Too many masters: CMS’s greatest weakness. (Pt 1 of CMS series)

Terence Tan
6 min readMay 16, 2021

It’s perhaps been my biggest bugbear with hospital work; Clinic Management Systems (CMS). The bane of my existence when I was working in almost every department over a range of hospitals.

In a great article on “Why Doctors Hate Their Computers” Atul Gawande described how IT systems create more work for physicians (1). Furthermore, Gawande wrote of a Mayo clinic study that showed, the time a physician spent on computer documentation was one of the strongest predictors of burnout.

Computers, automation and IT adoption are supposed to a time-saver, a tool to improve patient care, to make things, better, faster, shinier. So where did it all go wrong?

Definitions, first.

Before I jump in, let me quickly say I use CMS as a term for the IT system a clinic or hospital uses to manage patients, scheduling, prescriptions, inventory, ordering, etc. Basically, all the tasks which go into running a healthcare facility.

On the other hand, an electronic health record (EHR) is simply a digital version of a patient’s medical records. So, I prefer CMS in this instance to describe an organisation-wide, multi-function clinical IT tool.

“The road to hell is paved with good intentions”

I believe the reason why the CMSs are terrible to use stemmed from the main stakeholders being disconnected from daily clinical workflows. Many of these stakeholders were the administrative staff.

For many years, physicians were the main driver for change and workflows; many staff were there to support their main function; to see patients. And it was these physicians, who mostly took shortcuts and avoided administrative tasks in the interests of concentrating on patient care.

Hence, it was mostly left to administrative and support staff to pick up the pieces of poorly filled forms, decrypting handwritten prescriptions, and transcribing dictated notes. Now, with CMS implementation, it was finally a chance to get physicians to pull their weight (in paperwork) and actually do what they should be doing.

No more would it be possible to skip some critical fields on a form- after all, this would mean less time spent chasing after physicians for this data.

No more would coders need to sort through mountains of indecipherable handwritten notes- wouldn’t it be better for doctors to select the ICD code for their own diagnoses? After all, they know it best.

And the list went on as the number of masters the CMS served grew with each meeting.

Original image: Fight with cudgels by Goya

So what?

Maybe it was high time, physicians took on more administrative work. Maybe it was the right time as well. But, the problem is; it took up too much time.

Now, it was taking much longer to type up all the notes, fill out the necessary forms (correctly) and see patients. Yet, appointments remained. The same number, the same length. Increasingly, physicians stayed behind or started to bring work home to complete their documentation.

And it’s not just limited to my experiences. A quick bit of research showed studies reflecting this. Dr. Robert Wachter, professor and chair of the department of medicine at the University of California, San Francisco (2) said;

“EHRs contribute to burnout by turning physicians into unhappy data-entry clerks”

and, in 2016, Mayo Clinic Proceedings (3) reported that

“Physicians who used EHRs were less likely to be satisfied with the amount of time spent on clerical tasks”

even after adjusting for age, sex, speciality, practice setting, and hours worked per week!

That’s ok, right?

Well, burnout aside, worse still was that more time was spent during consultations typing away or filling out some form or addressing a code than actually paying attention to the patient sat in front of the physician!

A study in Kuwait (4) showed that:

“decreased physician attention toward patients during patient visits due to the use of EHRs”.

Another examining OB/GYN practices (5) also found

“Patient satisfaction dropped after initial EHR installation” and there was “no evidence of increased satisfaction linked to system integration.”

One study (6) from the US went so far as to conclude

“Higher clinician gaze time at the patient predicted greater patient satisfaction. This suggests that clinicians would be well served to refine their multitasking skills so that they communicate in a patient-centered manner while performing necessary computer-related tasks.”

So, no, it was and it is not ok.

“Hell is full of good meanings, but heaven is full of good works”

Farber et. al. (6) actually suggested:

These findings also have important implications for clinical training with respect to using an electronic health record (EHR) system in ways that do not impede the one-on-one conversation between clinician and patient.

This betrays a limited perspective on potential solutions for the woes of CMS applications. Clinical training on how to use an IT system so it does not interfere with physician and patient interaction is a typical administrative, top-down solution. Not that it would not work. It would work, but would not solve the root of the problem. There were still too many masters. In more corporate lingo, there are too many agendas.

In effect, by trying to serve too many masters, the CMS fails to serve the patient adequately.

I believe it is the product which needs to change. But, it does not need to be physician-centric or even admin-centric?

I argue that, instead, it should serve one master- it should be patient-centred. We have patient-centred care, patient-centred communication, why should a CMS be any different?

A patient-centred CMS would be optimised for fast, efficient workflows, which prioritise clinical workflows, allowing for clinical work to be done more accurately and efficiently. It would work towards reduced cognitive and administrative load on care staff, allow error prevention from patients (e.g. appointment reminders, dosing alerts). This would result in more time for patient care and better, more engaged clinical workflows.

Now that would be a CMS full of good works.

Stay tuned for my next article in which I dive into what one vision of a patient-centred CMS would look like.

-FIN-

References:

(1)

(2) Collier R. Electronic health records contributing to physician burnout. CMAJ. 2017;189(45):E1405-E1406. doi:10.1503/cmaj.109–5522

(3) Shanafelt TD, Dyrbye LN, Sinsky C, Hasan O, Satele D, Sloan J, West CP. Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. Mayo Clin Proc. 2016 Jul;91(7):836–48. doi: 10.1016/j.mayocp.2016.05.007. Epub 2016 Jun 27. PMID: 27313121.

(4) Al-Jafar E. Exploring patient satisfaction before and after electronic health record (EHR) implementation: the Kuwait experience. Perspect Health Inf Manag. 2013;10(Spring):1c. Published 2013 Apr 1.

(5) Meyerhoefer CD, Sherer SA, Deily ME, Chou SY, Guo X, Chen J, Sheinberg M, Levick D. Provider and patient satisfaction with the integration of ambulatory and hospital EHR systems. J Am Med Inform Assoc. 2018 Aug 1;25(8):1054–1063. doi: 10.1093/jamia/ocy048. PMID: 29788287; PMCID: PMC7646892.

(6) Farber NJ, Liu L, Chen Y, Calvitti A, Street RL Jr, Zuest D, Bell K, Gabuzda M, Gray B, Ashfaq S, Agha Z. EHR use and patient satisfaction: What we learned. J Fam Pract. 2015 Nov;64(11):687–96. PMID: 26697540.

Sketches are by myself.

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Terence Tan

I’m a primary care physician by training and I work towards providing accessible, quality healthcare for everyone. I write about healthcare, technology and UX.