HIV and ID Observations

A paper just appeared in the Journal of General Internal Medicine entitled “National Comparison of Ambulatory Physician Electronic Health Record Use Across Specialties.” The goal of the study was to track clinician workload by specialty, divided into various functions — documentation, chart review, orders, inbox.

Importantly, there was no gaming the system. By using Epic’s built-in function, they tracked “active” EHR time (any mouse activity or keystrokes) using a 5-second inactivity timeout. They additionally measured time spent on the EHR outside of scheduled hours on days with scheduled appointments, and time on unscheduled days.

Remember, some of this is time working on notes, follow-ups, and inbox wasn’t possible in the days of paper charts. Easy access to patient records for clinicians is mostly a good thing, but it has brought with it several untoward consequences, with longer hours of EHR use associated with physician burnout.

The results? Here’s the figure, reproduced with the kind permission of the lead author:

Gosh, does this ring true. Hey, I’m logged into Epic right now as I write this, and it’s 5:42 a.m. on a Wednesday, reviewing patient and clinician messages, test results, and — most importantly — prepping for the clinic session I have this afternoon and peeking ahead to tomorrow morning’s appointments, reading through charts to be ready for the visits.

Now none of this is unique to ID docs. I’m married to a primary care pediatrician, and her inbox activity easily exceeds mine. But here are several reasons why ID doctors finished #1 in this review, at least based on my highly anecdotal and admittedly biased perspective.

1. Chart review. Before, during, and after a visit. It’s so critical. It would be impossible to do this work without meticulous attention to the history and results. You know that Media tab in Epic, the one you’d like to ignore? That place where “information goes to die”? We ID docs dive right in, painful as opening those scanned documents and inscrutable PDFs might be. If we see someone is scheduled to see us and we don’t have the records to review ahead of time, this elicits deep anxiety and an all-out effort to remedy the situation ASAP. Code Chart.
2. Notes. The other day, we hosted some medical students for dinner at our house, and a (quite brilliant) future surgeon recounted something she learned on a recent Transplant Surgery rotation:  “Just read the ID notes,” she said. “My resident said you can get rid of the rest of the chart documentation and find a complete and accurate summary of even the most complicated cases.” Indeed. These works of art take time.
3. Complexity. People don’t refer to or consult ID for routine issues in Infectious Diseases — they manage them on their own. That community-acquired pneumonia responding to empiric antibiotics? That outpatient with a UTI getting better on nitrofurantoin? That drained abscess, now healing on cephalexin and local care? It’s the opposite of those cases that make up the daily ID doctor’s work — the diagnostic dilemma, the failure to respond, the highly resistant or confusing microbiology. Tough stuff all of them, and I’ve been at this a while.
4. OCD. To varying degrees, all us ID doctors suffer from obsessive-compulsive disorder. I’ll confess — the struggle is fierce. If you have never written a note that starts out, “Briefly, …” and is then followed by a scree of prose longer than any other note in the chart, the Infectious Diseases Society of America deserves the right to wonder about your ID credentials.
5. Breadth. If there’s a medical or surgical service out there that hasn’t had a patient with an ID complication or issue, I haven’t heard of it. From the broadest primary care clinicians to the super-specialized surgeons who only manage one component of a given body part, we’ve seen patients from them all. This creates quite the pressure to review records and do some pre-visit research about the latest obscure medical treatments or surgical techniques.

All of this requires a lot of EHR chart use, and time spent outside of clinical hours finishing up the work. Look at the distribution of activities in the figure — it shows it’s not just one thing we’re doing more than others. It’s the entire bundle, the results of an extremely diversified portfolio of clicks, keystrokes, and scrolling.

Some might argue that ID doctors should just write shorter notes, and I agree. Notes really should focus on our interpretation of what has happened, why we think it’s going on, and what we recommend — not just a re-statement of material that’s already available elsewhere, if others took the time to look at it.

But importantly, writing shorter notes is easier said than done. Many of my colleagues tell me that if they don’t write out the details of the history, or re-type all the results, they don’t really learn the full story, analogous to taking notes during an important lecture. Others cite the positive feedback they receive from others (see #2 in the above list), saying they don’t want to disappoint their non-ID consulters.

But here’s another motivator to stop providing this chronicling service. We non-procedural specialists consistently find ourselves at the low end of the payment scale for MDs, a situation that will never change with Relative Value Units (RVUs) providing the metric for determining salaries. Sadly, the recent trend wasn’t encouraging — our latest reported salaries were lower than the previous year.

And, as noted in this compelling post, I doubt anyone is getting paid for time spent on the EHR outside of work hours.

Or getting paid by the word.