Physician burnout has long been a significant healthcare challenge, but in recent years with the advent of various technologies into clinical workflows, along with an array of regulatory requirements, the problem seems to be getting worse.
Indeed, there is no shortage of research that backs up the notion that physicians are overburdened, with some surveys having found that 30 to 60 percent of clinicians report symptoms of burnout, which can threaten patient safety and physician health. What’s more, EHRs (electronic health records) are consistently cited as the top burnout factor, largely due to the time one must spend in them documenting and performing other administrative tasks. To this point, a commonly referenced study published in the Annals of Internal Medicine in 2016 found that for every hour physicians provide direct clinical face time to patients, nearly two additional hours are spent on EHR and desk work within the clinic day.
Although federal health officials have been outspoken about the need to combat these issues while improving physician satisfaction, some hospitals and have health systems have been taking matters into their own hands. In Sacramento, not long ago, clinical and IT leaders at the University of California, Davis (UC Davis) Health were eager to get funding to develop and roll-out a program to improve physician efficiency levels within the EHR.
Scott MacDonald, M.D., the health system’s EHR medical director, says that in order to get that funding, his team needed to show the organization’s leadership, via a pilot project, that a program designed around improving physician efficiency in the EHR was worthwhile and valuable. They ended up getting a small team together, mostly volunteers from various UC Davis Health locations, and piloted two high performing clinics and two low performing ones, based on efficiency data from Epic, MacDonald recalls.
In order to determine which clinics were doing well with their EHRs, and which ones were not, the UC Davis Health team looked at a number of factors. For one, they would examine a given individual physician to see if he or she was spending more than the average amount of time on certain EHR “in-basket” tasks, explains MacDonald. “We would then look and compare that data to others in that physician’s department and specialty to see if there were outliers. So that’s a useful tool for us to recognize that this person is efficient with chart reviews but inefficient with writing notes, [for example].”
MacDonald says that they would also survey the physicians to see what they personally feel they are most inefficient with in the EHR. “We wanted to make sure that we address their biggest areas of frustration,” he says, noting that the organization is also looking to add a chief wellness officer to help accomplish this.
Problems in the Trenches
MacDonald says that his team, based on anecdotal conversations with physicians, believes that it’s “patently obvious that doctors are frustrated by EHRs and IT, as well as the other factors from the changes to the healthcare system over the last few years, and the regulatory environment.”
That said, MacDonald doesn’t believe that EHRs are hurting the physician-patient relationship; more so that they are “blamed” for hurting it. “Because of what’s happened over the course of the last decade, with lots of regulatory requirements, even going back to the 1990s with CMS [the Centers for Medicare & Medicaid Services] billing regulations, all those things have been addressed in a lot of organizations through the EHR. So people tend to shoot the messenger and blame the EHR for these ills. But the EHR is really just a tool, and if that tool is built and trained well, it’s certainly a real boon to the quality of care we deliver,” he says. “If people know how to use the tool effectively when they are seeing a patient, [it will] become a partner in the care with the patient, rather than a mediator of the care,” he emphasizes.
Providing some more context, MacDonald believes that if doctors have the computer screen up between them and the patient, and all the patient sees are the wires coming out of the back of the monitor, that doesn’t make for a good experience for the patient. “But if you are in a triangle with the patient and the monitor, and you are engaging the patient in the data you are looking at, then it could be a real positive. Across the U.S., we have not trained our physicians in that aspect of modern medicine. How we use the tool is part of the relationship with the patient,” he says.
A Program Designed for the Physician
UC Davis Health’s Physician Efficiency Program (PEP), modeled after the pilot project in the four clinics last year, tapped program manager Melissa Jost, who oversees six analysts. Teams of three are deployed to clinics to train and build features within the Epic EHR platform. What’s more, Jost supervises two builders and four trainers, an approach that MacDonald believes makes this program particularly unique. “We integrate the building and training in one team. So when we go out to the clinics and work with [physicians], we can not only show them how to use the tools that exist, but also build the tools if one doesn’t exist and there is something that is workflow-specific that’s needed.”
Each team spends up to six weeks in a clinic monitoring workflows, reviewing EHR-use metrics and working one-on-one with each physician to personalize and optimize their use of EHR tools. Clinics also reduce each physician’s patient schedule by 50 percent to allow time for the training sessions right in the clinic during normal clinic hours, with team members also available for follow-up questions or sessions on site, according to officials, who also note that the goal is to engage all primary and specialty care ambulatory physicians by 2020.
MacDonald admits that to date, the data isn’t perfect, but it gives his team broad strokes about how effective individuals, clinics and groups are using the EHR system. Nonetheless, officials point to some encouraging results from the program—namely a 12-percent increase in physician satisfaction, 24-percent increase in physician efficiency, and an average reduction of 25 hours less per month in time spent working after hours per physician trained.
And in terms of anecdotal physician feedback, MacDonald says that they love the program so far. “We have been getting rave reviews,” he notes, noting that he recently asked physicians at one clinic their feelings about the program and how it can improve, to which the near universal response was, “When are you coming back?”
When asked if physicians feel that the core problem with EHRs is the documentation requirements, or technical flaws in the systems themselves, MacDonald chalks it up to a “mix of everything.” He says that this type of tension is common in informatics, and people ask, “Why can’t Epic just do [X]?” But MacDonald notes that oftentimes the system actually can do that thing and the physician might not know how to do it. “Often, people’s frustrations can be easily met with simple training because the tools are already there from the vendor. But that’s not always the case, and that’s why we do additional build work to customize it,” he says.
MacDonald adds that in healthcare, there is always this “undercurrent of external requirements that don’t appear to people to have much clinical value,” such as reporting on quality measures, data collection, and regulatory requirements, but most physicians do reluctantly accept the necessity of these things by working in the modern healthcare system. “But if we can mitigate [the burden] by giving them a faster way of doing it, they will appreciate it,” he says.