More and more Americans are working at least a portion of their jobs from home, facilitated by technological advances and encouraged by soaring gas prices. Even physicians, enabled by the spread of electronic health records (EHR), are increasingly able to perform some of their tasks at home, including updating patient records, checking lab results, and submitting orders for their patients. But for residents – the doctors-in-training who log the longest hours in the hospital – the ability to work at home can add even more burden to an already overstuffed schedule. In light of new national duty hour restrictions which limit residents to 80 hours a week, there could be increased pressure to push even more of their work to the home office.
However, few studies have looked at just how often these clinical activities already occur from home. To fill this gap, a team of Medical Center residents recently conducted a survey about the frequency of clinical and educational work done at home by their peers. The results of that study, published yesterday in the Archives of Internal Medicine, depict the double-edged sword of EHR home access: greater convenience and surveillance mixed with the potential for danger and abuse – especially as the new rules go into effect on July 1st.
“There are constantly new restrictions on duty hours but additions and new requirements in our training, which include more clinic time,” said Allison DeKosky, one of the study’s authors. “So we’re constantly logging in from home, not just to look up information for our research and education on our own time, but also to follow up on patient information that we simply couldn’t do in the hospital because we had to leave.”
The survey, conducted at two Chicago hospitals, found that performing clinical duties at home is commonplace. A majority of residents reported checking and ordering labs, reviewing records, e-mailing or paging staff at the hospital, and conducting clinic phone calls and orders at least once per month. Of more concern, significant numbers reported performing such activities at least once on their post-call day – when residents are supposed to be recovering from a grueling 30-hour hospital shift.
“Working from home is not necessarily always bad,” said Vineet Arora, associate professor of medicine and faculty advisor on the study. “After all, with electronic health records, working remotely is part of modern-day physician practice. The key question for residency programs is where do you have to draw the line and say that’s unsafe.”
The potential missteps are many: sleep deprivation could interfere with medical decision-making, the information received via EHR may be incomplete or out-of-date, and orders from the resident at home and the team working in the hospital could be redundant or conflicting. So why do residents have such a tough time leaving their work at work? DeKosky said that it’s a combination of responsibility, communication concerns, and looking out for their fellow residents. When shifts change after a call shift, the resident must turn their patients over to another resident to cover in addition to the incoming resident’s own patient load. Not wanting to over-burden the cross-cover resident or worried that an important test result or order might get lost in the shuffle, the post-call resident may feel compelled to check in via the EHR from home.
“It’s hard for us to relinquish responsibility for our patients, we all care very much about them,” DeKosky said. “It is a balance between getting out of the hospital and maintaining your ownership of the patient.”
Of course there are advantages as well to being able to check up on patients from the comforts of home. Arora talked about her own training before EHR, when patient information was not as easily obtained from home. Checking a lab result or a patient’s status – which used to require phone calls and pages – can now be performed on a computer at home, and a physician can also keep track of their outpatient population without having to spend extra time at the hospital or clinic. The important thing is to find the happy middle ground with the new tool, said lead study author and resident Roderick Corro Deaño.
“The advantages allow the medical doctors to follow patients from home, especially when one gets paged about a clinic patient and one wants to look up the results or review the last note. Secondly, it is nice to follow along on patients on tests to see how the disease is manifesting and if a patient is improving or deteriorating,” Deaño said via e-mail from Nigeria, where he is on an international medical elective. “However, this ability may interfere with one’s work-life balance – one must learn to separate the two and maintain a healthy balance.”
If work from home becomes a significant part of the residents’ schedule, those hours will need to be accounted for in the duty hour restrictions, Arora said. The Accreditation Council for Graduate Medical Education, which sets the duty hour rules, did not specifically address working from home in their new regulations. But in a subsequent Frequently Asked Questions [pdf], the group clarified the issue, saying “Any tasks related to performance of duties, even if performed at home, count toward the 80 hours.” Though a recent study measured home EHR use by noting the time that patient discharge summaries were filed, monitoring these activities on a regular basis would be difficult, the authors said.
“It would be difficult to implement,” Deaño said. “Personally, I like the capability to work from home and likely foresee this having to be monitored via the honor system.”
But before such issues are worked out, the current data addresses an objection made by some old-school physicians about the institution of duty hour restrictions for residents.
“The overriding concern from critics of duty hours was that we are creating unprofessional doctors with a shift-work mentality,” Arora said. “In contrast, this study shows that our residents are not shift workers; at home, they’re still thinking and reading and immersed in patient care.”