In surveys, physicians regularly identify electronic health records (EHRs) as a contributing factor in burnout. Health systems are taking a variety of approaches to address the issue. At Healthcare Innovation’s Health IT Summit on June 3 in Philadelphia, informatics leaders from Nemours Children’s Health System described a program to give some physicians special training in informatics and an opportunity to work with their colleagues on EHR optimization.
Nemours has children’s hospitals in Wilmington, Del., and Orlando, Fla. Gina Altieri, senior vice president and chief of strategy integration, said that through surveys Nemours recognized health IT does play a role in physician burnout. The question was what to do to mitigate its addition to the stress physicians feel.
Although the health system has many IT analysts working with the Epic EHR, Altieri said they may not understand the struggles physicians have or their work flows. Nemours decided to start a program called Physician IT (PhIT) to enlist physicians with an aptitude for creating efficiencies and working with their colleagues. “We send them to Epic for training,” she said. Then they take time to observe clinicians and their workflow before developing some solutions.
In a panel session of Nemours executives, Altieri asked David West, M.D., medical director of health informatics, what attributes he looks for in potential candidates for PhIT. The first two he mentioned are a comfort in working with data, and people who like to work with applications and create things themselves. “The third is creating relationships with colleagues on a plane you are not used to,” he said. “You are coaching. You need to be good at establishing relationships with individuals and groups so that they have a feeling of having more control over their experience. The issue about engagement is partly about how much I can control what is happening to me and make the experience better.”
Matt Di Guglielmo, M.D., was recently named chief of the Division of General Pediatrics in the Department of Pediatrics
He said participation in a Physician Leadership Development Program has had a major impact on his career. It allowed him to get a better understanding of organizational dynamics and physician wellness. “Without exposure to those topics, it would be more challenging to take on a leadership role as division chief,” he said. “It has allowed me to relate better to faculty and colleagues.”
Asked about barriers to impacting physician burnout, Di Guglielmo said, “System inertia can prevent us from making changes.” He added that there is a move away from using the term burnout and more about a syndrome of depersonalization, exhaustion and a feeling of not accomplishing anything. “It is a complex, multifactorial issue and it requires time, money and personnel, which are not always easy to come by in healthcare. We are taking bold steps. Whether they always work is not as important as doing them and trying to make things better.”
Sara Slovin, M.D., a primary care physician in the Department of Pediatrics, who went through the PhIT program, said solutions have to be custom-designed to meet the individual physician’s needs. “First we meet with them to identify what they are struggling with,” she said. For some it is that documenting is taking too long and they are typing notes late at night. They may want to try Dragon dictation or using a scribe or more macro tools. “It is so valuable to see the ah-hah moment,” she said. Making documentation easier can change their experience of work. “Our goal is not to change work flow completely,” she added, “but to enhance it and make them feel better.”
Immediately after their presentation, the panelists sat down for an interview with Healthcare Innovation Editor-in-Chief Mark Hagland. Below are excerpts from that interview.
What are the key elements in what you discussed just now that CIOs, CMIOs, and other senior healthcare IT executives in patient care organizations should be thinking about right now?
Altieri: As Matt said during the panel discussion, I think they need to appreciate that there’s an issue here. And the more technology we throw on people, the more they need to learn. And sometimes, it’s too much. I remember when we built our Orlando hospital, it turned out to be too much for the doctors. I think sometimes the tech people don’t understand that.
West: People’s personal experience with technology is, what works is what I can achieve on my own. It is complex. And healthcare has a different type of data set, with different, and multiple currencies. Many other industries work in a single currency, money—such as the financial services industry—but that’s simply not true in healthcare.
Are patient care organizations asking physicians to do so much on electronic health records? Not only asking that they document clinically, but also supply data for outcomes measures for quality regimens, and many elements related to billing and reimbursement, etc.?
Di Guglielmo: When you think about paper charts, which I trained on, things were very different. I would open a patient’s chart, and there were three things I had to look at, and I could tell you everything about that kid and that kid’s family. Things are different now. How do we bring the advantages that we had from working on paper, together with the electronic capabilities that have transformed how we work?
West: When I talk to residents who work on these templates for progress notes, whether ambulatory or inpatient, they’re trying to learn how to use a tool, and the most valuable thing is not your ability to use technology, but what you think [and which is translated into clinical documentation in the EHR]. I want them to write what they think. That’s the most valuable commodity, so we [can’t] add too much on there with documentation and billing requirements.
Slovin: Note bloat is a real problem, and there’s a lot contributing to making notes lengthy and convoluted, such as some of the graphical representations and trying to get to where you can digest a lot of information quickly. We struggle with that; so many elements have to be present in a note for billing purposes, but it gets too complex. So there’s an education piece to all of this as well.
Altieri: I don’t think the industry recognizes what you were saying, Dr. West, per value. When value comes into play, it’s more than just a change in reimbursement and taking care of populations, having this data. Then it does become a tool for population health.
Slovin: And we’re lucky working in a health system in which there are other people generating data that goes to insurance companies, that our employed physicians don’t have to do. But the fact that we’re provided with dashboards helps us think about how we might want to change some of the things we might do differently in our practice.
West: We need to think about who the data managers will be in all of this. One of the departments that has undergone a huge revolution has been the HIM [health information management] department. And HIM’s whole mission has changed with the advent of EHRs. I think a new paradigm for healthcare organizations is, how do we focus those resources into being effective managers for physicians, so that when they come to the chart, it’s recognized cognitively? We have a big clinical logistics center, where we process things. And we staff that center with EMTs. They’re used to making quick decisions on a fixed set of data, and are good at protocols, etc. So we’re thinking about how to make this HIM department into something else, something that helps physicians. We have all this interoperability and HIE, but nobody has solved how you incorporate vaccination list data, medication list data and allergy list data into the EHR, in a coordinated way. This is falling on the physicians, and most are balking.
Di Guglielmo: With regard to our discussion about CIOs and CMIOs, if the organization is having a meeting and all the folks are sitting around and talking about burnout, they’re missing the discussion—it’s how we change the organization and the system. And one piece of that is the information technology piece. So have to take a holistic viewpoint. And the CIOs and CMIOs can help facilitate that conversation.
Slovin: It’s also working to engage your team members to work at the top of their licensure. So how do we have a team-based approach to managing all the data. Informatics is a piece of it all, a very valuable piece; but it’s not the whole piece. It’s really the documentation that bothers people. How can we transform the requirements facing all the clinicians?
Di Guglielmo: Whenever anyone is thinking of reforming processes, they need to understand that if a process involves the physicians, then problem-solving with the doctors should happen first.
Slovin: We’re exploring reforming discharge summaries right now, and we’re actively talking with the physicians.
