Mouse Clicks and Key Strokes

I spend a good portion of my day clicking between 2 different electronic health records (EHRs). Both are first-class programs widely used by large health systems and the group practices that work within such systems. They are designed to enable scheduling and documentation of not only direct clinical care (subjective and objective findings, assessments, and plans), but also flowcharts, orders, prescriptions, procedure reports, patient instructions, letters to colleagues, and billing. But that’s just the beginning. EHRs also simultaneously enable assessments of meaningful use and production of provider reports containing the all-important care indicators for pay-for-performance incentives. Finally, they impart electronic checks and safety measures aimed at preventing mistakes. With so much riding on them, however, these marvels of information technology require me to take a great deal of time to create my progress notes. In order to legitimately write my notes, I spend an awful lot of time looking at my computer screen and clicking my mouse—over and over again.

Out of sheer frustration, today I actually counted the number of mouse clicks and key strokes it took to write a note for one typical, established patient: 221 mouse clicks and 633 key strokes, all of which required 7 minutes and 34 seconds. This didn’t include the time that I spent evaluating and treating my patient and switching between EHR programs to view radiographs (not so seamless, in that I had to enter my username and password 3 additional times). The 7½ minutes that I spent producing my notes in the medical record for one established patient may not seem like much, but multiply this by just 20 patients, and that’s 2½ hours of charting. If I see 40 patients, it takes about 5 hours to produce the notes! And this doesn’t take into consideration the additional time required for a new patient or a complicated surgical case, both of which require more time for evaluating and treating the patient (activities I actually trained for and enjoy) and documenting the visit. Still further, it doesn't include the time required by my residents and fellows, and other members of my office staff, to input additional information in the chart notes. After 32 years in practice, I now take 5 to 6 times longer to complete my chart notes (i.e., mouse clicking and key stroking) than I ever did before, the details of which need to be locked in perpetuity in order to define my meaningful use of the EHR so that I can get paid for the services that I have rendered. My handwritten notes, the ones that I used to make, served me well for most of my career, but they were just notes that enabled me to keep track of what I was thinking and doing in regard to my patients. My handwritten notes required very little time to make a useful chart note, in comparison to the time and effort required by the EHR (which contains considerably more information). Now, my notes are something much more complex. They are, in fact, a primary element in an intricate information system designed to minimize medical mistakes and to collect and keep track of information on a huge scale. And, if I take the time to create an acceptable note, it still lets me keep track of what I am thinking and doing in regard to my patients.

The sharp increase in time required to produce a note—in the face of increased costs for hardware and EHR tech support and declining reimbursements for services—has not made life easier but actually adds to physician frustration, as we flat out sprint from patient to patient. Worse, it threatens to make a computer screen the focal point of patient interaction, as many practices have placed terminals in treatment rooms in an attempt to save time. Others have resorted to employing more staff to enter various parts of the record. Both of these measures are costly. Use of electronic shortcuts, known as smart sets and smart phrases, and other templates for various elements of the medical record can save some time, but they increase the likelihood of inappropriate repetition.

Thus, the promise of reducing documentation time through use of an EHR is not likely to be realized any time soon. According to a recent study, the time required to produce a note actually increases the longer the EHR has been used (). Another study has documented what we clinicians already know: that physicians’ use of EHRs actually increases the time it takes to produce and review patient notes (). In talking with colleagues, I found that many, if not all, have experienced the same kind of frustration with their EHRs. The way out of this quagmire is unknown, but as an alternative to throwing a computer terminal through a window, we should use the tools that have served us well. Scientific research can document and quantify the effects of EHR use and ultimately point the way to a more efficient system for clinicians that meets the requirements of a pervasive EHR and, more importantly, the needs of our patients.