Can clinical optimization reduce physician burnout?
Efforts to optimize the use of medical records hold the promise of success – if they can overcome subjective factors.
Even as I started to write about this subject, new stories and comments appeared to demonstrate that burnout (and worse) among healthcare providers is a persisting crisis.
In Forbes, a contributor noted a recently released survey from Medscape Psychiatry, showing the burnout rate among U.S. physicians at an all-time high. Similar pieces appeared in Newsweek and The New York Times, with one calling the prevalence of burnout a symptom of a broken system that is now delivering a lower quality of care and the other focusing on the great increase in the number of administrators in healthcare while the number of caregivers remains, at best, stagnant.
At the same time, the healthcare trade publications continue to raise the alarm and offer opinions about its causes and cures. Becker’s Hospital Review notes that of the physicians reporting burnout, the highest rate can be found among emergency medicine specialists.
EHR Intelligence identified the factors that can affect clinician burnout rates (with health IT and EHR optimization heading the list), while an opinion piece appearing in Medical Economics discusses the effect of electronic health records: “The clunky user interfaces and excessive documentation requirements of these systems have forced doctors to work many additional hours in the evening and on weekends, which they are not paid to do, and which interferes with their ability to have balanced lives.”
Academic and institutional researchers also reveal, regularly and quantitatively, just how extensive the problem is. Typical of this: The Journal of the American Medical Informatics Association (“Electronic medical records and physician stress in primary care”) or The American Journal of Medicine (“Physician stress and burnout”).
But burnout among healthcare providers is not a new development.
The current malaise affects 63 percent of women physicians and 46 percent of men physicians; in 2018, it was 48 percent and 38 percent, respectively. The pandemic has obviously had a drastic impact on the incidence of burnout but having half of the women and more than a third of the men in healthcare unhappy is not satisfactory.
Analysis of burnout captures the state of physicians’ psyche. But how does their psyche affect their behavior? Clearly, it has produced carelessness, indifference, substance abuse, and self-harm. Some, before it gets too far, just leave the profession. In many specialties more than half of practitioners are nearly out the door.
The blame for burnout
Now that the pandemic seems to be abating, although it is clearly far from over, there is some hope that other, more long-term system-wide sources of burnout might be identified and addressed.
Among the culprits most often cited are the challenges caregivers must confront with the introduction of various kinds of electronic health records systems. While these technologies were supposed to make life easier for the medical community and safer for patients, the opposite seems to have occurred. One (of innumerable studies) says: “Clinicians report that they spend more than half of their day documenting patient care. When clinicians spend more time on clerical tasks, they have a decreased rate of job satisfaction which correlates to increased symptoms of burnout.”
Another report that connects burnout to the introduction of electronic health records says, “Almost 70 percent of physicians who use EHR technology during patient care delivery have experienced stress because of the demands of health IT use. These physicians singled out insufficient time for documentation as particularly burdensome. About half of survey respondents reported not having enough time to complete clinical documentation. Additionally, documentation time is generally not reimbursed, which may contribute to physicians’ frustration, particularly if, as our study shows, a majority of physicians feel that EHRs do not improve patient care,” the researchers noted.
But it’s not all glum news. Another recent report on burnout and workload finds evidence that the stress “may be in part due to subjective differences at an individual level, and not solely as a function of the objective work environment. This suggests the need for both individual and organizational-level interventions to improve alert workload and subsequent burnout. Additional research should confirm these findings in larger, more representative samples.”
In other words, efforts to optimize the use of medical records hold the promise of success – if subjective factors can be overcome.
Another study provides intriguing encouragement. Neurologists at the University of Colorado School of Medicine aimed to find out if a two-week “EHR optimization sprint” could reduce the burden on inpatient clinicians. A team led by physician informaticists worked with 19 advanced practice providers (APPs) in one specialty unit. Over two weeks, the team made 21 changes to the records, and provided 39 one-on-one training sessions to APPs, with an average of 2.8 hours per provider.
At the end of the sprint, user log data showed that the clinicians spent about as much time in the records as they usually did, but 40 percent believed that they spent less time. The researchers concluded that “this inpatient sprint improved satisfaction with the EHR.”
What needs to be done
If a “sprint” can bring a small degree of change, carefully thought-out institutional adoption of clinical optimization should go far towards regaining confidence in the value of medical records systems while halting the slide towards burnout and depression.
Medical records are not universally disliked. Most are well-designed, saving time and supporting clinical workflows. But it’s also true that for some users, EMRs add work, decrease face time with patients and create usability issues and slowdowns.
A helpful insight can be found in a widely read opinion piece written by three prominent Boston-area physicians. Their point, summarized in their title, “Death by a Thousand Clicks,” notes that when doctors and nurses turn their backs on patients to focus on a computer screen, they sacrifice the time and undivided attention every patient deserves. Multiple prompts and clicks in an EMR system, they declare, affect patients, and contribute to physician burnout.
Clinical optimization as it has come to be applied in the last few years, addresses this with a systems-based organizational approach that targets the cultural, practical and personal domains in which caregivers perform.
Clinical cycle management
It’s with this background that the concept of clinical cycle management (CCM) has been formulated. According to R. Hal Baker, MD, senior vice president of clinical Improvement and CIO at WellSpan Health, the currency of executive clinicians is attention, and they must decide where to spend their attention units and be judicious with how they spend them. A recent study from the University of Wisconsin School of Medicine and Public Health and the American Medical Association, finds that primary care physicians spend more than half their workdays in the EHR, with heavy attention investment on what the study calls “administrative” tasks.
The goal of CCM is to optimize the EHR by profiling its applications. It entails robust and rich usage data gathering, including clicks, mouse movements, and time spent.
Analysis of these workflows, using a temporal query tool, enables identification of bottlenecks, poor workflows and other time sinks. It shows both individual user activity, as well as aggregate data, and defines logical EMR “tasks.” It provides the basis for realizing workflow optimization efficiency gains.
Physician efficiency and satisfaction can be enhanced by adaptation of ideas contained in the KLAS Arch Collaborative. These include effective, ongoing training, EMR personalization, and EMR governance and physician engagement. This is a feasible, practical approach because most EMR users have already accepted and begun to use the configuration. It was handed to them along with their credentials.
Users who take the time to personalize their EMR usage to their needs are three to five times more likely to be highly satisfied with their EMR. Further, effective organizations have found ways to quickly incorporate end-user feedback into the EMR optimization process.
The benefits of clinical optimization
Clinical application efficiency is all about workflow. Providers can deliver good care without becoming data entry operators, while still taking advantage of everything healthcare information technology has to offer. Optimization through clinical cycle management uses a combination of great technology and improved workflow, and it can have a profound impact on addressing and significantly reducing physician burnout.
Clinical optimization is necessary for numerous reasons. Where it has been successfully deployed it has, among other benefits:
- • Saved 28 to 36 minutes per nurse per shift
- • Reduced lab test use and drug costs by 15 percent
- • Reduced average lengths of stay by 5 to 10 percent
When electronic medical records are utilized to their capacity, they can increase efficiency and productivity to such an extent that it fully rationalizes and justifies investment. To do so, healthcare organizations need to identify the deficiencies that can limit provider capacity. If productivity can be increased by an additional three patient visits per day, there is the potential to increase revenue by more than $60,000 per provider each year.
Insights gathered into performance and outcomes data can transform EMRs from a burdensome necessity to a driver of strategic value that can become a sustainable competitive advantage. Success requires a disciplined, data-driven, outcomes-based approach that meets a defined set of objectives. And if clinical optimization can reduce the frustration that has produced a psychological malaise among caregivers, the wave of news stories and depressing surveys of burnout may recede, replaced by more reassuring reports of optimism from our caregivers.