Implementing beneficial modifications one specialty at a time ultimately took two and a half years for one large medical group.


March 19—About half of all U.S. practicing physicians experience burnout, and several recent studies have placed the blame squarely on the widespread adoption of electronic health records (EHRs), which require data entry and other click-based tasks.

For each hour that physicians spend on direct patient care, they spend two hours on EHR data entry and other administrative work, according to a 2016 study of ambulatory care physicians. Outside of office hours, physicians spend one to two hours of personal time on additional computer and clerical work, the study indicated.

Contributing to burnout is a lack of recognition and a breakdown of the clinician community as providers spend increasing time in front of computer screens instead of interacting with one another and their patients, said Paul DeChant, MD, deputy chief health officer at IBM Watson.

“Those things have eroded in the past 15 years,” DeChant said recently in a presentation at the HIMSS 2018 annual conference.

The manifestations of physician burnout have an effect on health system performance. As physicians experience exhaustion and a loss of enthusiasm for work, burnout can cause them to distance themselves from their patients or the organization. Burnout also causes a feeling of ineffectiveness at work, DeChant explained.

Burnout's negative effect on a healthcare organization's bottom line can take the form of staffing turnover, increased medical errors, absenteeism, and increased medical costs for the burnt-out providers.

With physician burnout now seen as a national epidemic, technology companies are entering the space to offer solutions that aim to free physicians from their desktop computers. However, the effectiveness of these tools in reversing burnout remains unclear.

Practice Experience

One California-based medical group lowered its physician burnout rate to below the national average by implementing new technology solutions while providing increased training and oversight of how much time physicians were spending in front of their computers, and intervening on an individual basis.

Sutter Gould Medical Group, based in Modesto, Calif., is affiliated with health system giant Sutter Health. Sutter Gould has 360 physicians, more than 1,000 employees, 1.6 million patient visits per year and $380 million in annual net patient service revenue.

Implementing a systematic approach that gives physicians the choice of how to reduce click-based tasks was important to successfully reducing burnout levels, said Martin Pricco, MD, president of Sutter Gould.

The medical group focused on four areas of improvement: initial EHR training, user interface personalization, expanded options in note documentation, and reduced volume of physician in-baskets.

Initial EHR training for all physicians was expanded to six hours, even for physicians who had used a similar EHR at another health system.

The positive effects of intensive initial training persist, Pricco said. “Those physicians who are trained properly go on to have greater satisfaction and usability over time, not just months but years later," he said.

Personalizing the EHR to fit physician needs by specialty also has helped to shorten time spent doing data entry, he said. The medical group found that only 45 percent of personalization tools in the EHR were being used. Ten percent of physicians were using no personalization tools at all.

“That is very sad because they can be extremely helpful,” Pricco said.

Sutter Gould assembled a team from each specialty to identify areas where the EHR could be made more personalized and less cluttered to improve efficiencies. The initiative resulted in removal of unnecessary buttons and alerts, introduction of "smart phrases," and construction of a cleaner interface customized for each specialty. Additionally, the medical group flew in analytics specialists from the EHR vendor, EPIC Systems, to help with design and implementation. A rapid-cycle improvement approach rebuilt, tested, and went live within three weeks. Then, a follow up at six weeks after implementation refined improvements.

This approach was not quick or inexpensive, however. Implementing modifications one specialty at a time ultimately took two and a half years for the entire medical group, Pricco said.

The approach worked because it included physicians in the improvement process, he said.

“You had the doctors now really engaged in the build of the EHR and the workflow,” Pricco explained. “It did improve their proficiency and it simplified the training because they were already engaged."

More Choice

Sutter Gould gave physicians choices in how they wanted to input their patient notes into the EHR. Progress notes account for about 60 percent of physician computer desktop tasks, according to a Health Affairs study by the Palo Alto Medical Foundation, another Sutter Health affiliate.

Today, about one-third of physicians at Sutter Gould use voice recognition software for note creation, while another third key in their notes using templates. Ten percent use dictation, 7 percent use medical assistant scribes to input notes, 4 percent use remote scribe technology in partnership with Google Glass, and 21 percent use a combination of these methods.

“The point here is we give everyone choice,” Pricco said.

As for electronic in-basket tasks, the medical group focused on de-cluttering folders and eliminating tasks that could be done by other clinicians, such as medication refill requests. 

Importantly, the medical group tracks how much time each physician is in the EHR and at what time of day—to target interventions at over-users. One physician was observed in the EHR at all hours of the day and night, spending most of her time in the notes section. Sutter Gould intervened, and she switched over to a voice recognition technology for note entry and is spending far less time in the EHR , Pricco said. He added that the medical group is conducting interventions with about 10 physicians for overuse to curb burnout. Two different surveys are in place to monitor burnout as well, he said.

“We have a lot of work yet to do,” Pricco said. “What's been extremely important is streamlined governance and the right mindset and leadership."   


Rebecca Vesely is a freelance writer based in San Francisco. Follow Rebecca on Twitter @rebvesely 

Publication Date: Tuesday, March 20, 2018