Knowledge Expansion Bringing joy back to medicine: Battling burnout through better EHR optimization Insight Article Electronic Health Records Sign in to save Doug Cusick Results from a recent study show that physician burnout is likely costing health systems far more than the changes needed to combat it. Direct expenses tied to physician burnout cost the United States approximately $4.6 billion annually, according to a study published in Annals of Internal Medicine, but that price tag could reach as high as $6.3 billion per year.1 These cost estimates are based on the turnover and reduction of clinical hours from physicians who are emotionally exhausted, cynical and detached from their work, which is how authors defined burnout symptoms. Per physician, burnout costs healthcare organizations $7,600.2 With the National Academy of Medicine (NAM) in October 2019 proclaiming burnout to be an epidemic,3 what can be done to reverse the troubling trend? The American Medical Association (AMA) published an article in December 2019 suggesting that burnout prevention can begin in medical school and by changing how residents are trained. The article highlighted how Johns Hopkins University School of Medicine is looking at variables in the residents’ learning environment — such as time at bedside, technology burden, workload and schedules — that can be modified to alleviate stress and burnout.4 But what about physicians in post-residency who are currently practicing? It’s not too late to start identifying and preventing burnout with them, too. Programs to treat burnout and remove the stigma are important, but so too are the practical, operational changes that need to occur; namely, fixing EHRs and their effect on workflows. Supporting clinicians’ preferred workflows EHRs are often blamed for the burnout problem, but it is not these platforms alone that caused the issue. Rather, as technology tools for healthcare environments rapidly expanded over the past two decades, different health system departments or service lines often made purchases tied to narrow areas of concern, such as paging systems, nurse communications, secure messaging, list creation tools, and rounding and handoff tools. EHRs, combined with these numerous other technologies, demonstrated a lack of consideration of the physician’s workflow, both from technology developers and the health systems themselves, which hastened burnout symptoms for many clinicians. To measure how this proliferation of technology affected internal medicine residents, the AMA article highlighted how Johns Hopkins conducted a time-motion study of more than 2,000 trainee hours across eight sites that found residents were spending just 20% of their time in the hospital on education and direct patient care and 66% on indirect care, while 43% of their time was spent with the EHR. The AMA article described another motion study involving residents wearing radio-frequency identification badges. After nine months of data collection, researchers found residents were spending just 13% of their time in patient rooms.5 Given this lack of time with the patient and so many hours spent in front of a computer, it is no wonder burnout is such a crisis. However, rather than wait for burnout symptoms to emerge, hospitals and health systems can apply more sensitivity to clinicians’ workflow needs when designing software, especially EHRs. For example, using apps embedded within the EHR could reduce the time spent with the technology and allow for the clinician to spend more time at patient bedsides. Unlike inflexible and generic user interfaces, these apps would surface patient lists that can be viewed by teams but would be highly specific to the clinician’s role. Upon access, the clinician would be able to immediately view all the patients for whom they are responsible during their shift, distinguishing between primary or consult patients. The list would serve as a workflow launching point for a myriad of other tasks and should minimize the search for critical information, such as care team identities, clinical and quality data, process information, handoff/sign-out notes and other tasks. Health systems are using the EHR as a mechanism to standardize care — and reduce variability — across the enterprise. These apps now enable the “personalization” of the EHR based on specialty practice requirements and unique roles on the care team. Optimization technology should also eliminate tedious steps that were added when EHRs were implemented, such as requiring the clinician to enter their relationship to the patient or requiring a physician to sign off on an order that once was part of an accepted nursing protocol. Streamlining in this way would “reduce tasks that do not improve patient care” and “improve usability and relevance of health IT,” which are goals the NAM called for in its burnout report.6 These apps can also play a big part by auto-completing mundane steps that have been filled elsewhere in the chart and apply rules or algorithms to prompt a next step based on contextual repetition and pattern recognition. Reducing this workflow friction would go a long way in reducing the stress that leads to burnout. Decreasing physicians’ cognitive burden and eliminating manual steps to enable more rapid assessments of patient needs and speeding the time it takes to make diagnoses would further foster more positive work environments. Streamlining communication As texting became the norm in the nonclinical setting, many clinicians also found it to be a better and faster communication option compared to cumbersome pagers or EHR messaging platforms that were not routinely checked. In 2020, we can expect a continued increase in reliance on mobile for clinical communication. If the EHR is more deeply integrated with mobile, handoffs and other care transitions will become more streamlined, as well as care team messaging and alerts. Improving communication in this way requires workflow-oriented design to allow the transition of key functionality between the desktop EHR to mobile devices and ensure there is a bidirectional flow of information between the two platforms. As an example, providers should be able to dictate an update to a patient’s to-do list directly on their phones and have it automatically write to the EHR. Allowing a single entry of information to populate both the mobile and desktop platforms supports the goal of reducing unproductive tasks, such as double documentation, that do not improve patient care. It also enables the entire care team to know simultaneously what needs to be done and who is responsible for which tasks, which promotes collaboration and supports a positive work environment. The most progressive organizations are seeing providers use their mobile devices for more than just secure messaging and are rolling out advanced mobile apps that offer one-tap linking to their patient list and to the most relevant patient information. These health systems are battling “alert fatigue” by empowering the clinician to subscribe to smartphone alerts that are only most important to them, such as when a test result is ready or a consult note is available for review. Mobile capabilities also enable rounding providers to finally go paperless and reduce the need for clinicians to find a desktop computer for key clinical information, which simplifies communication and improves workflow efficiency. Since mobile is becoming more essential for how teams work in hospital settings today, highly intuitive mobile platforms greatly enhance overall EHR usability and clinician satisfaction, as well as improve care team communication, collaboration and ― ultimately ― patient care. Bringing joy back to medicine Bringing joy back to the practice of medicine and reenergizing clinicians through less frustration and wasted time will require more than just EHR improvements provided by the EHR vendors themselves. It requires a complete examination and overhaul of workflows and providing clinicians information where, when and how they want it. As these more well-designed workflow optimizations are adopted, clinicians’ cognitive efforts can transition to fostering patient engagement and applying their experience to each patient’s situation rather than navigating, extracting and inputting information in various systems. As a result, health systems can combat the monumental costs of burnout and help return the joy of practice for their organization’s most valuable asset. Notes: Han S, Shanafelt TD, Sinsky CA, et al. “Estimating the Attributable Cost of Physician Burnout in the United States.” Ann Intern Med. 2019; 170: 784–790. doi: https://doi.org/10.7326/M18-1422. Ibid. NAM. “To Ensure High-Quality Patient Care, the Health Care System Must Address Clinician Burnout Tied to Work and Learning Environments, Administrative Requirements.” Oct. 23, 2019. Available from: bit.ly/2SNdpN8. Smith TM. “Burnout prevention can begin in medical school, residency training.” AMA. Dec. 13, 2019. Available from: bit.ly/2SNd9h8. Ibid. NAM.