Death by 10,000 clicks: electronic health records

Electronic health records (EHRs), once promising to revolutionize healthcare, are becoming a burden. We audited EHR logs at our institution, the University of California San Francisco, to examine the work of our neurosurgery residents and gain a better understanding of benefits and burdens. The results shocked us: On-call residents spent 20 hours a day logging into the EHR in a single shift.

When we shared these results with the residents, they were not surprised. They feel that the burden of EHR is there every day.

The promise and disappointment of the EHR

There are many benefits of EHR. Gone are the days of hunting for films in the radiology basement, searching the floor for that missing chart, or deciphering the notoriously bad doctor’s handwriting. For patients who have a common place of care, having quick access to their past records is valuable.

We considered that perhaps this hectic work has been replaced by more efficient EHR workflows. To see if this was the case, we examined what tasks residents were performing when interacting with certain areas of the EHR. This “active time” (any time spent moving the mouse or clicking on the keyboard in the patient chart) totals 9 hours per shift, but excludes computer activities outside of the patient chart, specifically imaging review . This active time log revealed a number of inefficiencies, such as spending an average of 45 minutes per day searching for orders, matching orders, and navigating order decision support tools. This deep dive showed us that the work of old has been replaced by a bad EHR burden.

Our program is not unique in this regard. Surgery residents spend approximately 8 months of their 5 years of training at the EHR. Residents regularly perform EHR work outside of the hospital, completing about one-third of it from home. It’s even worse for non-surgical residents, who spend about 40% of their time on the EHR and only 12% on direct patient care. Over 90% of residents say documentation responsibilities are excessive, and they take away time with patients.

The EHR burden doesn’t just affect residents. One trauma surgery required 73 full 24-hour days to complete the documentation required for 1 year of billing alone. In ambulatory practice, physicians spend 2 hours at the computer for every 1 hour of patient time. EHR use linked to physician burnout, a problem that costs the US billions of dollars

We found that many inefficiencies stem from Medicare regulations. The Fair Use Criteria program is a good example. It was developed to reduce unnecessary imaging ordered by physicians. When ordering a CT or MRI, the physician must click a few boxes to ensure that the order is appropriate for the diagnosis. In our EHR audit, we found that this adds only a few minutes of computer time to residents’ days. However, there is no evidence that this regulation reduces unnecessary imaging. We believe this is completely unnecessary. There are many other rules that add a few minutes here and a few minutes there. This is death by 10,000 clicks.

offloading measures

To overcome these inefficiencies, their systematic identification is necessary. Our study, with its granular breakdown of EHR functions, was just a start. There are many regulations around billing, coding, value-based reimbursement, and physician order entry that are adding to the EHR burden. It was easy to add to these many regulations — it would be difficult to identify and eliminate them. The Centers for Medicare and Medicaid Services “Patients Over Paperwork” initiative was a good start, as it eased some of the documentation requirements for physician notes. This effort should continue.

Some of the inefficiencies come from the EHR itself. Physicians often have little say in which EHR is selected and how it is set up. However, in physician-owned hospitals, where doctors have more input, their satisfaction with the EHR improved and they reported more positive perceptions of the time spent on documentation. Reversing the virtual ban on physician-owned hospitals would give physicians more authority in purchasing EHRs, shifting the burden of computers toward a market that is less burdensome.

Of course, increasing advanced practice provider support helps offload the remaining EHR tasks. It is encouraged by the Accreditation Council for Graduate Medical Education (ACGME). However, mindless administrative tasks should be eliminated, not simply transferred to other employees. This shifting burden explains why healthcare must employ more and more workers to care for the same number of patients. Advanced practice providers don’t want to be burdened with mindless administrative tasks.

What don’t help are mandatory wellness programs, doctor appreciation days, or EHR training sessions. In fact, our data showed no improvement in EHR efficiency as trainees became more experienced. The problem doesn’t come from a lack of mental toughness, fitness or ambition. It is built into the system.


As neurosurgeons, we must advocate for policies that reduce administrative burden. This is detracting from the educational experience of our trainees. Health care costs are rising because of the inefficiencies that come with EHRs. We must be aware of this to protect our residents and protect our industry. Reversing the growing EHR burden requires continued involvement in advocacy.

Anthony M. DiGiorgio, DO, MHA, is assistant professor in the Department of Neurological Surgery at the University of California San Francisco, and affiliated faculty at the Institute for Health Policy Studies. Praveen V. Mummaneni, MD, MBA, is the Joan O’Reilly Endowed Professor and Vice Chair of the Department of Neurological Surgery at the University of California San Francisco.


DiGiorgio receives research funding from The Mercatus Institute.

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