While optimizing the electronic health record (EHR) remains a major pain point for provider groups across the country, some organizations that are committed to reducing IT-caused burnout are reaping the benefits and turning the EHR back into a tool that improves care rather than causes dread among physicians.
As a follow-up to the “call of action” report that was released earlier this year by the Massachusetts Medical Society (MMS) and the Massachusetts Health and Hospital Association (MHA) Joint Task Force on Physician Burnout, a whitepaper was issued detailing the story of how Reliant Medical Group, a 500-provider multispecialty group practice in Massachusetts, was able to change its EHR system from a liability to an asset.
Reliant Medical Group scored 59 percent above the national average—among the highest in the nation—when it came to users assigning scores to EHR implementations in a national 2015 Press-Ganey survey. Then in 2016, Reliant’s EHR ranked in the 97th percentile nationally for usability.
Healthcare Innovation Managing Editor Rajiv Leventhal recently spoke three key leaders involved in the call to action report, as well as the whitepaper: Alain Chaoui, M.D., immediate past president of the Massachusetts Medical Society; Steven Defossez, M.D., vice president, clinical integration at the Massachusetts Health & Hospital Association; and Larry Garber, M.D., a practicing internist and the medical director for informatics at Reliant Medical Group.
Part two of this two-part piece on how medical informatics leaders are working to reduce physician burnout illustrates Reliant’s EHR optimization journey, while exploring the role the government should play in the requirements it places on vendors, as well as taking a look at the evolution of EHRs, and if providers aren’t being patient enough. Below are excerpts of that discussion; part one can be read here.
EHRs are commonly cited as a primary factor of burnout and are perhaps even the most significant pain point for physicians. Dr. Garber, as a medical director for informatics at a physician group, can you describe what you’re doing to relieve physicians of EHR-related burnout?
Dr. Garber: The key thing we did was actively involve clinicians on our IT team. We have four physicians, a physician assistant, a medical assistant, and a nurse on our IT team. So, that’s about five FTEs of clinicians for a 500 provider practice on our IT team. We are employed by IT, we work in IT, we have cubicles in the middle of our IT department, we are certified on our EHR, and we go in there, configure it, optimize it, and do programming for it, so we are embedded in the team.
That accomplishes a few things. We are all users of the system, so we are acutely aware of what’s efficient and inefficient. We are broadly trained so we know the full suite of solutions and can help the group decide which one makes the most sense from a clinical, operational and efficiency perspective. And because we are constantly meeting with the team, and are part of the team, we make decisions rapidly so when there’s a problem that comes up, we rapidly come up with the best solution and implement that solution.
Because of that, we have fine-tuned our EHR quite a bit, focusing to make sure it works for us and our colleagues. And we can do that quickly. We have built up the trust of our colleagues, our clinicians and other staff, because they know when they have an idea or problem they can bring it to us and get it rapidly solved. Through rapid iterations, we have improved our EHR dramatically.
The government has put an emphasis on this issue as well, and having software developers make patients’ medical information available via APIs appears to be a significant step to improvement. What progress is being made in this area?
Dr. Chaoui: The EHR is a leading cause of burnout, and I applaud Dr. Garber and his team for being able to modify his [system] through his access and edition of APIs. It’s also the demands for prior authorizations which have only increased the quality reporting and documentation [demands]. There are a lot of administrative issues that take the physicians away from the patients. But Dr. Garber and his team have been able to modify that and it’s not something that a lot of physicians have been able to accomplish. We have not been able to modify our EHRs because of the restrictions placed on every EHR for adding those APIs.
Dr. Garber: I don’ think the API piece is going to in itself solve the physician burnout problem. It is important for care, and will enable us through technologies, such as CDS Hooks, which is based in FHIR, to resolve gaps in care faster and give us better access to clinical decision support right in the middle of our workflows.
But that isn’t getting to the root of the problems for physician staff burnout. The issue there is that many of us have too much work and not efficient enough tools to deal with that work. That’s why our focus has been working within the EHR to not have physicians do the work that nurses can do, not have nurses do the work that medical assistants can do, and not have medical assistants do the work that secretaries can do. Then the EHR can be used to substitute tasks to other people; we have maximized our use of that.
Also, for each of us doing our tasks within the EHR, we have optimized it to make it easier to do things that can be automatedly done by the computer. And we have them done automatedly—that’s an extraordinary amount of stuff. For instance, reconciling immunizations—as part of Meaningful Use, we all had to turn on the ability to reconcile outside immunizations. Well, you don’t need a human to reconcile them. A computer can do that; it can identify if there’s a duplication, and if it’s primary source data, and then can automatically load it into our EHR. So we’re doing a lot of little things where we are reducing the amount of work that all our physicians and staff have to do, and in turn that reduces the burden of the EHR and turns it into a powerful and useful tool. For APIs, I think there’s a lot of hype which probably means a lot of disillusion that will come from that.
Dr. Defossez: I would agree with what Larry said. The power of the computer is to automate multi-step processes and a lot of organizations have focused on reducing the number of clicks that humans have to do since computers can do it more rapidly, accurately and obviously without creating burnout.
In terms of the APIs, Larry has expressed the point of view of the physician community. We wrote a letter to ONC regarding the government’s recent interoperability proposals, and we said that instead of requiring patient-facing APIs, there needs to be some kind of requirements for baseline API access without complex business models, without IP constraints, and without transaction costs. We recommended that ONC require that every vendor make these APIs available, without transaction fees, so that third-party innovators can create tools to reduce physician burden.
Do you think that perhaps we’re all too hard on EHRs in their current state and that we should give them time to evolve, just like all other technologies?
Dr. Garber: I think there are some superb EHR vendors out there that have great functionality, like the one I use—Epic. And others are superb, too. They have improved by a lot in the dozen years I’ve been using them, to the point where they are incredibly functional. The problem very often is with the implementation. We have spent a lot of focus on configuring it properly, training it properly, and retraining it properly. We have a team that goes out and continues to optimize our physicians and staff to make sure they are using it in the most efficient way possible, and also that they remember the efficient ways to use it. So I think at this point the biggest problem is inconsistent and inadequate implementations, including the configuration, training, retraining, and optimization that needs to be all part of it. That’s the biggest flaw at this point; not the vendor functionality.
Dr. Defossez: I agree with a few of those points strongly; the first one being the importance of local investment in individualized training. These EHRs are incredibly mailable with lots of optionality, but there is growing evidence that when we focus on individual clinician training and optimization, we can get significant improvements in efficiency, quality of care and clinician satisfaction.
A study came out this year about local investment and training driving EHR user satisfaction. They looked at physician satisfaction of EHRs across a number of different brands, from the inexpensive to expensive ones, and the satisfaction wasn’t necessarily correlated with what brands you had or how much money you spent on it. But they concluded that much of the variation in user satisfaction across platforms was due to the individualized training and optimization. So the good news is we are uncovering areas to improve the user experience and decrease worker burden, and I think that’s the take-home message: we are making a lot of discoveries and as we get these discoveries out on the field, things will get better.
EHRs are relatively new. If you think about when the first automobile was invented by Karl Benz, it wasn’t [until] 25 or 30 years later when it was coming off an assembly line on the Ford Model T—and that was a great improvement on the first motorized cart. But by today’s standards, it was unreliable, difficult to start, had no safety features, no self-driving features, or no airbags.
So we are still early on in the development of the EHR. I am confident that the doctor-patient conversation will be automatically brought into the EHR, in the right fields, and by the time the doctor is finished talking to the patient, the EHR will spit out the prescriptions for the patient at the drugstore, and a follow-up with the specialist will already be set up at a convenient point in time for the patient by looking at their cell phone and calendar. The technology will only continue to improve.