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Physicians Cite Lack of Interoperability, Documentation Burden as Top EHR Pain Points

September 12, 2018
by Heather Landi, Associate Editor
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A recent survey of primary and specialty care physicians by Deloitte reveals that physician feedback on how to improve electronic health records (EHRs) is often overlooked as physicians continue to be frustrated with EHRs, particularly due to lack of interoperability and the burden of documentation.

Deloitte recently released a report about physician interaction with EHR technology based on the Deloitte 2018 Survey of U.S. Physicians, a survey of 624 U.S. primary care and specialty physicians.

With regard to EHR technology, the survey results suggest that at best, physicians perceive themselves as passive participants in EHR optimization efforts and, at worst, they feel ignored. Just one-third of physicians surveyed (34 percent) say their organization or EHR vendor sought their feedback on EHR enhancements; and this proportion is about the same for employed or affiliated physicians vs. independents. Primary care physicians are an exception: forty-four percent of them have been asked for feedback.

The survey results also point to a link between inviting feedback and sustaining engagement—half (51 percent) of physicians who were not asked for feedback say they are unaware of EHR optimization efforts within their organization or through their EHR vendor, but only 16 percent of physicians invited to provide feedback say so, the survey found.

The survey results indicate that lack of interoperability and ease of use continue to be big pain points with EHR systems. When asked what changes they would make to their current EHR system, 62 percent of respondents cited “making the current system more interoperable” and 58 percent would like to improve their EHR’s capability to easily add patient visit information.

What’s more, 39 percent of physicians want their EHR to be seamlessly available and accessible by mobile devices, 38 percent want their EHR to better support workflow management across the continuum of care and 37 percent see an opportunity to automate reporting to meet quality reporting requirements. Another 37 percent of respondents want EHR vendors to improve the capability to generate custom reports on their patient populations. Only 10 percent of physicians said they were satisfied with their EHR “as is.”

Documentation is the number one area where physicians see opportunities for efficiencies, according to the survey. Physicians also cited communication and care coordination (20 percent) as another area that could be completed more efficiently. Based on the responses, specific documentation tasks that could be done more efficiently include charting, capturing visit notes, data entry, and inputting boilerplate information to meet administrative requirements.

“The frequency and context of the mention of dictation tools in the survey responses suggest that physicians either underutilize them or find them subpar. Prior to the advent of EHRs, dictation was a common way to record notes. Though early generations of EHRs did not have the capability to convert dictated notes into structured information, the technology has evolved and new tools are becoming available to codify typed or dictated text,” the survey report authors wrote.

The survey report also notes that many healthcare organizations are experimenting with natural language processing (NPL) to unlock critical information from narrative reports, such as progress notes, discharge summaries and radiology and pathology reports to support patient care, administrative requirements and research. “Today, NLP technology is either expensive or requires considerable computer science expertise. As off-the-shelf NLP software becomes more accessible, organizations may discover additional documentation-related uses. Other technologies, such as artificial intelligence, robotic process automation, and blockchain, may support revenue cycle management activities that rely on EHR inputs,” the report authors wrote.

On the issue of interoperability, the report notes that organizations often face interoperability-related challenges at multiple level. As health systems have grown through mergers and acquisitions, different parts of the organization may be on different EHR systems. What’s more, multiple other information systems and clinical equipment may need to be connected to contribute to and/or extract data from EHRs. And as the number of connected devices grows, so does the need to ensure data security without inhibiting user experience.

Market dynamics, such as the Fast Healthcare Interoperability Resources (FHIR) standard, are helping to spur interoperability, however, solving the interoperability challenge can require multiple external and internal parties to collaborate and agree on common standards and governance, the report authors wrote.

“At a minimum, health systems and EHR vendors can share updates with their EHR users about important interoperability milestones achieved or functionalities added. Any interoperability improvement could support physicians in delivering care more efficiently,” the report authors wrote.

Survey respondents were asked what kind of EHR enhancements are underway at their organization or their EHR vendor. Fifty-six percent cited “improve/add capability to more easily input information about a patient visit” and 52 percent said current enhancement efforts are focused on making the current system more interoperable. Forty-three percent said enhancement efforts are focused on making the EHR seamlessly available and accessible by mobile devices and 41 percent said their organization and/or EHR vendor is working to improve the capability to generate custom reports on physicians’ patient population. Forty-percent of respondents said their organizations are working to automate reporting to meet quality reporting requirements to various payers and 37 percent said efforts are focused on better supporting workflow management across the care continuum.

Interestingly, as noted above, physicians who were not asked for feedback on EHR enhancements were less aware of those enhancement efforts. For instance, 17 percent of respondents who had not been asked for their feedback said their organizations were currently working to make their EHR systems more interoperable, while more than double (39 percent) of physicians who had been asked for their feedback were aware of interoperability enhancement efforts underway at their organizations.

The report also recommends a number of steps that healthcare organizations leader can take to improve clinicians’ experience with EHRs.

  • Proactively seek physician feedback. Direct feedback combined with other data can help the informatics team understand the goal of an optimization request and identify the best method to achieve that goal.
  • Optimize workflow. When using an EHR, how one team member uses it can affect how others do their work. Organizations may realize that a solution to a problem may not always involve changing the system but rather ensuring that all users adhere to the correct and standard workflow.
  • Communicate progress. Fully addressing certain EHR issues (such as interoperability) may be a lengthy process. Communicating the progress and attainment of interim goals can signal continued commitment to resolving the issues that vex users.
  • Stay abreast of new technology and the vendor landscape. Many emerging technologies are in the early stages of development, but the landscape is changing, with some technologies and use cases quickly approaching maturity.

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Survey: Physicians Sour on Value-Based Care Metrics, EHRs

September 19, 2018
by Rajiv Leventhal, Managing Editor
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They new research has several key findings related to value-based care, health IT and burnout

More than 50 percent of U.S. physicians who receive value-based care compensation said they do not believe that the metrics the reimbursement is tied to improve the quality of care or reduce costs, according to a new survey.

The research comes from The Physicians Foundation, an organization seeking to advance the work of practicing physicians and helps them facilitate the delivery of healthcare to patients. The Foundation’s 2018 survey of U.S. physicians, administered by Merritt Hawkins and inclusive of responses from almost 9,000 physicians across the country, reveals the impact of several factors driving physicians to reassess their careers.

Specifically, the new survey underscores the overall impact of excessive regulatory/insurer requirements, loss of clinical autonomy and challenges with electronic health record (EHR) design/interoperability on physician attitudes toward their medical practice environment and overall dissatisfaction—all of which have led to professional burnout.

The research revealed several key findings, including that value-based compensation is directly connected to the overall dissatisfaction problem, which is tied to metrics such as EHR use, cost controls and readmission rates, etc. Forty-seven percent (compared to 43 percent in the 2016 survey) of physicians have their compensation tied to quality/value, but when physicians were asked if they believe that value-based payments are likely to improve quality of care and reduce costs, 57 percent either disagreed or strongly disagreed that this is the case, while only 18 percent either agreed or strongly agreed that it is.

As one responding physician put it: “We are no longer in the business of healthcare delivery, we are in the business of ‘measures’ delivery.” More than 13 percent of physicians are not sure if they are paid on value.

What’s more, the research found that 88 percent of physicians have reported that some, many or all of their patients are affected by social determinants. Conditions such as poverty, unemployment, lack of education, and addictions all pose a serious impediment to their health, well-being and eventual health outcomes. Only one percent of physicians reported that none of their patients had such conditions.

Additional notable findings from the research included:

  • 18.5 percent of physicians now practice some form of telemedicine
  • 80 percent of physicians report being at full capacity or being overextended
  • 40 percent of physicians plan to either retire in the next one to three years or cut back on hours—up from 36 percent in 2016
  • 32 percent of physicians do not see Medicaid patients or limit the number they see, while 22 percent of physicians do not see Medicare patients or limit the number they see
  • 46 percent of physicians indicate relations between physicians and hospitals are somewhat or mostly negative

Coupled altogether, 78 percent of physicians said they have experienced burnout in their medical practices, according to the survey’s findings. And the results show that one of the chief culprits contributing to physician burnout is indeed the frustration physicians feel with the inefficiency of EHRs.

“The perceptions of thousands of physicians in The Physicians Foundation’s latest survey reflect front-line observations of our healthcare system and its impact on all of us, and it’s sobering,” Gary Price, M.D., president of the Foundation, said in a statement. “Their responses provide important insights into many critical issues. The career plans and practice pattern trends revealed in this survey—some of which are a result of burnoutwill likely have a significant effect on our physician workforce, and ultimately, everyone’s access to care.”

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Brigham Health’s 3-Pronged Approach to Reducing EHR’s Contribution to Burnout

September 18, 2018
by David Raths, Contributing Editor
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Focus is on individualized training, reducing unnecessary clicks, voice recognition tools

Research studies have found that “burnout” is nearly twice as prevalent among physicians as among people in other professions.  Physician surveys have found that 30 to 60 percent report symptoms of burnout, which can threaten patient safety and physician health. With EHR documentation ranked high among aspects of their work physicians are dissatisfied with, Brigham Health in Boston has taken a three-pronged approach to reducing the pain.

Brigham Health, which is the parent organization that includes Brigham and Women’s Hospital, Brigham and Women’s Faulkner Hospital and the Brigham and Women’s Physicians Organization, rolled out its implementation of Epic in 2015. In a Sept. 18 presentation that was part of the Harvard Clinical Informatics Lecture Series, Brigham Chief Information Officer Adam Landman, M.D., said the organization’s initial EHR physician training was eight hours of classroom training on where to find things in the EHR instead of focusing on workflows and how to use the EHR to support it.  “Our experience was not the best,” Landman admitted.  They followed up with tip sheets, a help desk and a swat team to do service calls, but providers only rated those interventions as somewhat helpful, so Brigham informaticists re-doubled their efforts to:

• Improve the EHR;

• Provide one-on-one training in the clinical setting; and

• Offer voice recognition software and training.


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Landman said IT teams at Brigham feel a sense of urgency about reducing the burden of EHR documentation. “Burnout is an epidemic, and the EHR is a component of this,” he said, adding that the changes are not just a one-year cycle but must involve continual iterative improvements. “We need to be more aggressive about making changes,” he said.

He described some efforts to reduce notifications and remove clicks from the medication refill process. They also removed a hard stop when discontinuing a medication. Those three changes alone reduced the number of clicks per month by 950,000 across the health system.

They also worked to reduce clinical decision support alerts with very low acceptance rates by turning them off. Three alerts with very low acceptance rates were turned off. “If we thought they were important, we would fine tune them to increase the acceptance rate,” Landman stressed. “That is part of clinical decision support lifecycle management. But we will continue to iterate to reduce the number of unnecessary clicks.”

A year and a half ago, Brigham also created a one-to-one support program, in which an expert trainer would meet the physicians in their practice and help them with their work flow. A pilot project involved four specialties, including general surgery. Each session was 90 minutes to two hours long, and providers were offered one or more follow-up sessions, as well as optional training on speech recognition. After seeing some negative feedback on their initial classroom training, the one-to-one sessions were met with a very positive response. Almost 95 percent said it was valuable, and 95 percent said they thought their efficiency with the EHR would improve following the training. Based on that early success, the training effort is now being rolled out to much larger groups of physicians at Brigham and across the Partners HealthCare network.

In another attempt to improve documentation turnaround time, Brigham has made voice recognition tools and training available to physicians. They made two-hour training sessions mandatory for those interested in adoption, with additional personalization sessions also available. Informaticists partnered with departments to build department-specific order sets. (Brigham also started offering 15-minute e-learning sessions for residents.) More than 90 percent of surveyed physicians said the training met expectations, and 70 percent said they would be willing to have additional training, Landman said. Currently 5,000 physicians across Partners are trained to use voice recognition tools with the EHR.

Landman also cited a study that compared U.S. and international use of Epic that saw a huge disparity in length of documentation notes. The U.S.-based users’ notes were nearly four times longer on average than those of their international counterparts. Epic users overseas tend not to complain about the burden of documentation, he noted. This has to do with how the provider notes are used in billing, he said, adding that CMS is working on proposals to change billing requirements that may alleviate some of the documentation burden for physicians.

In closing, Landman urged informatics colleagues to think about working on EHR optimization research and studying the impact of policy and technology changes. “New technology tools can seem fun and exciting, but for physicians who see up to 100 patients per day, they can be quite overwhelming,” he said. “We don’t want physicians spending half their time doing administrative work.”






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