Clinician Burnout in the EHR era Christopher A. Longhurst, MD, MS CIO and Associate CMO, UC San Diego Health Clinical Professor of Medicine and Pediatrics @calonghurst Mike South, MBBS, PhD CMIO and Paediatrician , Royal Children’s Hospital Professor of Paediatrics, Melbourne University @mikesouthRCH
Population Patient Health Experience Caregiver High Value Experience Care The Triple Aim: Care, Health, and Costs, Health Affairs , 2008 From Triple to Quadruple Aim, Family Medicine , 2014
UC Davis UCSF UCLA UC Irvine UC San Diego
UC San Diego – UC Irvine collaboration
Clinician Burnout “A psychological syndrome in response to chronic stressors on the job - overwhelming exhaustion, feelings of cynicism and detachment from the job; a sense of ineffectiveness; lack of accomplishment or fulfillment.”
Abraham Verghese, New York Times Magazine , May 16, 2018
UC San Diego EMR Satisfaction @KLASresearch #ArchCollaborative UC San Diego Health medical staff surveyed in September 2017
Off the Record?
What about outside the US?
What about outside the US?
Annals of Internal Medicine, June 2019
Progress note length in US and international health systems using the same EHR
UC San Diego Health Campus UC San Diego Physician Network UC San Diego Health Clinic(s) Affiliate Hospital Affiliate Medical Group Clinic Southwest Coachella Valley Riverside Eisenhower Inland Valley Medical Center Medical Center Rancho Springs Medical Center Temecula Valley Hospital North County Tri-City Healthcare District Imperial Valley El Centro Regional Medical Center San Diego VA San Diego Healthcare System Rady Children’s Hospital 13
Family Medicine – UC San Diego Health Family Medicine – Community Affiliates
Neurology – UC San Diego Health Neurology – Community Affiliates
What are we doing locally? UC San Diego Health led by informatics team • Use data analytics to target areas of impact (“hot spotting”) • “Home for Dinner” program • Physician Informatics service owners! • Voice recognition tools UC San Diego Health led by ambulatory operations • Practice transformation! Workflow redesign, supported by IS team, to ensure all roles functioning at the top of their license
UC San Diego Health KLAS EMR Experience Survey – September 2017 @KLASresearch #ArchCollaborative Where we have IS medical directors, we tend to have high provider ratings on EMR experience
Key opportunity identified from survey: @KLASresearch #ArchCollaborative Half of UCSD medical staff rated themselves as low efficiency for outpatient charting
UCSD Home for Dinner program User feedback physician surveys Before and after surveys “I need my entire group to do this, it was amazingly helpful. I have used EPIC for 5 a long time and I am terribly set in my 4 ways but set up ways to help with less jumping around.” 3 *100% would recommend to a colleague 2 1 After hours time report for physicians 0 Comfort with Ability to use workflows knowledge Before After Reduced by up to 75% for half of the individuals. 2018 goals: • Program is aligned with Primary Care Flow Collaborative • Goal is to CLOSE VISITS before seeing next patient • Creating webinars for common issues and videos for training
Feedback from the Dean for Clinical Affairs 20
What is happening nationally? • Center for Medicare Services (CMS) Administrator Seema Verma announced “patients over paperwork ” initiative “At CMS, our top priority is putting patients first. CMS Administrator Seema Verma launched the “Patients over Paperwork” initiative, which is in accord with President Trump’s Executive Order that directs federal agencies to “cut the red tape” to reduce burdensome regulations. Through “Patients over Paperwork,” • CMS established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience. In carrying out this internal process, CMS is moving the needle and removing regulatory obstacles that get in the way of providers spending time with patients.”
Breaking news… 22
Is clinician burnout a big topic in Australia? Is the use of EMRs commonly cited as a Not Yet! contributing factor in Australia?
Big bang implementation New Hospital - 2011 April 30 th 2016 Entire hospital Hospital units still on paper: None Departmental CISs: Retired
@KLASresearch #ArchCollaborative
Documentation - clinics
@KLASresearch #ArchCollaborative
So what is going on here? Same EMR system
So what is going on here? USA RCH Problem: Abdominal pain The problem has been getting worse. The pain is in the Right Lower Quadrant. The pain is currently at a severity level of 8/10. The quality of the pain is sharp. Associated symptoms currently include fever
So what is going on here? USA RCH Problem: Abdominal pain Abdo pain • The problem has been getting worse. Sharp • The pain is in the Right Lower getting worse • Quadrant. The pain is currently at a Now 8/10 • severity level of 8/10. The quality of the Febrile pain is sharp. Associated symptoms currently include fever We actively encourage this style Note-writing tools reconfigured
So what is going on here? “Time - saving” tools Transcription Voice recognition Scribes Copy Forward into notes
So what is going on here? “Time - saving” tools – Pre-Charting
So what is going on here? USA - Documentation driven by something other than clinical care?
So what is going on here? Compliance Revenue Documentation Anticipating litigation Perfunctory
So what is going on here? C ompliance Documentation R evenue A nticipating litigation P erfunctory
What is the documentation in a note for? Australia USA Clinical care The documentation seems to serve many non-clinical At RCH – no staff other than purposes. clinicians look at the outpatient notes. Patients and families can Clinical care often seems to be a view. secondary purpose There are no drivers for clinicians to document anything other than what is needed for good clinical Many non-clinicians are reviewing the notes care There are strong drivers for clinicians to document +++
It’s not just documentation Ordering Inbasket Messages
It’s not just documentation We also do much less • Ordering • Co-signing orders • Attesting trainees notes • Marking things as “reviewed” • Alerting – drug and other warnings
So – what is to be done?
So – what is to be done? Australia USA Protect the clinical purpose ? Back to the drawing board of documentation and the EMR Hands off our medical record!!!
Population Patient Health Experience Caregiver High Value Experience Care The Triple Aim: Care, Health, and Costs, Health Affairs , 2008 From Triple to Quadruple Aim, Family Medicine , 2014
Thank you…and a favor Mike.South@rch.org.au @mikesouthRCH clonghurst@ucsd.edu @calonghurst
Help us win!
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