On Tuesday, April 23 at the InterContinental Hotel in downtown San Diego, Christopher Longhurst, M.D., the CIO and associate CMO at UC San Diego Health, shared his perspectives on the challenges around electronic health records (EHRs) and physician burnout, during the Southern California Health IT Summit, sponsored by Healthcare Innovation.
Speaking on the topic “Physician Burnout and Data-Driven Medicine in the EHR Era,” Dr. Longhurst, a practicing pediatrician and current CIO and associate CMO who is also a former CMIO, shared with his audience of healthcare leaders some fascinating research around physician burnout and EHRs, and his perspectives on that research. Longhurst is helping to lead colleagues forward not only at the 8,900-employee, 1,286-physician, two-campus UC San Diego Health, but also, with a team of fellow CIOs, across the five-health system UC Health system; the collaborative of CIOs from those health systems is working to evolve forward some large-scale initiatives around data and IT, including efforts to improve physician satisfaction with EHR use across UC Health.
With the goals of the Quadruple Aim—including the fourth goal, around caregiver well-being, first suggested by medical researchers in 2014—top of mind, Longhurst and his colleagues at UC Health have been trying to determine how EHRs and EHR-related processes can possibly be improved in order to reduce or end physician burnout around EHR use. An early step in that journey was the creation of the UC San Diego EMR Satisfaction and Efficiency, which involved the surveying of UCSD Health medical staff in the fall of 2017 and 2018.
With regard to that survey, not only did Longhurst and his colleagues execute the survey twice; the survey was nationalized, with the leaders of individual patient care organizations able to gauge the level of satisfaction or dissatisfaction of their physicians, relative to the experiences of physicians in other organizations. “If you listen to physicians, it may sound as though everyone’s upset nationwide,” Longhurst told his audience. “But on this scale than ran from -100 to +100, we actually scored a +27.4 score, which put us in the 75th percentile” of patient care organizations nationwide. So while there certainly are UCSD Health physicians who are highly dissatisfied with their organization’s EHR, there are also many who are relatively positive about their EHR experience. Meanwhile, Longhurst noted, “The reality is that this is a national conversation now. Abraham Verghese wrote about this in the New York Times Magazine” in May 2018 (“How Tech Can Turn Doctors Into Clerical Workers: The Threat That Electronic Health Records and Machine Learning Pose to Physicians’ Clinical Judgment—and Their Well-Being”).
Meanwhile, Longhurst told his audience on Tuesday, “We need to look at a range of issues” to address physician burnout, not just around EHR dissatisfaction itself, but also such factors as “rapid patient turnover, decreased autonomy, merging hospital systems, an aging population, and the increasing complexity of patients,” all of which are impacting physicians, and which are not EHR-related specifically, but which tie into physicians’ perceptions of EHR use.
The fact of the diversity of actual causes, came home to Longhurst when he was in Singapore a couple of years ago, having been asked to observe an EHR rollout. “I was there observing the rollout, and was asking physicians how they liked the EHR, which is from the same vendor we use,” he told the audience. “I went back to the CMIO, and I asked, ‘Why are your doctors happy?’ And he said, ‘I don’t know, Chris, but why are your doctors unhappy?’ And one of my observations during that visit was that when the doctors there wrote notes, they were about the patients and patient care, not about billing or finance or regulatory compliance.”
Following that visit, Longhurst and some of his colleagues did an analysis of the various lengths of physician notes in the EHR. “There’s a bell-shaped curve in the U.S. around note length,” he said, “with a median note length of 4,000 characters—that’s a novel!” he told the audience. “And then we looked at the international clients of our EHR vendor; and the median there among its international clients was 500 characters. Also, the shortest note lengths are among physicians at capitated organizations in the U.S. So we wrote all that up in the Annals of Internal Medicine, in July 2018,” he noted, in an article entitled “Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause?”—authored by N. Lance Dowling, M.D., David Bates, M.D., and Dr. Longhurst. “My bias,” he said, “is that EHR burnout is a symptom for something else—the fact that we’re documenting things other than documenting patient care.”
Following up on that point, Longhurst asked, “So what can we do about this problem of the EHR contributing to physician burnout? First of all, you need to use local data to understand how your physicians are using the system,” he said. “We’ve expanded our EHR platform to over 200 locally affiliated specialists. They’re spending significantly less periods of time putting in orders, because significantly bigger portions of orders are being teed up by their support staff—in contrast to what they have to do inside our organization. We’ve also launched the UCSD Home for Dinner Program,” he said, describing the program he has helped to lead at UCSD Health, which is working to reduce the amount of time that practicing physicians need to spend documenting every day and evening—a key source of frustration for doctors. Significant reductions in documentation time have resulted, he noted: in particular, the program has resulted in a median reduction of 75 percent of after-hours documentation time. The goal, he noted, is to close visits before seeing the next patient. And the Home for Dinner program is aligned with the organization’s Primary Care Flow Collaborative.
At the same time, Longhurst noted that workflow redesign, as supported by the information systems team in an organization, are needed, in order to ensure that all clinicians are practicing at the top of their license—a key source of satisfaction for physicians and all clinicians. And, he added, using data analytics to target areas of impact can be very useful as well. He also discussed the connection between and among improved physician documentation, patient engagement, and OpenNotes, which the entire UC Health system has embraced.
The horizons continue to emerge, Longhurst noted, including the participation of all five UC academic medical centers’ participation in the Apple Health venture, in which patient care organizations nationwide are participating in Apple’s initiative to provide patients/consumers with their stored health data via their iPhones. As Drs. Longhurst and Aaron Neinstein reported in a blog published on January 16, “In a major advance for patients, the nearly 5 million people who receive care annually at any of the University of California medical centers – including Davis, Irvine, Los Angeles, San Diego, and San Francisco – can now securely download their medical records data to their own Apple smartphones. Over the past decade,” the physicians wrote, “our patients have had increasing access to their own health data via electronic patient portals. Now, in an exciting transformation in health care, patients are shifting from simply accessing their health data to more directly managing and using it to improve their health and care.”
