Electronic health records may improve quality and efficiency for doctors and patients alike—but physicians give them an “F” for usability and they may contribute to burnout, according to new research.
By contrast, in similar but separate studies, Google’s search engine earned an “A” and ATMs a “B.” The spreadsheet software Excel got an “F.”
“A Google search is easy,” says Edward R. Melnick, assistant professor of emergency medicine and director of the Clinical Informatics Fellowship at Yale University. “There’s not a lot of learning or memorization; it’s not very error-prone. Excel, on the other hand, is a super-powerful platform, but you really have to study how to use it. EHRs mimic that.”
Usability ratings for everyday products measured with the System Usability Scale. Google: 93%; microwave: 87%; ATM: 82%; Amazon: 82%; Microsoft Word: 76%; digital video recorder: 74%; global positioning system: 71%; Microsoft Excel: 57%; electronic health records: 45%. (Credit: Michael S. Helfenbein)
There are various electronic health record systems that hospitals and other medical clinics use to digitally manage patient information. These systems replace hard-copy files, storing clinical data, such as medications, medical history, lab and radiology reports, and physician notes.
The systems were developed to improve patient care by making health information easy for healthcare providers to access and share, reducing medical error.
But the rapid rollout of EHRs following the Health Information Technology for Economic and Clinical Health Act of 2009, which pumped $27 billion of federal incentives into the adoption of EHRs in the US, forced doctors to adapt quickly to often complex systems, leading to increasing frustration.
Two hours of personal time
According to the study, physicians spend one to two hours on EHRs and other deskwork for every hour spent with patients, and an additional one to two hours daily of personal time on EHR-related activities.
“As recently as 10 years ago, physicians were still scribbling notes,” Melnick says. “Now, there’s a ton of structured data entry, which means that physicians have to check a lot of boxes.
“Often this structured data does very little to improve care; instead, it’s used for billing. And looking for communication from another doctor or a specific test result in a patient’s chart can be like trying to find a needle in a haystack. The boxes may have been checked, but the patient’s story and information have been lost in the process.”
The AMA, along with researchers at the Mayo Clinic and Stanford University, surveys over 5,000 physicians every three years on topics related to burnout. Most recently, the burnout rate was 43.9%—a drop from the 54.4% of 2014, but still worryingly high, researchers say. The same survey found that burnout for the general US population was 28.6%.
Electronic health records and burnout
Researchers also asked one quarter of the respondents to rate their EHR’s usability by applying a measure, System Usability Scale (SUS), previously used in over 1,300 other usability studies in various industries.
Users in other studies ranked Google’s search engine an “A.” Microwave ovens, ATMs, and Amazon got “Bs.” Microsoft Word, DVRs, and GPS got “Cs.” Microsoft Excel, with its steep learning curve, got an “F.”
In Melnick’s study, EHRs came in last, with a score of 45—an even lower “F” score than Excel’s 57.
Further, EHR usability ratings correlated highly with burnout—the lower physicians rated their EHR, the higher the likelihood that they also reported symptoms of burnout.
The study found that certain physician specialties rated their EHRs especially poorly—among them, dermatology, orthopedic surgery, and general surgery.
Specialties with the highest SUS scores included anesthesiology, general pediatrics, and pediatric subspecialties.
Demographic factors like age and location matter, too. Older physicians found EHRs less usable, and doctors working in veterans’ hospitals rated their EHR higher than physicians in private practice or in academic medical centers.
Benchmarking physicians’ feelings about EHRs will make it possible to track the effect of technology improvements on usability and burnout, Melnick says.
“We’re trying to improve and standardize EHRs,” Melnick says. “The goal is that with future work, we won’t have to ask doctors how they feel about the EHR or even how burned out they are, but that we can see how doctors are interfacing with the EHR and, when it improves, we can see that improvement.”
New research shows how some types of proteins stabilize damaged DNA and thereby preserve DNA function and integrity.
Two proteins called 53BP1 and RIF1 engage to build a three-dimensional “scaffold” around the broken DNA strands. This scaffold then locally concentrates special repair proteins, which are in short supply, and that are critically needed to repair DNA without mistakes.
“This could be compared to putting a plaster cast on a broken leg.”
The finding also explains why people with congenital or acquired defects in certain proteins cannot keep their DNA stable and develop diseases such as cancer.
Every day, the body’s cells divide millions of times, and the maintenance of their identity requires that a mother cell passes complete genetic information to daughter cells without mistakes.
This is not a small task because our DNA is constantly under attack, not only from the environment but also from the cell’s own metabolic activities. As a result, DNA strands can break at least once during each cell division cycle and this frequency can be increased by certain lifestyles, such as smoking, or in individuals who are born with defects in DNA repair.
In turn, this can lead to irreversible genetic damage and ultimately cause diseases such as cancer, immune deficiency, dementia, or developmental defects.
“Understanding the body’s natural defense mechanisms enables us to better understand how certain proteins communicate and network to repair damaged DNA,” says professor Jiri Lukas, director of the Novo Nordisk Foundation Center for Protein Research.
“This could be compared to putting a plaster cast on a broken leg; it stabilizes the fracture and prevents the damage from getting worse and reaching a point where it can no longer heal,” says first author Fena Ochs, a postdoctoral researcher at the Novo Nordisk Foundation Center for Protein Research.
The previous assumption was that proteins such as 53BP1 and RIF1 act only in the closest neighborhood of the DNA fracture. However, with the help of super-resolution microscopes, scientists were able to see that error-free repair of broken DNA requires a much larger construction.
“Roughly speaking, the difference between the proportions of the protein-scaffolding and the DNA fracture corresponds to a basketball and a pin head,” says Ochs.
According to the researchers, the fact that the supporting protein scaffold is so much bigger than the fracture underlines how important it is for the cell to not only stabilize the DNA wound, but also the surrounding environment.
This allows it to preserve the integrity of the damaged site and its neighborhood and increases the likelihood of attracting the highly specialized “workers” in the cell to perform the actual repair.
One of the most notable benefits of basic research such as the new study is that it provides scientists with molecular tools to simulate, and thus better understand, conditions that happen during development of a real disease.
When the scientists prevented cells to build the protein scaffold around fractured DNA, they observed that large parts of the neighboring chromosome rapidly fell apart.
This caused DNA-damaged cells to start alternative attempts to repair themselves, but this strategy was often futile and exacerbated the destruction of the genetic material.
According to the researchers, this can explain why people who lack the scaffold proteins are prone to diseases caused by unstable DNA.
Amazon Web Services (AWS) customers experienced service interruptions yesterday as the company struggled to fight off a distributed denial-of-service (DDoS) attack.
As part of such an assault, attackers attempt to flood the target with traffic, which would eventually result in the service being unreachable.
While customers were complaining of their inability to reach AWS S3 buckets, on its status page yesterday the company revealed that it was having issues with resolving AWS Domain Name System (DNS) names.
The issues, AWS said, lasted for around 8 hours, between 10:30 AM and 6:30 PM PDT. A very small number of specific DNS names, the company revealed, experienced a higher error rate starting 5:16 PM.
While reporting on Twitter that it was investigating reports of intermittent DNS resolution errors with Route 53 and external DNS providers, Amazon also sent notifications to customers to inform them of an ongoing DDoS attack.
“We are investigating reports of occasional DNS resolution errors. The AWS DNS servers are currently under a DDoS attack. Our DDoS mitigations are absorbing the vast majority of this traffic, but these mitigations are also flagging some legitimate customer queries at this time,” AWS told customers.
The company also explained that the DNS resolution issues were also intermittently impacting other AWS Service endpoints, including ELB, RDS, and EC2, given that they require public DNS resolution.
During the outage, AWS was redirecting users to its status page, which currently shows that all services are operating normally.
One of the affected companies was Digital Ocean, which has had issues with accessing S3/RDS resources inside Droplets across several regions starting October 22.
“Our Engineering team is continuing to monitor the issue impacting accessibility to S3/RDS/ELB/EC2 resources across all regions,” the company wrote on the incident’s status page at 23:25 UTC on Oct 22.
Accessibility to the impacted resources has been restored, but it was still monitoring for possible issues, the company announced yesterday.
– NIST National Cybersecurity Center of Excellence (NCCoE) has partnered with Microsoft to develop concise industry guidance and standards on enterprise best practice patch management.
The pair is also calling on vendors and organizations to join the effort, including those that provide technology offerings for patch management support or those with successful enterprise patch management experience.
According to Mark Simos, Microsoft’s Cybersecurity Solutions Group lead cybersecurity architect, the effort began following the massive 2017 WannaCry cyberattack. Microsoft released a patch for the targeted flaw months before the global cyber incident, but many organizations failed to patch, which allowed the malware to proliferate.
“We learned a lot from this journey, including how important it is to build clearer industry guidance and standards on enterprise patch management,” Simos wrote.
Over the last year, NCCoE and Microsoft have worked closely with the Center for Internet Security, Department of Homeland Security, and the Cybersecurity and Infrastructure Security Agency (CISA) to better understand the risks and necessary patching processes.
The groups also sat down with their customers to better understand the challenges and just why organizations aren’t applying timely patches. Microsoft found that many organizations were struggling with determining the right type of testing to use for patch testing, as well as just how quickly patches should be applied.
The project will include building a common enterprise patch management reference architectures and processes. Vendors will also build and validate implementation instructions at the NCCoE lab, and the results will be shared in a NIST Special publication as a practice guide.
For the healthcare sector, a patch management guide would be critical as industry stakeholders have long stressed that patching issues have added significant vulnerabilities to a sector that heavily relies on legacy platforms.
In March, CHIME told Sen. Mark Warner, D-Virginia, that patching, data inventory, and a lack of regulatory alignment are some of healthcare’s greatest vulnerabilities.
To NIST, the issue goes beyond awareness as there is widespread agreement that patching can be effective at mitigate some security risks. Organizations are challenged by the resource-intensive patching process, as well as concern that patching can reduce system and service availability.
Often, attempts to expedite the process, like not testing patches before production deployment can inadvertently break system functionality and disrupt business operations, NIST officials explained. However, patching delays increase the risk a hacker will take advantage of system vulnerabilities.
For NIST, the partnership with Microsoft will examine how both commercial and open-source tools can help with some of the biggest challenges of patching, including “system characterization and prioritization, patch testing, and patch implementation tracking and verification.”
Ultimately, this project will result in a NIST Cybersecurity Practice Guide, a publicly available description of the practical steps needed to implement a cybersecurity reference design that addresses this challenge throughout the device lifecycle.
“Applying patches is a critical part of protecting your system, and we learned that while it isn’t as easy as security departments think, it isn’t as hard as IT organizations think,” Simos explained. “In many ways, patching is a social responsibility because of how much society has come to depend on technology systems that businesses and other organizations provide.”
“This situation is exacerbated today as almost all organizations undergo digital transformations, placing even more social responsibility on technology,” he added. “Ultimately, we want to make it easier for everyone to do the right thing and are issuing this call to action.”
Interest stakeholders should visit the NCCoE posting in the Federal Register for more information.
“There were words we couldn’t say at Theranos, like ‘biology,’ ‘pipette,’ ‘research,’” Shultz recalled. “And we weren’t supposed to talk to other people at Theranos about what you were doing.”
Still, the two didn’t have any other career experience, so it took a while for the red flags to add up, Cheung said.
Now, with the former leadership of Theranos waiting for a 2020 trial, Cheung and Shultz have established an organization they call Ethics in Entrepreneurship, hoping to prevent other tech and health startups and employees from going through what they did.
“We’re all here because we want to make an impact and we want to do good and we have good intentions, but making sure you have that strong vision and figuring out how to maintain that” is challenging, Cheung said. “You have to figure out how to stick to those morals and standards and values despite the chaos.”
Though they’re far from having all the answers at this point, they pointed to some basics that can be applied to almost any company:
Discretion from investors: “If the average age of the board is 80, maybe insist on a board seat,” Shultz said. “Or insist on younger blood.”
So-called vanity boards are popular in Silicon Valley, Cheung agreed, but especially in a highly regulated space like health care, “you need the right people asking the right questions.”
Be proactive: Think about the impacts a startup will have on customers, investors, employees and society. It’s better to think about these ethical issues early on in the process, Cheung said, rather than reactively.
Consider realigning incentives: Shultz and Cheung agree that there should be a way within the investment landscape to prevent an unethical situation from going too far. For example, if someone was personally profiteering or committing egregious actions, there could be a system in place for investors to pull back money. “There need to be ways to keep people accountable, to nudge them to good behavior,” Cheung said.
Think before investing: When people were investing in Theranos, Cheung pointed out, it was during a time when investors were scared of losing the next opportunity to buy into an Amazon. “There was not a lot of deep thinking about how to invest in tech companies,” she said. Theranos should serve as a warning to potential investors that they need to ask the questions before signing the check.
Create a culture of healthy disagreement: Shultz has started a new company, and while it only has three employees so far, one of his primary missions is to establish a culture in which people are allowed to disagree — even with the boss. “My lab bench scientist and I get into some arguments that are pretty intense, but I tell him it’s really healthy — and we can move on,” he says. How do you scale that for a bigger company? “That’s the hard question,” Cheung said. “But the biggest one is, do you have a way for employees to report problems? Are the right mechanisms in place to compile evidence, and is there investigation and followup?” An ethics hotline, she said, is one way to do that.
Despite spending most of his 20s wrapped up in the Theranos scandal, Shultz maintains a sense of optimism.
“So many things had to go wrong [in the Theranos case] that I think it’s unlikely something like this would happen again,” he said. “Though maybe I’m naive.”
Moderator Rebecca Jarvis of ABC asked the pair whether they thought former Theranos CEO Elizabeth Holmes should go to jail.
“There has to be some justice,” Cheung said, to great applause from the audience. “There has to.”TrendMD v2.4.3
I have advocated before for putting a visit synopsis at the beginning of each visit note. I have called that the aSOAP note. I think that works immensely better than APSO notes that only rearrange the order of the elements. The reason I say that is that in today’s EMR notes, it’s too darn hard to find the story. If a note is half a dozen pages or scrolls long, why would I want the medication changes and the reason why they were made at opposite ends of the note? The order means less than the distance between them, in my opinion.
The way I approach reading a note is with the two questions, “What happened in the last visit?” and “Why was that the clinical decision?” In more and more of my office notes, I answer these two questions for future readers, which would include me, in temporal, typographical, and spatial connection with each other, right on top.
Let’s face it, how often would it be more useful to try to scan a lengthy review of systems and a comprehensive exam to find the pertinent positives than to read in the top paragraph that the patient who was placed on a potassium-sparing diuretic two months ago and kept rescheduling their followup appointment is now hypotensive and nauseous with an unusually pale complexion and putting out less than normal amounts of urine. Consequently, we stopped the medication, sent the patient for STAT labs, or to the ER. Seriously, I don’t need to read anything more in that office note: You and I both know this person is in acute kidney failure, caused by the spironolactone. Don’t waste my time as a future reader by mixing those crucial elements with other, less pertinent information. Put it in there, away from the story in case somebody needs to check if we screened for depression or smoking status, but those are filler materials and side plots in this riveting story of iatrogenicity.
I admit that in today’s health care environment, the office note serves many “stakeholders” (I’m not sure I like that word), but since I am the clinician who sees the patient, makes treatment plans and then has to follow up on what parts of the treatment plan worked and what parts didn’t, I can’t accomplish anything without the thread of the chain of events I am ending up calling the story. It belongs to the patient, but I’m the one that needs it, desperately sometimes, as even small nuances in the narrative of a life or a disease can change my assessment and the trajectory of care I provide.
And, here’s a confession: If I don’t have time to finish my note in real-time, or if (ahem) I’m catching up on a backlog of chart notes, it’s the “a for abstract” segment I focus on. The number of “bullets” and 99213 versus 99214 is not my priority when I’m in survival mode (mine and possibly the patient’s).
So I am again making the case for a narrative abstract at the top of each office note, an executive summary if you will, just like the world of academic journals has decided to present complex information.
If it’s good enough for the New England Journal of Medicine, it should be good enough for this country doctor.
Hans Duvefelt, also known as “A Country Doctor,” is a family physician who blogs at A Country Doctor Writes:. =============================================================================================
===================================Function for Custom Button Styles Ends========================