Beyond The Coat

It is no secret that the job satisfaction of physicians is dwindling.   Burnout is at an all time high and the rate of physician suicide is on a steady upward trend and is the highest of any profession.  There are many physician authors who devote their spare time or “side gig” to addressing these issues and are much better suited to speak and/or write on these issues.  Here are a few:

http://www.idealmedicalcare.org  – Pamela Wible, MD focuses on the physician suicide epidemic

https://www.nishamehtamd.com – Nisha Mehta, MD focuses on physician burnout and well being

For more information from the American Medical Association go here.

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What I came to share today was an example of how health IT can contribute to some of these feelings of devaluation and burnout. I have spoken about being in school over the course of the last year.   I am in my final ‘classroom based’ class and it deals with healthcare information technology.  If I’m being totally honest, I just needed a flexible class and this one was online and I was remotely interested in it, so I enrolled.

It is called Human Factors in Health Care and it is all about how humans interact with technology.  While I really hate some of it (I am completely inept at coding, writing html or css) some of it has been kind of interesting.  Our assignment this week was to do KLM modeling.  This essentially breaks down a task done on a computer to individual keystrokes or actions, then adds up the time and relative mental energy that it takes to complete the task.

Our assignment was to model the task  “Order metformin 500 mg twice daily for 14 days”in the electronic health record (EHR).  If I was writing a paper prescription for this, I would take out a prescription pad and write the following:

Metformin 500 mg tablet

Sig: 1 tab PO BID x 14 days

Disp: 28 tabs  Refills: 0

And I would sign my name at the bottom and hand it to the patient.   End of task.

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This is the how it looks when it is completed in an EHR (get ready):  This doesn’t even take into account the annoying task of making sure it is the appropriate drug that is on formulary for the insurance company that the patient has OR that the pharmacy is the correct pharmacy linked in the computer.   This also does not have a sign function allotted in this task.  If a medication is a controlled substance (metformin is not) then the task becomes about 40 steps longer.

The letters after the numbered items are just operator codes so that I could add up the time.  Notice that the time for the task is not actually that long – 79 seconds (but can be quite variable based on the M or mental tasks).

The frustration comes when you do one of these out of sequence or inadvertently skip over a field, the prescription is incomplete or won’t be accepted by the system.   The millions and millions of clicks that we do as providers is overwhelming and exhausting.  EHRs were created for a good reason, but they are created as many problems as they intended to fix.   Take a peruse below and compare it to the same task above an tell me what you think.

If you ever feel like your physician doesn’t look at you in your visit – EHR is likely the culprit.

Task: Ordering Metformin 500mg twice daily for 14 days.

 Assumptions:

• User is a healthcare provider who has used Provider Order Entry (POE)
• User is logged into EHR where medications can be ordered
• User has selected patient EHR chart
• User is an average non secretarial typist
• Wt was not included because it was negligible for this exercise

Operator Sequence

1. Initiate the medication order M
2. Direct attention to patient banner M
3. Direct attention to patient name M
4. Verify patient name is correct M
5. Direct attention to patient DOB M
6. Verify patient DOB is correct M
7. Decide to check patient’s known medication allergies M
8. Direct attention to ‘allergens’ tab in patient banner M
9. Home hands to keyboard and mouse H
10. Move cursor to hover over ‘allergens’ tab P
11. Click mouse button to select ‘allergens’ BB
12. View patients known allergens M
13. Verify ‘metformin’ is not on allergen list M
14. Direct attention to ‘patient chart’ section M
15. Move cursor to ‘medication list’ under ‘patient chart’ section P
16. Click mouse button to click ‘medications’ BB
17. Direct attention to ‘medication list’ M
18. Move cursor to vertical scroll bar at edge of screen P
19. Scroll through medication list P
20. Verify ‘metformin’ is not on list currently M
21. Verify current medications don’t interact with metformin M
22. Move cursor to hover over ‘Add medication’ P
23. Click mouse button to click ‘add medication’ BB
24. View popup screen M
25. Notice cursor is already in search field M
26. Type “metformin” by individual letter keystrokes T9
27. Find “metformin hydrochloride 500 MG oral table [Glucamet] in drop down list M
28. Hover cursor over correct entry (from step 27) P
29. Click mouse button to select entry BB
30. Hover mouse over ‘save and close’ P
31. Click mouse button to click ‘save and close’ BB
32. Direct attention to ‘Medication List’ M
33. Verify Metformin has been added to ‘Medication List’ M
34. Move and hover cursor over ‘Edit’ button P
35. Click button to click ‘edit’ button BB
36. Move cursor to hover over “add” button for problems P
37. Click mouse button to select “add” button and view drop down list BB
38. Move cursor to highlight appropriate problem (E11.1 Non insulin dependent diabetes mellitus” P
39. Click mouse button to select entry (from 38) BB
40. Move cursor over ‘dose’ field P
41. Click mouse button to select field BB
42. Type “500” into dose field T3
43. Move cursor over unit selection P
44. Click mouse button to select drop down menu BB
45. Move cursor to highlight “milligram” P
46. Click mouse button to select “milligram” BB
47. Move cursor to hover over ‘duration’ field P
48. Click mouse button to select ‘duration’ field BB
49. Type “14” into duration field T2
50. Move cursor to hover over duration unit P
51. Click mouse button to select drop down menu BB
52. Move cursor to hover over “days” P
53. Click mouse button to select “days” BB
54. Move cursor to hover over “route” P
55. Click mouse button to select drop down menu BB
56. Move cursor to highlight “oral” P
57. Click mouse button to select “oral” BB
58. Move cursor to hover over “dispense” field P
59. Click mouse button to select “dispense” field BB
60. Calculate total tablets needed for duration based on formulation and days (2 tablets x 14 days = 28 tablets) M
61. Type in “28” T2
62. Move cursor to hover over ‘formulation’ drop down menu P
63. Move cursor to select “tablet” P
64. Click mouse button to select tablet BB
65. Move cursor to hover over “take” field P
66. Click Mouse button to select “take” field BB
67. Type “1” into take field T1
68. Move cursor to hover over “formulation” field P
69. Click mouse button to select drop down menu BB
70. Use cursor to highlight “tablet” in formulation field P
71. Click mouse button to select “tablet” in formulation field BB
72. Move cursor to hover over “frequency” field P
73. Click mouse button to select drop down menu BB
74. Use cursor to highlight “BID” P
75. Click mouse button to select “BID” BB
76. Move cursor to hover over “start Field” P
77. Click mouse button to select start Field BB
78. Determine what day patient should start medication (Tomorrow) M
79. Move cursor to highlight 11/5/18 (tomorrow) in calendar P
80. Click mouse button to select 11/5/18 BB
81. Move cursor to hover over “end date” P
82. Click mouse button to select “end date” BB
83. Retrieve duration length from memory M
84. Calculate 14 days from start date M
85. Move cursor to hover over 11/19/18 in calendar P
86. Click mouse button to select 11/19/18 BB
87. Move cursor to hover over “patient instructions” P
88. Click mouse button to select “patient instructions” BB
89. Type in “For diabetes” T11
90. Move cursor over “save and close” P
91. Click mouse button to select “save and close” BB
92. Direct attention to medication list M
93. Verify medication has been added and all details are correct. M

 

Total Time = 25 M + 32P + 29BB + T28 +1H

= 25 (1.2) +32(1.1) + 29(0.2) + (28*0.28) + 1(0.4)

= 30 + 35.2 + 5.8 + 7.84 + 0.4

= 79.24 seconds

On average, it takes 100 keystrokes to order a medication in an EHR. Share on X.