What does the apparently widespread dissatisfaction of physicians in practice, with electronic health records (EHRs) mean for the eventual success or failure of EHRs, in the context of the essential need for them to succeed in patient care organizations? And what can—and should—medical informaticist leaders in those organizations be doing right now to change the narrative around MD EHR dissatisfaction?
Those questions were at the heart of the discussion during the course of the CMIO Roundtable, held Tuesday afternoon at HIMSS18 in Las Vegas. John Halamka, M.D., CIO of Boston’s Beth Israel Deaconess Medical Center, led a lively session that involved four brief presentations by panelists, and then a wide-ranging discussion, and audience question-and-answer session, in front of an audience that was overwhelmingly composed of clinical informaticists.
Halamka was joined by Michael I. Hodgkins, M.D., vice president and CMIO at the Chicago-based American Medical Association (AMA); Natalie M. Pageler, M.D., CMIO at Stanford (Calif.) Children’s Health; and Taylor Davis, vice president of innovation at the Orem, Ut.-based KLAS Research.
(l. to r.) Davis, Pageler, Hodgkins, Halamka, on panel
Hodgkins went first, and spoke about the broad national trends in the area of physician satisfaction/dissatisfaction with EHRs—and what needs to be done about that. “We didn’t have much control over the EMR,” Hodgkins said. “Remember 2008, when they we relooking for shovel-ready projects, and they decided that every EMR was a shovel-ready project? The current problem? We’ve all heard about burnout. And the AMA has been doing biopsies on burnout for years. In 2014, the number was 40 percent; in 2016, that number was already about 50 percent.”
The implications of the reality of high percentages of EHR-embittered physicians are many, Hodgkins said. “Burned-out physicians do a poor job; they create more patient safety problems,” he said. “A year ago, the AMA hosted ten of the CEOs of the leading integrated health systems, and they published a white paper, and declared burnout the most important health crisis of our time,” he noted. “Just to quantify it for you, the CEOs of these health systems basically said that a burned-out physician costs them between $500,000 and $750,000 a year. Think about that—in terms of replacement costs, lost productivity, etc. So, however you want to measure it, in terms of physicians leaving the field, or patient care issues, your organization needs to pay attention to this. And studies from the AMA and Mayo or the AMA and Dartmouth, studies have shown that for every hour that physicians spend on direct patient care, they spend two hours on documentation and administrative issues; and that doesn’t even include so-called ‘pajama time.’”
Hodgkins continued, “Between 2011 and 2014, somebody did the math and said there was a 1-percent loss of productivity as the result of EHR use; and that sounds very conservative, really. That’s the equivalent to the graduating class of seven medical schools during the same timeframe. Think about the loss of people leaving as a result of burnout. Think about that from a workforce perspective, and from a patient care perspective. And we have been struggling with this… There are now 200,000-plus or so health apps, and 320 mobile apps [emerging] every day, by some estimates. All this sets us up for a whole new wave of potential problems that can generate even more burnout among physicians, unless we address the issues early and quickly. 200,000-plus apps. There’s no FDA oversight of that space; it’s a Wild West. And those apps generate reams of new data.”
In that regard, Hodgkins said, “The AMA feels very strongly that physicians and clinicians need to be involved in the development of these apps. We did a survey in 2016 and found that in general, in spite of their experience with the EHR, 75 percent of physicians thought they could potentially benefit from this new crop of digital health solutions; they recognize that it’s hard to manage chronic health problems like hypertension, in the clinic.”
What Stanford Children’s Health is doing to improve MD EHR satisfaction
Despite all the challenges, the leaders of some patient care organizations are actively working to improve the situation. Dr. Pageler, the CMIO at Stanford Children’s Health, told the audience that she and her colleagues have been working hard to enhance physicians’ satisfaction with EHRs and with their work. Among their strategies: “We have a very extensive education and personalization program; we call it Home For Dinner,” she testified. “Three components were involved that allowed us to gather information about providers. We used our EMR’s data to obtain an efficiency profile” with regard to how efficiently physicians appeared to be documenting. “We did a survey to get their own perspective on what they’re doing with the EHR. And finally, we did observation sessions with individual physicians, with [help desk] trainers going out and observing physicians” doing their documentation. Those sessions clearly gave us a lot of information on what MDs were doing, but also on what we could do to improve workflows in the clinics.”
Following those steps, Pageler said, “From that information, each provider was given a personalized learning plan, complete with personalized tips, with special tools. The providers were incentivized by our organization to do this; they got funding for participating in the program. From the program we did see some significant improvement in education and decreased turnaround time.” Physicians motivated to set goals for themselves made “dramatic changes” in the amount of time they spent documenting. “For example,” she said, “one of our more experienced nephrologists, was spending a ton of time documenting on the weekends; his goal was to stop spending time on the weekends; and he’s achieved that.”
One key element in all this, she said, was that “CMIOs need to get involved at all levels, within medical specialties,” across patient care organizations, and nationally.
A fresh look at the landscape nationwide
KLAS Research’s Davis spent some minutes sharing information about surveys of CIOs and others, around this set of issues. “I am really, really nervous that the level of hope around EMR success is at an all-time low,” Davis said. “When you don’t have hope that you can be successful, you act in different ways, and it becomes a self-fulfilling prophecy. I was in a focus group with 14 CIOs. Everyone agreed that EMRs were key” to overall work satisfaction among practicing physicians. “I asked, who here agrees that you can get your physicians to be successful and even grateful for your EMR? One hand came up. That’s a problem. And let’s talk about the issues. There are documentation requirements; we’re turning physicians into clerks. But there are organizations that are highly successful with their EMRs, and their clinicians are satisfied with them.”
In that regard, Davis said, KLAS 15 months ago created something called the Arch Collaborative, to help the leaders of patient care organizations rethink EHR usability, and the satisfaction of physicians and other clinicians, with EHRs. One key insight? Physicians feel incompetent, stupid, when interacting with EHRs. Like Pageler, Davis told the audience that it is essential for healthcare IT leaders to help the physicians in their organizations personalize their EHRs, for greater usability. And, he added, “The most predictive factor of satisfaction is not which EMR you’re using, but your organization, based on culture. … We believe that the EMR magnifies culture, and issues within an organization,” he said. “But you can be successful.”
“At Beth Israel Deaconess,” Halamka noted, “we’ve created a program called Crowdsourcing. We have clinicians who code. And if you create an app specific to your area, go for it. We tell them, here are the rules of the road, and we do version control, and then we’ll put it into our approved app store. We have about a dozen apps in that store already—in orthopedics, cardiology, and so on, and all kinds of interesting emerging technologies. And it truly is pride of work, created by doctors and for doctors.”
And, Halamka added, speaking of the keynote address delivered Monday by Eric Schmidt, the former chairman of Google, in which Schmidt proposed that in the future, physicians will make use of virtual-assistant technology in their patient visits that will eliminate the need for the burdensome levels of documentation currently required, “Eric Schmidt stole my thunder” in this context. “The future of documentation,” he said, “should be, the doctor and patient have a discussion, with an ambient device recording key information, and what is included in documentation should be determined by the specialty societies.”