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Electronic Health Records and Physician Burnout: Fraught with Frustrations

Electronic Health Records (EHRs) have become a scapegoat for physician burnout. A quick google search of “EHR” and “burnout” will yield nearly 350,000 results. Systematic reviews over the last 10 to 15 years look at much of this data and draw a similar conclusion; higher physician burnout rates are correlated to use of EHRs. They point at increased documentation times, decreased user satisfaction, and “clerical burden” as causes of burnout. Data from other sources suggest we may be laying the blame in the wrong place.

At Stanford Children’s Health, in an effort to improve physician satisfaction with EHR use, they have created extensive and personalized education programs. They obtained data from the EHR to develop an efficiency profile, surveyed physicians on their perspective of their efficiency, and performed observation sessions with physicians so support staff could see how physicians used the EHR. With this information, personalized learning plans were developed. Providers were incentivized to participate and they found physician satisfaction with EHR improved as well as their efficiency and less time spent on medical records outside of the hospital.

This suggest that the problem with the EHR is not of the EHR, but rather the onboarding and training process related to it. Most EHRs can be made to work for you, rather than against you, and improve your efficiency with documentation and patient care.

Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause? Annals of Internal Medicine. July 2018.

Drs. Downing and Bates recently published in JAMA that there may be another underlying cause that is driving physician burnout and dissatisfaction which is being blamed on the EHR. In looking at health systems across the United States and abroad on a similar EHR (Epic Systems), they found that physicians abroad reported higher satisfaction with the EHR and that it improved their efficiency. In other countries, they noted, documentation is briefer, containing only essential clinical information rather than bogged down by compliance and reimbursement documentation. On average, within the same EHR, notes in the United States were found to be four times longer than those abroad. Notes in the United States had documentation requirements from a “clinically irrelevant” number of elements in each part of a note so that fee-for-service components are fulfilled.

Their argument suggest that a key cause of physician burnout which is being blamed on EHRs is actually our “outdated regulatory requirements.” With reform of these requirements, documentation would become only the essential clinical data, rather than notes with strict documentation requirements of a “clinically irrelevant number of elements” in the various components of a note.

A third argument that I would challenge us to consider as a more likely cause of physician burnout rather than the EHR is the cultural state of medicine in the United States. Due to increasing numbers of lawsuits over the last 20 years, physicians are spending a lot of time on “CYA” medicine (Cover Your A**), feeling forced to order unnecessary testing for an unlikely diagnosis “just in case” things do not go according to planned. We also get pulled into the trap of what I refer to as “Burger King” medicine, playing off the fast food giant’s slogan of “Have it your way.” Patients are coming to the physician already “knowing” their diagnosis and requesting specific treatments or testing. If the physician disagrees? No problem, the patient will just go find one down the road who will do what they want.

In an era of electronic health records on the rise and an increase in rates of physician burnout in the United States, it looks easy on paper to show a correlation between the two. What if instead the EHR is not to blame, but any number of other things like lack of physician EHR training and support, documentation regulations, or “Burger King” medicine? Is it more likely that the relationship between EHR prevalence and physician burnout is only a correlation and not a causal relationship? My hope is that in the coming years we will recognize the EHR as a tool to improve patient care and outcomes, increase our efficiency, and return to practicing medicine at the bedside.

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Comprehensiveness + Comprehension: effect of technology on discharge instructions

Whether patients are leaving the emergency department or being released from an extensive hospitalization, they need discharge instructions in order to solve their initial problem, better self-manage, and coordinate the appropriate follow-up. These instructions are typically written and are also articulated to the patient. We know that due to varying levels of health literacy, or the degree to which individuals have the capacity to process and understand basic health information needed to make appropriate health decisions [1], a patient is especially vulnerable during the process of discharge in terms of overall understanding and appropriate follow through. Can technology empower patients operating from a position of weakness in this transition?

  • According to the 2013 study entitled Information Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality Measure, researchers were able to show that electronic discharge instructions were more complete than paper-based information. The electronic discharge instructions had 97.3% compliance to a CMS quality measure while the paper-based discharge instructions were at 46.7%. This compliance is more than doubled with electronic discharge documentation (relative risk 2.09, 95%CI 1.75-2.48) [2]; however, there were no statistically significant differences in documentation of patient care instructions nor diagnosis between paper-based and electronic formats.
  • In a 2015 study entitled Readability of patient discharge instructions with and without the use of electronically available disease-specific templates, patient readability of a web based discharge module, which has diagnosis-specific templated discharge instructions, was assessed. Patients had better readability with electronic templated discharge instructions than those that were clinician-generated (p< .001). Furthermore, the primary reason doctors created discharge instructions by themselves was due to lack of disease specific template availability.

The most exciting time in medicine is now, where the application of information technology during vulnerable transitions can provide a patient more complete information that he/she can actually act upon. Taken together, these studies suggest enhancement of both comprehensiveness and comprehension; the former very important for the primary care physician who will assume care of this patient status post hospitalization and the latter important for the patient’s overall health literacy necessary for improvement. The next logical extension is to have web based applications assist a patient in the transition from the hospital to the outpatient setting, something that innovative companies like Wellpepper are doing.

References

  1. Nielsen-Bohlman, L.; Panzer, AM.; Kindig, DA. Health literacy: A prescription to end confusion. National Academies Press; Washington, DC: 2004.
  2. Bell EJ et al. Information Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality Measure: A Quasi-Experimental Study. Appl Clin Inform. 2013; 4(4): 499–514.
  3. Mueller SK et al. Readability of patient discharge instructions with and without the use of electronically available disease-specific templates. J Am Med Inform Assoc. 2015; 22(4): 857-63.

Posted in: Healthcare Technology, Patient Satisfaction

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The Disneyfication or Consumerization of Healthcare

I had the privilege of participating in my second panel hosted by Curtis Kopf, Senior VP of Customer Experience at Premera, at the recent Washington State of Reform Health Policy Conference. Curtis was formerly of Alaska Airlines and is new enough to healthcare to be able to point out idiosyncrasies of healthcare, and he led the audience, my fellow panelists, Elizabeth Fleming, VP of Group Health Cooperative, Tabitha Dunn, VP of Customer Experience at Concur, and me on a rollicking discussion of who excels in customer service, how to emulate consumer organizations, and how not to emulate consumer organizations.

I enjoy panels as they afford the opportunity to evaluate my own perspective based on the insights of others usually in extremely different roles. This panel was unique as we represented payer, provider, employer, and digital health/technology: practically a cross-section of the industry.

Both over coffee prior to the panel and on the panel, we talked a lot about the influence and guiding principles of Disney as the quintessential consumer experience focused organization. Tabitha had just returned from a holiday trip with her family, and Curtis had the opportunity to attend the Disney Institute for customer service training during his time at Alaska airlines.

Before getting into the takeaways from our experiences and thinking about what to take away from Disney, we started the panel by discussing why consumerization was a topic in healthcare at all.

A number of factors have converged to drive consumer or patient-centric approach we now see in healthcare:

  • 20M newly insured people offered an opportunity that brought new players, like Walgreens, Walmart, Medical One, and Zoom+ into primary and urgent care market
  • On demand services like Uber and constant communication through messaging apps, and the ubiquity of smart phones created an expectation of healthcare on demand.
  • High-deductibles made consumers evaluate more closely how they were spending their healthcare dollars
  • Getting over the hump of initial EMR integration made physicians ask why they couldn’t have consumer-quality tools to do their jobs

Regardless of what happens with the ACA with the incoming administration, we don’t expect many of these things to change, although there may be more competition in primary care as these new players put pressure on incumbents.

How do you react when there is more competition? A customer-centric approach is a good place to start, which brings us back to Disney. As a child, I did a school project on Walt and his empire, but have to admit I didn’t know as much about them as my fellow panelists.

Here are my key takeaways from the discussion:

  • Disney is extremely consistent, which provides autonomy for their staff to make good decisions within the 4 values that Disney holds. Although you may think that the brand is the highest value, it is actually safety. A Disney cast member is allowed to break character only when safety is at risk. Consider this as you think about the healthcare experience: safety and good experience are not mutually exclusive.
  • If you’re going to try to emulate an experience from another industry, make sure you fully understand that company’s or industries core values. The that resulted when executives managed to the HCHAPS survey: Nurses were given scripts to follow rather than making decisions, which is the exact opposite of how Disney actually operates. Nurses should have been given autonomy to work within the values of the health system and the needs of the patient.
  • Disney has an entire underground operations center that supports what guests experience above ground. This supports both the safety but also the experience of the park. Curtis toured this facility while at the Disney Institute. What struck me the most about this was the realization that the hospital has no back-office. We’ve met with administrators in their offices that are converted hospital rooms. First, think how uninspiring this is for employees as an office. Second, these are usually on active hospital floors, so patients experience random water cooler conversation as they are in care.

As an outsider to healthcare, it took me a while to get used to going to the hospital to have meetings, and it still makes me uncomfortable to pass patients waiting in hospital beds in the hallway while I’m going to negotiate a contract. This lack of a “back-office” impacts patients and staff alike, and really extends to every patient interaction. The EMR is essentially back-office software. Why hospitals run their patient-facing experience from this essentially line of business technology is beyond me.

Although at Wellpepper our client is the health system, our most important user is the patient. We want to ensure that the patient experience is as good or better than any popular-patient facing applications, and represents how the patient understands their care. As a result, we are able to enable patients to participate, and self-manage, and still deliver valuable information to help the internal health system operations center be more effective, which is why I’m always happy to talk about the consumer experience in healthcare.

 

Posted in: Behavior Change, Patient Advocacy, Patient Satisfaction, Seattle

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Helping Patients Protect Their Own Personal Health Information

Last week I was leaving a meeting at a large hospital when I saw a patient record sitting on top of the payment machine in the parking garage. Incredibly this is the second time that I’ve seen documents left here. People put them down when they pull out their wallets to pay for parking and then walk away.

Patient Record on ParkingThe information the patients left behind included treatment plan instructions – so you can be pretty sure they are not doing their follow up home care – but worse than that it contained a schedule of future appointments with the patient’s name, date of birth, and social security number. Yes, you read that right: a perfect package for anyone practicing identity theft. This was all on a page that was printed directly from the EMR. The DOB and SSN were probably included on the record to verify that the information was for the correct patient, but this could be verified by asking the patient without printing it on a schedule of appointments.

So – first things first – I took the paper records back into the hospital. But afterwards it got me thinking about information protection and privacy, and in particular about the many people who still think that a paper print out is more secure than the cloud.

Although concerns about information protection and privacy are valid, many of the major HIPAA breaches of the last few years have had nothing to do with the cloud and usually are related to human error and not great security practices.

A few examples:

Good protection of patient information is important whether that information is in the cloud, on an internal computer or system, or on paper. HIPAA regulations encourage building good encrypted software, however we also need to have safeguards to protect against human error.

If patient information were in the cloud, the patient would either access the information through a secure portal, email, or application on their mobile device. He or she would then authenticate themselves to receive the information, and would not need to worry about accidentally forgetting their treatment plans sitting on a parking payment machine.

While patients expect to be able to interact with their healthcare providers through portals and mobile applications in the same way they interact with their banks, many healthcare CIOs we’ve encountered are still extremely wary of cloud-based systems. Financial services is another heavily regulated industry that has been able to successfully move to the cloud to better serve its customers.

Wellpepper is a cloud-based application, which in the healthcare world, makes us a business associate and on the hook for any breaches of patient health information. On the hook means that we need to sign a HIPAA agreement with any organization and we have liability for breaches of information. This is a job we take very seriously and we do our utmost to protect all information that flows through Wellpepper. This includes encrypting information at rest and in transit, ensuring strong passwords, and conducting audits of our system as well as making sure we are well-insured.

With Wellpepper, we provide the same level of encryption and safeguards to the patient’s own device as we do on the clinical devices. Information is not stored locally so if a device is lost or stolen there is much lower risk than in the laptop examples. Patient can do whatever they like with their own data. If I want to post my x-rays on the lamppost in-front of my house I can do that. However, that doesn’t mean that a healthcare organization should facilitate me in sharing my personal health information, which is actually significantly easier with paper-based systems than cloud based.

Yes this information would have been transferred over the Internet which could leave it open for hacking but a secure cloud system is no less, and sometimes more secure than internal IT systems which are also vulnerable. The key is to ensure that everyone in the chain, from internal IT to external partners, and finally to the providers and the patients understands the importance of protecting health data, and has the tools they need to do so, whether that’s on paper, online, or in the cloud.

Posted in: Data Protection, Health Regulations, Healthcare Technology, Healthcare transformation, M-health

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Adopting Technology in Healthcare for the Right Reasons

Regulations, process, and records keeping are all important parts of managing health IT; however, when implemented without a strategy focused on patient and business value, they can create headaches for CIOs, not to mention patients and healthcare providers. This was an emerging theme Institute for Health Technology Transformation Conference held in Seattle at the end of August.

IHT2 Summit in SeattleThe conference featured speakers from across major healthcare organizations. Mayo Clinic CIO Chris Ross gave the final keynote which summarized many themes of the conference and provided direction for the future. He described Mayo’s tradition of using industrial and process engineering to deliver on Mayo’s promise of team-based integrated care. Viewed through this lens, imperatives to integrate EMRs, adopt ICD-10 and attest to Meaningful Use became opportunities that aided the business, and enhanced patient care. However, he was clear that while these projects were necessary, they were not sufficient by themselves to achieve Mayo’s vision. He went on to describe projects underway to optimize the workflow for their clinicians, in one instance reducing the amount of time doctors spent using IT tools from 30 minutes to 5 minutes per patient. He also described the vision of having hundreds-of-millions of lives under Mayo’s care, and the patient-centric model that they were following to achieve this. This included projects like delivering the Mayo app deeply integrated with Apple’s HealthKit technology.

Ross also asked his peers to consider the move to electronic records keeping to be a move to digitizing the healthcare industry to keep pace with the innovation available in other industries instead of a regulatory requirement. He envisions a system where a unified data platform provides digital care and knowledge management and recording keeping is a by-product of that system.

Focusing on the right strategy was also a theme in a talk by Dr. Nick Wolter of the Billings Clinic. Wolter described a 1993 merger with Deaconess that nearly bankrupted the organization. The merger was focused on regulatory and process integration while ignoring the vision for the new organization. In 1997, with financial losses posted, they hired turnaround experts who focused on physician leadership development. By 2005 they had established a vision to be best in the nation for patient safety, quality, and service. In 2010 Billings Clinic added value to their mandate and are looking closely at ACO metrics to make sure they are delivering on these promises.

Throughout the two-day conference, panelists called out EMRs as a significant driver of physician dissatisfaction. While meaningful use requirements have increased the focus on moving to electronic records, in many cases this is apparently happening without a vision that leverages these transformations to improve physician efficacy and patient care, which is unfortunate as these two areas if provided with appropriate electronic tools could see some of the biggest benefits.

Although there is was definitely a dissatisfaction expressed with the current state of health IT, it was promising to see shifts towards tools that are more focused on provider workflow and patient engagement. Even more promising was the general understanding at this conference that digital healthcare can and should be better delivered. At Wellpepper we’re excited to support this shift to a patient- and value-centered system.

Posted in: Health Regulations, Healthcare Disruption, Healthcare Technology, Seattle

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