Surveys suggest that more than half of U.S. physicians show symptoms of burnout, and other studies have linked burnout to work process inefficiencies and administrative and documentation burdens, particularly the use of electronic health record (EHR) systems.
A time and motion study by the American Medical Association and published in the Annals of Internal Medicine in the fall of 2016 found that during office hours physicians spent nearly 50 percent of their time on EHR tasks and desk work. Researchers concluded that for every hour physicians provide direct clinical face time to patients, nearly two additional hours is spent on EHR and desk work within the clinic day, And, outside office hours, physicians spend another one to two hours of personal time each night doing additional computer and other clerical work. A separate study published in the Annals of Family Medicine last fall also found that primary care physicians spend more than one-half of their workday, nearly six hours, interacting with the EHR during and after clinic hours.
In light of the ongoing administrative and documentation burdens that providers face, healthcare leaders are concerned about physician satisfaction and the link to patient safety and care quality. According to the Agency for Healthcare Research and Quality (AHRQ), physician burnout can threaten patient safety and care quality when depersonalization leads to poor interactions with patients and when burned-out physicians suffer from impaired attention, memory and executive function.
To proactively address provider burnout, executive leaders at Cleveland-based University Hospitals accelerated a partnership with the health system’s EHR vendor, Allscripts, to address EHR usability and workflow issues, with the aim of making the EHR system more user-friendly, seamless and interoperable.
“This notion of physician burnout, or stress to physicians in their workplace, is something that has been brewing and getting progressively worse over last three to five years,” Cliff Megerian, M.D., president of University Hospitals’ Physician Services, says. In his role, Megerian oversees a physician network comprised of 2,500 physicians across the 18-hospital health system.
Megerian also is a professor and surgeon, and, as a practicing physician, he sees firsthand the usability issues with EHRs. “The EHR is a fairly recent innovation; it was mandated as part of the American Recovery and Reinvestment Act, so many mature physicians have grown up in an environment where they were dictating and having their dictations transcribed or they were writing on paper. This is a fairly new burden, within the last decade, and I think it is stressing many physicians because many believe it is forcing them to spend less time with their patients and more time with the computer.”
As part of its efforts to address provider burnout, UH conducted physician surveys and responses to those surveys point to the administrative burden of the EHR, as well as other regulatory hurdles, as an ongoing source of stress. “The reason this has risen to the forefront is because the survey results are showing that it’s the EHR,” Megerian says, adding, “And the survey results show that it’s agnostic as to which brand of EHR is being used.”
UH project leaders took a number of steps to help minimize administrative burdens and streamline physicians’ workload. The end goal, Megerian says, was to reduce the amount of time clinicians have to deal with counter-intuitive solutions, giving them more time to spend with patients, and thereby reducing the likelihood that they suffer from burnout and decreased job performance.
The project team, which consists of UH’s IT team and Allscripts’ team, first addressed stability issues in the EHR platform. “One of the earliest complaints was that the system was logging me out, or the system was going down, and we have been very successful in working with Allscripts, as well as our own IT people, in making the system a lot more stable, and the amount of downtime has logarithmically decreased,” Megerian says.
The project team also worked to create a bridge between systems to provide a more unified view and better access to information across the 18-hospital UH system, or what’s called OneUH. “Many hospital systems that have EHRs have different versions for different platforms, so you have an inpatient system, an outpatient system, a system that works with your oncology patients, and another system for cardiology, and they may be under the same vendor, but they are different. We worked with Allscripts to create a bridge between the systems,” he says, adding, “It’s a huge project and we’re still in the middle of that.”
Megerian asserts that close collaboration with Allscripts has played a key role in accelerating improvements with EHR usability and physician satisfaction. “About a year and a half ago, the partnership accelerated as we really became cognizant of the fact that we can’t, on our own IT platform, make every improvement without them making improvements on their end.”
As a result of this ongoing initiative, UH project leaders have noted a number of improvements—an increase in application response time, a reduction in dictation software issues, and improved screen-flip time. Application response time has increased 30 percent from March 2015 to January 2017 as a result of the collaboration between UH’s IT team and Allscripts’ team, Megerian notes. And, Citrix log-in times have improved 36 percent. UH physicians also use Nuance’s Dragon dictation application, and there has been a 75 percent reduction in dictation software issues.
With regards to improving screen-flip time, Megerian says in the past doctors complained that it took too long to flip screen to screen. “It was 1.47 seconds, and now it’s 1.09 seconds. That is actually better than Allscripts’ documented performance standards, and they worked with us because our doctors wanted improvements, our doctors wanted speed.”
And these IT improvements lead to increased productivity for clinicians, Megerian notes. “With reducing screen-flip time from one and a half seconds to one second, if you think about a physician seeing one patient, he or she is going to be going through six screens, so that’s six seconds for six screens, versus nine seconds. Or, it might not be six screens, but 15 screens if you do the billing, and the CPT coding, and the ICD 10 coding. That physician is seeing 30 patients a day, so you can do the math. That’s additional, unnecessary time that you could have been completing your notes and not spending extra time in the office or taking away time from your patients,” he says.
As part of this initiative, UH also developed a physician services and IT panel comprised of physicians and physician leaders, and has increased the number of meetings between Allscripts teams and physicians. “We created physician work groups that create a list of challenges they are having and those are moved to the top of the queue for our IT team and Allscripts team to remedy. And those physician work groups meet on a regular basis,” he says, adding that Allscripts CEO Paul Black personally visits several times a year to meet with executive leadership and physicians to learn about ongoing EHR challenges.
Megerian emphasizes that accelerating the health system’s partnership with its EHR vendor was critical to effectively addressing EHR usability issues. “If you are a physician organization and you buy a product, I don’t see how it’s possible to improve some of the functioning of that product without partnering with that vendor. Allscripts partnered with us and we’re showing significant signs of success. I’m not saying it’s perfect, it’s not. But, the company has been fantastic in partnering with us to improve things beyond the factory specifications,” he says.
Moving forward, the UH project team plans to continue making improvements, guided by feedback from physician work groups. “We are doubling down on creating more transparency between the vocal physicians who have an interest in IT and improving the EHR and create conduits and touchpoints between our own CIO and our own CMIO (chief medical information officer) and through extension, through Allscripts,” he says. “It’s important to understand the providers’ expectations; you have to realize that for every specialty there are certain nuances they need from the IT system.”
He also contends that it’s impossible to achieve 100-percent physician satisfaction with EHR systems. “There is no one who is fully satisfied with their EHR platform. But, the bottom line is, studies show that if you improve caregiver satisfaction, then you improve patient experience and outcomes. So, the good news is that they [Allscripts] partnered with us to move in a direction to become more focused on the problem solving.”