Health systems have done studies and surveys to try to determine some of the reasons clinicians report such high rates of burnout. Of all the possible causes, “smack in the middle are EHRs,” said Craig Monsen, M.D., chief medical information officer, at Atrius Health.
Speaking Dec. 17 part of the Harvard Clinical Informatics Lecture Series, Monsen said a basic question Massachusetts-based Atrius Health has to ask itself is: Are we enabling providers to be successful? A primary care doctor and clinical informaticist, Monsen is described as being on a mission to leverage health information systems to enable the joyful practice of reliable, high-quality care.
He noted that an Atrius Health wellness survey found that 45 percent of care team members reported feeling some symptoms of burnout. In one sense, he joked, this may be the easiest time of all to be in his position because “there is no place to go but up. Probably no matter what I do, this is going to improve.”
Formed in 2004, Atrius Health is a nonprofit ambulatory provider with 31 medical practice locations in eastern Massachusetts. It has 715 physicians and primary care providers, along with 425 additional clinicians. It adopted EHRs quite early, has a system-level data warehouse, and gets three-quarters of its revenue from value-based contracts.
Monsen said the approach to addressing burnout at Atrius has been to adopt the Stanford WellMD model. (The Stanford Medicine WellMD Center was created in late 2015 and jointly funded by the School of Medicine, Stanford Health Care and Stanford Children's Health to advance the well-being of physicians and those they serve.)
There are three main areas this focus addresses: a culture of wellness, efficiency of practice, and personal resilience. Although creating a culture of wellness is very important, he said, “We think efficiency of practice is the strongest lever we have.” That is where informatics comes into play.
In a survey of Atrius physicians, they reported spending 41 percent of their time on documentation; 21 percent on their in-basket chores; 18 percent placing orders; and 20 percent retrieving data. One of the main complaints from clinicians is how long it takes to document in Epic, he noted.
Monsen gave some examples of the types of things informatics execs at Atrius are working on. One involves tracking and responding to regulatory requirements that create administrative burdens, and the EHR is the core manifestation of that because you have to click boxes or answer questions that are often federally mandated.
He said Atrius has a strong emphasis on clinical governance. Borrowing from the patient empowerment movement, he likes the phrase, “No decision about me without me.”
“We want to avoid the perception that IT is happening to providers,” he said, adding that the IT/clinical operations partnership at Atrius is a contributor to the KLAS Arch collaborative, a provider-led effort to identify EHR best practices. As an example, he described the work of Atrius service line informaticists who work in specialty groups. “They have a role in evaluating topics emerging in an Epic upgrade or optimization,” he said. They help us decide which ones we take on and localize to their service line. They also help identify other opportunities, and when multiple priorities compete, whether the juice is worth the squeeze.”
Responding to that survey number of physicians spending 21 percent of their time on in-basket chores, informaticists have been looking at what they can do to bring that number down. One effort involved configuration changes about the type of messages they receive. Many were automatic and some didn’t need clinical review.
Another effort involves prescription renewals, which is about 16 percent of in-basket work. Atrius determined that approximately 50 percent of those could be delegated to renewal coordinators using a smart protocol. The health system started work on this change in 2017. In 2019, 30 percent of those renewals have been delegated. The goal is to get to 50 percent. Because each office has different resources and work flows, standardizing these changes has been difficult, Monsen noted. “None of this is for the faint of heart,” he added. “Getting to consensus around protocols is the hard part.”
Finally, Monsen mentioned using EHR audit logs to understand how many clinicians are working too many hours in the EHR, doing “work after work.” They might take a break for dinner and then get right back into the EHR for documentation at night. The informaticists have broken this down by specialty. “It is a metric that we think is important, looking at work after work by department,” he explained, and a focus of 2020 projects they initiate will be to see if they can move the needle on this issue.