Even before the pandemic, the introduction of new digital health tools and regulatory and administrative requirements put additional stress on providers who have grown to dread the “pajama time” spent working on charts at home late at night. During an Aug. 11 Digital HIMSS21 session, several clinical leaders discussed how their organizations are addressing the issue.
“There’s a huge influx of data coming into our systems, and there are a lot of tools and documentation needs, said Isil Arican, information services director at Stanford Children’s Health, where she oversees the Ambulatory, Fertility & Transplant EMR systems, Mobile EHR Applications, and Patient & Provider Portals. “There are regulatory and billing requirements, like the Cures Act that went live recently. Also, I think patient expectations are shifting, and patients want to be more informed, with faster information flow to them. It all creates a lot of additional tasks and burden on all of us.”
Panelists mentioned that with the addition of technology tools, clinicians have lost some of the staff support that used to serve as filters for them and do some of the administrative and patient engagement work, stressing them out even more.
Arican said Stanford has done a lot of work to address physician burnout using multidisciplinary teams to study EHR usage. Some aspects of EHR usage that are aligned with burnout are a lack of alignment with workflow and insufficient training, Arican said.
“The frustration with technology is mostly rooted at the individual level, rather than the work setting level,” she added. “We are able to identify providers at risk by looking at the data but also by doing a lot of in-person observations of them to see what they struggle with and talk to them and come up with some ways to help them. It can be different from person to person or from specialty to specialty or related to that person's overall comfort level with technology. So there's not like really one-size-fits-all approach. I think what we learned over time is that to be able to personalize it and find solutions for each individual user works the best.”
Moderating the panel, Christine VanZandbergen, M.P.H., M.S., P.A., vice president of analytics and research at Penn Medicine, said her organization found “that needs to be a pretty gentle conversation. Physicians were already feeling pretty burned out, and when you go to them and say ‘here's all the data we have about you and what you're not doing well, let me help you,’ it wasn't always received well.”
Jenifer Lightdale, M.D., a gastroenterologist at UMass Memorial Children's Medical Center in Worcester, Mass., said when you come to a clinician with data about them, it's important to recognize that they are going to go through a grief process. “They are absolutely going to be first off in denial; then they'll be very angry at you,” she said. “I tell people to embrace the anger because after that is when you're more likely to actually get towards acceptance. I do think you need to couple that with telling them you came to them with the data, because we want to help.
Emily Oken, M.D., a professor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute, remembered that when she stepped away from part-time practice, the stress caused by shifting to a new EHR system was part of the reason. "My institution had a homegrown EMR that was well refined to work pretty well in that setting,” she said, “and we adopted a national commercial EMR and the amount of time and energy and money spent on implementing this new EMR just wasn't worth it to me, to be honest, given that I was a part-time provider,” she said. She shifted more of her time to teaching, and she says her quality of life improved dramatically.
Lightdale said that burnout has been a very common experience for pretty much anyone in a clinical role because of the pandemic. She said that burnout clearly affects the entire clinical team, and it affects patients and patient outcomes. “What you see with physicians initially seems kind of subtle, where the physicians seem a little cynical, they may be kind of negative, they're clearly not enjoying being at work,” she said. “You get a sense that they are not happy when they're at home, and unfortunately, a lot of that is because of the so-called pajama time where all the bureaucracy is following them home, and they really are not able to get away from work.”
Unfortunately, she added, that can spill over into their personal life. That can lead to marital distress, challenges in caring for children or aging parents, self-medication and even suicide. “To the patients, what they're feeling is a physician who's not connected, who isn't really having a meaningful relationship with them either in the office or after the visits. And, of course, the big concern is that bad decisions are being made, errors are happening, bad patient outcomes are happening.”
Arican said EHR optimization can have a positive impact. “We did a program called ‘home for dinner,’ which we used to decrease their out-of-clinic documentation time and help them be more effective in the system so they don't spend as much time as before,” she explained. “We did pre-surveys on things that they are struggling with most often and need help with most. We use remote and in-person observations and EHR data and created individual learning plans for each individual that we work with. Because as I mentioned before, everyone's needs are different.”