Healthcare have been transformed over the last decade as electronic medical records have been rolled out across America. Unfortunately, information technology has not yet fulfilled its immense promise. To a great extent, this is because most EMRs were designed primarily as giant billing systems. They were not conceived as patient care systems, and efforts to use them for patient care have been compromised by issues of usability and efficiency. Of equal concern have been the effects on morale these shortcomings are having on the hundreds of thousands of physicians toiling away for their patients. All current studies conclude that the number one daily contributor to physician burnout and job dissatisfaction is frustration with the time-consuming complexity posed by health care information technology.
According to a new Medscape survey of 15,000 practicing U.S. physicians, nearly two-thirds report feeling burned out (42%), depressed (15%) or both (14%). Some of the familiar culprits are to blame for burnout: the weight of documentation (56%) and increased computerization of work with EHRs (24%). These findings echo research highlighting the impact of administrative burdens on physicians. An Annals of Family Medicine paper last September revealed primary care physicians spent more than half their workday on EHR tasks.
Ask healthcare providers how they feel about this and you’ll find their frustration boiling over. “Too many drank EHR Kool-Aid, thinking it would fix everything. Now we have to go back to basics and fit technology into the daily lives of users.” Another sputters, “Physicians are intended to be diagnosticians practicing the artful science of medicine, not data-entry clerks.” And one suggests we “Imagine writing a novel in Excel. That would be annoying and not-at-all efficient. Can it be done? Yes. Would you want to? No.”
After all the time that has been devoted to the study of healthcare IT efficiency and all the money that has been invested in the the adoption of electronic medical records, how did we find ourselves in such a situation?
It was only a few years ago that most hospitals reached the stage at which they were able, theoretically, to realize benefits from fully-deployed clinical information systems. But too many tried to do too much too fast. They binged on a “Big Bang approach” before fully incorporating and understanding its impact on staff. Instead of experiencing EMR optimization they found themselves spending far more time and money than was acceptable, fixing technical flaws that were overlooked, adding more technology and struggling to standardize all their mismatched clinical and operational processes.
“One of the key mistakes that organizations have made for the projects that I’ve been a part of, is to take a current process and wrap technology around it. If the process and workflow is flawed, or inefficient, we’re just going to exacerbate that and make it worse. We need to spend time looking at how we do our business, optimizing those things, and then wrapping technology around that to enable it.”
– Shane Pilcher, CIO, Siskin Rehab
In terms of workflow, most EHRs were implemented using out-of-the-box kits that don’t resemble reality and as a result, are not feasible. On the flip side, some workflow blueprints tried to mimic paper processes, an approach that is unrealistic. The key to any optimization is gaining input and consensus from clinicians, but too many of these IT projects were undertaken seemingly to check Meaningful Use boxes. In short, the emphasis has been on process. A clear view of the benefits to be obtained has been obscured.
“Burnout is associated with lower patient satisfaction and care quality, higher medical error rates and malpractice risk, higher physician and staff turnover, physician substance abuse/addiction, and physician suicide. The causes are numerous, and in many cases physicians point to the increasing demands of electronic medical records, quality metrics, administrative tasks such as prior authorization, and value-based payment requirements, which take time away from direct clinical care”
-Donald O. Mack, MD, FAAFP, AGSF, CMD, Ohio State University Wexner Medical Center
The direct and indirect costs associated with physician burnout are often underestimated. Through a more engaged, satisfied workforce, physicians and their organizations can provide better, safer, more compassionate care to patients, which reduces the total costs. Burnout can be prevented with a systems-based organizational approach that targets the cultural, practical and personal domains that must be addressed to improve physician well-being.
It’s with this background that the concept of clinical cycle management (CCM) has been formulated. According to Dr. R. Hal Baker, Sr. VP Clinical Improvement & CIO, WellSpan Health, the currency of executive clinicians is attention, and they must decide where to spend their attention units and be judicious with how they spend them.
A recent study from the University of Wisconsin School of Medicine and Public Health and the American Medical Association, finds that primary care physicians spend more than half their workdays in the EHR, with heavy attention investment on what the study calls “administrative” tasks. The goal of CCM therefore is to optimize the EHR such that it enables the clinicians to use it in real-time during patient interactions to ensure accurate documentation, increase overall efficiency, and take advantage of decision support built into the technology.
What We Should Do:
Profiling an EMR application allows for robust and rich usage data gathering, including clicks, mouse movements, and time spent. Analysis of these workflows, using a temporal query tool, allows for identification of bottlenecks, poor workflows, and other time sinks. It shows both individual user activity, as well as aggregate data, and lets you define logical EMR “tasks.” It provides the basis for realizing workflow optimization efficiency gains through:
1. Workspace modification
2. Training
3. Automation through macros
4. EMR UI augmentation
“We are using Physician Efficiency Profiles, which are reports from our EHR, to identify the physicians that we’re specifically focusing on to help them spend less time in the EHR, be more efficient in the EHR, spend more time with patients, and get home on time, not doing work late at night and on weekends when they’re not scheduled to be working. Those are big factors in physician burnout.”
-Brian D. Patty, VP, CMIO, Clinical Information Systems, Rush University Medical Center
Physician efficiency and satisfaction can be further buoyed by the KLAS Arch Collaborative, an initiative aimed at capturing performance with factors that have already been clearly identified to improve user efficiency and satisfaction. These include effective, ongoing training, EMR personalization, and EMR governance and physician engagement. This is a feasible, practical approach because the majority of EMR users have already accepted and begun to use the configuration. It was handed to them along with their credentials. Users who take the time to personalize their EMR usage to their needs are three to five times more likely to be highly satisfied with their EMR. Further, effective organizations have found ways to quickly incorporate end-user feedback into the EMR optimization process.
Clinical application efficiency is all about workflow. Providers can deliver good care without becoming data entry operators, while still taking advantage of everything healthcare information technology has to offer. Optimization through clinical cycle management uses a combination of great technology and improved workflow, and can have a profound impact on addressing and significantly reducing physician burnout.
Justin Campbell is the VP at Galen Healthcare Solutions, a professional services firm helping healthcare clients migrate from paper to electronic health records. Prior to joining Galen, Justin served as the IT Director for a long-term care pharmacy, leading a paperless initiative, the migration of the Pharmacy Information System (PIS) from a legacy platform, and the integration of the PIS to the pharmacy’s packaging system.
