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UC Davis Health’s Physician-Specific Approach to Addressing Burnout

October 16, 2018
by Rajiv Leventhal, Managing Editor
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To combat the physician burnout epidemic, one health system is taking matters into its own hands

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].”

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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.

 


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Gazing Into the Crystal Ball with LRVHealth’s Keith Figlioli

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2019 Predictions on Value-Based Care, Digital Startups, EHR Trends

Here’s a confession: I am much better at writing end-of-year review stories than I am at looking into the crystal ball for preview pieces at the beginning of the year. I might be able to make educated guesses about which issues we will be writing about in the coming year, but I prefer leave predictions about what is actually going to happen to others.

Luckily, people braver and more knowledgeable than I am are willing to weigh in. For instance, Dave Levin, M.D., chief medical officer of Sansoro Health recently shared his predictions for 2019 with Healthcare Informatics. One of his predictions is that “the excitement around new health IT players like Apple and Amazon will fade in late 2019. We need fresh ideas, but in the short-term, expect disappointments and missteps. Health IT (and healthcare in general) is much harder than it looks and the winners in the long-run will master the mash-up of the best of old and new. Health IT history is littered with companies like these that underestimate this challenge.” Good point!

Dave’s company, Sansoro Health, provides a set of APIs that read and write to EHRs. One of its investors is Boston-based LRVHealth, and one of LRVHealth’s general partners is Keith Figlioli, who served as senior vice president of healthcare informatics at Premier Inc. for nearly a decade. In December I spoke with Keith about some of his predictions for 2019.

One is that capital will be less abundant for digital health startups in 2019. I asked him why he thought that would be the case. “There already is a tremendous amount of capital in this space, including capital coming from other industries. The threat is that capital could be less abundant,” Figlioli said. “We are starting to see earlier stage companies have a little harder time raising capital. What that signals to us is that the greater market is pushing capital to later stages. Because capital can be harder to get in earlier rounds, valuations tend to float down a bit. The other thing is that the greater macro economy does feel like things are shifting a bit and that will also have an effect. I think 2019 may be a peaking year for valuations. I don’t think we are going to go much higher than we are right now.”

While Dave Levin had predicted that the enthusiasm about outside disruption from Big Tech might fade by the end of 2019, Figlioli predicted that these emerging entrants will start showing their cards. “Some of these guys are fairly secretive in their moves, but Apple has been hiring in healthcare and Amazon acquired PillPack. My sense is that we are going to know more about the ones that have been secretive,” he said. Now that the CVS/Aetna deal is done they will start to reveal more, he added. “We are going to see more announcements from these players over the course of 2019. People will be able to start deciphering what their plans are, at least out of the gate.” With its leadership in place, the Amazon/Berkshire Hathaway/JP Morgan entity will reveal an initiative, he predicted.

He also noted that Walgreens made some strategic announcements in 2018. “I call them the sleeping giant now, because CVS and Aetna made all the noise with their purchase deal. But Walgreens is making some very calculated moves with the incumbent players.”

Figlioli predicts that in 2019 the pace will pick up again on value-based care activity. “At LRVHealth, we have a saying that value-based care is inevitable but it is gradual,” he said. “I think we are finally going to get back up on the hamster wheel with things that really matter, because it feels like we have basically been at a dead stop since Trump took office.” He expects to see a handful of new mandatory and voluntary programs across cancer, cardiac and new bundled payment models. “When [HHS Secretary] Azar came in, it revved the engine back up and he is talking very publicly about ramping up mandatory programs. I think another signal is him talking more about CMMI [the Center for Medicare & Medicaid Innovation] and what may come out of it in terms of social determinants of health. I think we will see one or two CMMI pilots in 2019 dedicated to social determinants.”

In a related prediction, he said we should expect to see community programs such as local food banks become more closely affiliated with healthcare providers and payers. And just as there have been startups in the transportation area of social determinants, expect to see a few food-as-medicine related startups emerge in 2019, he added.

Figlioli’s final prediction touches on something I have written about a few times, the new “app store” approach to EHR add-ons. With open APIs gradually becoming the norm, he said, more CIOs who will become comfortable layering best-of-breed applications on top.

“There has been this lure in the CIO suite to say that the EHR vendor is going to do everything.  But because of what Cerner and Epic are doing and what athena has done all along, we are finally getting to a place where the average CIO is going to going to be OK going back to more of a hybrid model.” He stressed that the core EHR is not going anywhere. “You can think about them the same way you do about ERP systems. Over the last five years there has been a proliferation of overlays on top of them. And I feel like we are finally going to get to that with the EHR. It is not going to be clean or easy. There are going to be issues. It is going to be a pretty messy situation depending on how FHIR gets implemented. But it will become more of a cultural norm that Epic and Cerner don’t have to do everything. CIOs will say, ‘we are OK with them being our core workflow tool, but now we are allowing an overlay to take place.’”

 

 

 

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Research: Physician Burnout is a Public Health Crisis; Improving EHR Usability is Critical

January 18, 2019
by Heather Landi, Associate Editor
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Physician burnout is a public health crisis and addressing the problem requires improving electronic health record (EHR) standards with a strong focus on usability and open application programming interfaces (APIs), according to a new report from leading healthcare researchers.

The report is a “call to action,” the researchers wrote, “to begin to turn the tide before the consequences grow still more severe.” The researchers also recommend “systemic and institutional reforms” that are critical to mitigating the prevalence of burnout.

The result of collaboration between researchers with the Massachusetts Medical Society, the Massachusetts Health and Hospital Association, the Harvard T. H. Chan School of Public Health, and the Harvard Global Health Institute, the report's aim is to inform and enable physicians and health care leaders to assess the magnitude of the challenge presented by physician burnout in their work and organizations, and to take appropriate measures to address the challenge, the researchers say.

The report also offers recommended actions for healthcare leaders to take, which the researchers acknowledge are not exhaustive, but “represent short-, medium-, and long-term interventions with the potential for significant impact as standalone interventions.”

The authors of the report include Ashish K. Jha, M.D., the K.T. Li Professor of International Health at the Harvard T. H. Chan School of Public Health, and director of the Harvard Global Health Institute; Andrew Iliff, lead writer and program manager, Harvard Global Health Institute; Alain Chaoui, M.D., president of the Massachusetts Medical Society; Steven Defossez, M.D., vice president, clinical integration, Massachusetts Health and Hospital Association; Maryanne Bombaugh, M.D., president-elect, Massachusetts Medical Society; and Yael Miller, director, practice solutions and medical economics, Massachusetts Medical Society.

In a 2018 survey conducted by Merritt-Hawkins, 78 percent of physicians surveyed said they experience some symptoms of professional burnout. Burnout is a syndrome involving one or more of emotional exhaustion, depersonalization and diminished sense of personal accomplishment. Physicians experiencing burnout are more likely than their peers to reduce their work hours or exit their profession, according to the report.

By 2025, the U.S. Department of Health and Human Services predicts that there will be a nationwide shortage of nearly 90,000 physicians, many driven away from medicine or out of practice because of the effects of burnout.  Further complicating matters is the cost an employer must incur to recruit and replace a physician, estimated at between $500,000-$1,000.000. 

“The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients, contributing to a growing epidemic of physician burnout,” Dr. Jha, a VA physician and Harvard faculty member, said in a statement in a press release accompanying the report. “There is simply no way to achieve the goal of improving healthcare while those on the front lines – our physicians – are experiencing an epidemic of burnout due to the conflicting demands of their work. We need to identify and share innovative best practices to support doctors in fulfilling their mission to care for patients.”

The beginning of the physician burnout crisis can be traced back to several events, according to the researchers, including the “meaningful use” of electronic health records, “which transformed the practice of many physicians, and was mandated as part of the 2009 American Reinvestment and Recovery Act.” Going back further, the 1999 publication of the Institute of Medicine’s “To Err is Human” highlighted the prevalence of medical errors, brought new attention to quality improvement and the value of physician reporting and accountability, the report states.

The researchers note that the primary impact of burnout is on physicians’ mental health, “but it is clear that one can’t have a high performing health care system if physicians working within it are not well. Therefore, the true impact of burnout is the impact it will have on the health and well-being of the American public,” the researchers wrote.

The researchers note, “If we do not immediately take effective steps to reduce burnout, not only will physicians’ work experience continue to worsen, but also the negative consequences for health care provision across the board will be severe.”

And, while individual physicians can take steps to better cope with work stress and hold at bay the symptoms of burnout, “meaningful steps to address the crisis and its root causes must be taken at a systemic and institutional level,” the researchers wrote.

According to the researchers, the primary drivers of physician burnout are structural features of current medical practice. “Only structural solutions — those that better align the work of physicians with their mission — will have significant and durable impact,” the researchers wrote in the report.

To that end, the researchers’ immediate recommendation is for healthcare institutions to improve access to and expand health services for physicians, including mental health services.

In the medium term, technology can play a large role. Addressing physician burnout will require “significant” changes to the usability of EHRs, the researchers wrote, including reform of certification standards by the federal government; improved interoperability; the use of application programming interfaces (APIs) by vendors; dramatically increased physician engagement in the design, implementation and customization of EHRs; and an ongoing commitment to reducing the burden of documentation and measurement placed on physicians by payers and health care organizations.

New EHR standards from the Office of the National Coordinator for Health IT (ONC) that address the usability and workflow concerns of physicians are long overdue, the researchers state. One promising solution would be to permit software developers to develop a range of apps that can operate with most, if not all, certified EHR systems, according to the report. The 21st Century Cures Act of 2016 mandates the use of open APIs, which standardize programming interactions, allowing third parties to develop apps that can work with any EHR with “no special effort.” There already have been efforts on this front, such as Epic’s “App Orchard,” the researchers note, but more work remains to be done.

To expedite this critical process of improvement, the report recommends physicians, practices, and larger health care delivery organizations, when seeking to purchase or renew contracts for health IT, adopt common RFP language specifying and requiring inclusion of a uniform health care API.

The researchers also say that artificial intelligence (AI) can play a promising role as AI technologies can support clinical documentation and quality measurement activities.

Long term, healthcare institutions need to appoint executive-level chief wellness officers who will be tasked with studying and assessing physician burnout. Chief wellness officers also can consult physicians to design, implement and continually improve interventions to reduce burnout, the researchers wrote.

“The fundamental challenge issued in this report is to health care institutions of all sizes to take action on physician burnout. The three recommendations advanced here should all be implemented as a matter of urgency and will yield benefits in the short, medium, and long term,” Jha and the research team wrote.

 

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GAO Report: Patient Matching Efforts Can Be Significantly Improved

January 17, 2019
by Rajiv Leventhal, Managing Editor
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The report did conclude that no single effort would solve the challenge of patient record matching

There is a lot that can be done—such as implementing common standards for recording demographic data—to improve patient matching, according to a new Government Accountability Office (GAO) report that closely examined the issue.

The 21st Century Cures Act included a provision for GAO to study patient record matching, and in this report, GAO describes (1) stakeholders' patient record matching approaches and related challenges; and (2) efforts to improve patient record matching identified by stakeholders.

The 37 stakeholders that GAO interviewed, including representatives from physician practices and hospitals, described their approaches for matching patients' records—comparing patient information in different health records to determine if the records refer to the same patient.

The respondents explained that when exchanging health information with other providers, they match patients' medical records using demographic information, such as the patient's name, date of birth, or sex. This record matching can be done manually or automatically. For example, several provider representatives said that they rely on software that automatically matches records based on the records' demographic information when receiving medical records electronically.

Stakeholders further said that software can also identify potential matches, which staff then manually review to determine whether the records correspond to the same patient. They said that inaccurate, incomplete, or inconsistently formatted demographic information in patients' records can pose challenges to accurate matching. For example, records don't always contain correct information (e.g., a patient may provide a nickname rather than a legal name) and that health IT systems and providers use different formats for key information such as names that contain hyphens.

Those who GAO interviewed identified recent or ongoing efforts to improve the data and methods used in patient record matching, such as the following:

  • ·         Several stakeholders told GAO they worked to improve the consistency with which they format demographic data in their electronic health records (EHR). In 2017, 23 providers in Texas implemented standards for how staff record patients' names, addresses, and other data. Representatives from three hospitals said this increased their ability to match patients' medical records automatically. For example, one hospital's representatives said they had seen a significant decrease in the need to manually review records that do not match automatically.
  • ·         Stakeholders also described efforts to assess and improve the effectiveness of methods used to match patient records. For example, in 2017 the Office of the National Coordinator for Health Information Technology (ONC) hosted a competition for participants to create an algorithm that most accurately matched patient records. ONC selected six winning submissions and plans to report on their analysis of the competition's data.

Those who were interviewed said more could be done to improve patient record matching, and identified several efforts that could improve matching. For example, some said that implementing common standards for recording demographic data; sharing best practices and other resources; and developing a public-private collaboration effort could each improve matching.

Stakeholders' views varied on the roles ONC and others should play in these efforts and the extent to which the efforts would improve matching. For example, some said that ONC could require demographic data standards as part of its responsibility for certifying EHR systems, while other stakeholders said that ONC could facilitate the voluntary adoption of such standards. Multiple stakeholders emphasized that no single effort would solve the challenge of patient record matching.

To this end, a recent report from the Pew Charitable Trusts outlined several key themes related to patient matching, while also suggesting recommendations to improve matching and the infrastructure needed for more robust progress in the medium and long term.

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