an important part of their work, but the time it takes to do this has not been allotted. I think this inherent disconnect is a large contributor to burnout. 

EHRs are a legal repository of the meta-data about every data. What advice would you give to the young attending physicians, fresh out of fellowships, to guard against potential liabilities when writing notes in the EHR?

It is critical for all physicians to understand that every interaction with the EHR is recorded and discoverable – not just every note and order, every interaction. Audit trails can track who did what, when, and often from where. Electronic interactions can feel anonymous because of the lack of the human component. Just remember that they most definitely are not.

EMR is here to stay. The American Recovery and Reinvestment Act of 2009  ushered in mandatory EHRs but the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is slated to bring a paradigm shift in health care delivery, making EHRs central to all health care processes. How can FITs and early career cardiologists make EHRs work for them?

I think that it is a priority for all of us to shift our utilization of the EHR from data-entry to information-understanding. Yes, we need to get all the info in, make sure it is correct, dot the “I’s” and cross the “t’s”. But, afterwards, we should have time set aside to make sure that we can use that information to make a difference in patient care. As an example, we should make sure that we have time built in to our schedules to go through our data and find those patients whose blood pressures are not well-controlled (patient-entered data can be very useful for this) so we can intervene in-between their visits to us.

We should be able to easily use our patient portals to reach out to our patients to check on their weight management or smoking cessation efforts with a quick message – we all know that patients take better care of themselves when they know that their physicians are checking up on them. We should be sure that our EHR is easily accessible to us in the way that we work – on the fly, via mobile devices, via remote access. Health care is no longer constrained by bricks and mortar. We should harness this flexibility.

Open medical records are the latest trend in health care reform. What is your take on this? What advice would you give to FITs to optimally use an open medical record?

I have found almost uniform terror when discussing open medical records with colleagues. I think it is in our future, whether we like it or not. We always say that the medical record belongs to every patient. But, why do we shiver when thinking of allowing our patients to read their records? I think that a record that is shared with patients will be better for patient care in the end. Patients can help us to correct errors, resolve inconsistencies and an open, honest discussion of medical issues can allow patients to share responsibility for their health.

Many patients feel that health care is “done to them”. Good health should be fostered and maintained jointly by the patient and their physicians. When patients are engaged and understand goals and risks, they can be active participants in their health. I personally have started by completing my charting with the patient watching me navigate the EHR. I turn the screen towards them, and speak out loud what I am entering. If I utilize a medical scribe, I dictate to the scribe in the room in front of the patient. For young physicians, this may be an interim step toward open medical records that can ease the transition. Every patient I have interacted with in this way has appreciated watching my interaction with the record – it has not come between me and the patient.

This article was authored by Sumit Som, MBBS, a Fellow in Training (FIT) at Rutgers New Jersey Medical School based at Hackensack University Medical Center, Hackensack, New Jersey.