EMR event log study shows 6 hrs of use per day, but implicitly belittles the clinician’s cognitive effort and the EMR’s support

In a recent paper in the Annals of Family Medicine by Brian Arndt and colleagues at the University of Wisconsin, the authors described the results of an analysis of the user event logs of their Epic EMR.  The authors determined that primary care clinicians used the system nearly 6 hours per day out of an 11.4 hour work day, and that 44% of that time was spent on tasks that the authors categorized as “clerical and administrative.”  It is an interesting paper, but I think it represents a lack of vision and insight on the part of the authors regarding the role that technology can and should play in supporting the cognitive effort of clinicians.
Most specifically, when a clinician was using EMR-based template charting and orders modules, the authors categorized that work as “clerical.”  Such a classification fails to acknowledge that the clinician is (or should be) using such modules to create a coherent, evidence-based plan of care:
  • using condition-specific templates that help remind her of the clinical observations and treatments to consider,
  • viewing reminders and order sets to help her to remember to include important evidence-based services in the plan of care,
  • receiving alerts to help her avoid ordering services that may cause an allergic response, conflict with other medications that the patient is taking, or that are dosed inappropriately considering the body mass of the patient,
  • viewing prompts for a needed referral for care management, or
  • receiving referral guidance to help direct specialty referrals to the specialists that have agreed to integrate care processes with the primary care practice within a clinically integrated network or accountable care organization.

The authors implicitly dismiss the cognitive work being done by the clinician when they are doing “documentation” and “ordering” and the support that the technology is providing to that cognitive work.  They reduce it all down to being wasteful paperwork, and suggest that it be eliminated through voice dictation or assignment of such paperwork to other members of the care team — both of which would preclude the decision support to those important cognitive processes.

I share the authors’ implied frustration with the failure of the current generation of health information technology to live up to the long-standing vision of supporting clinicians’ decision-making and coordination of care across a multi-disciplinary care team.  I acknowledge that today’s EMR-based care planning and coordination functionality feels like clerical work.  I’ve spent time on that problem.  I have two patents on proposed solutions to that problem.  I hope some day to help solve that problem, which I consider to be one of the most important problems in the broad fields of health care improvement, population health management and medical informatics.
I strongly agree with the idea of using user event logs to study how users actually spend their time and how they use application functionality, and I applaud the author’s efforts to validate the event log data with some direct observations.  But, I don’t agree with the authors’ suggestion that others should use their “EHR task categories” because they implicitly reject the vision of real technology-assisted care planning and coordination.  We shouldn’t give up on that vision.  We can and must do better to make it reality.
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