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Taming the EHR

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Audio Transcript

Speaker: Hello, and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMAs STEPS Forward® program is open access and free to all at stepsforward.org

Jennifer Mathews: Today's podcast guest is Dr Marie Brown, director of practice redesign here at the American Medical Association, professor emeritus at Rush University, and a practicing physician in internal medicine for over 30 years. Today, Dr Brown will be speaking about taming the EHR.

Marie Brown, MD: EHRs have transformed our work in health care, and none of us want to go back to paper. However, it's a source of great frustration, and it can lead to burnout. I began working in internal medicine at an FQHC. When that closed and I moved down the bus line and went into private practice, a two-person practice for almost 20 years, and most recently I joined Rush University. So, I went from paper to implementing my own electronic health record called amazing charts, and then when I joined Rush, a large integrated center here in Chicago, uses Epic. So, I will be sharing some of my experiences with Epic and hopefully, most of what we talk about today will be relevant to all the other vendors as well. We're really going to focus very briefly on the impact of the electronic health record on burnout, your well-being, and the patient experience.

We're really going to highlight that you have more control than you think, and we're going to spend most of our time talking about time-saving tips and tricks. And I want to highlight that of the three strategies at the American Medical Association, the number one strategy is this, removing obstacles that interfere with patient care, because everything we're trying to do here is to save time, not so that we can go home early, but that we can spend the time we have with our patients, looking them in the eye and having a meaningful discussion, work to get that diagnosis, and develop a trusting relationship. Technology should be an asset and not a burden, but we blame the electronic health record for many of our frustrations. And it may be the tool we see, but the regulations, the performance measurements, and everything that hits us through that computer screen is not related completely or provided by the vendor. It is sometimes helpful to separate CMS regulations, performance measurement, and the vendor capabilities.

But what's happened over the past 15 to 20 years is truly a knowledge explosion. And I coined this talk 1600 guidelines in 17 minutes for an internist like myself and geriatrician, this could not possibly be communicated with the patient. We cannot apply 1600 guidelines in the short time we have, we have to use team-based care, and we need to use the electronic health record because, with that amount of knowledge, it is simply not possible to do that in the old-fashioned paper charts. However, in this study done by our vice president, Dr Christine Sinsky, also an internist, she looked at a time-motion study in four specialties, family practice, internal medicine, cardiology, and ortho. This was done with Dartmouth-Hitchcock, and they found that for every one hour of face-to-face time with a patient, there were two hours of documentation time, and more often than not, one or two hours of work was taken home.

We can't take the patient home, but we can give our undivided attention to the patient. But then we have to take that documentation time, that documentation work home, which takes us away from our family and any time for ourselves. Other publications have confirmed the same data, the Annals of Family Medicine, primary care physicians spend half of their workday, nearly six hours, interacting with the EHR, and again, work after work. And we know that the use of the electronic health record and sometimes the frustration or the meaningless work that is required there is associated with stress and burnout. Also at the American Medical Association, we've done research, looking at metrics for assessing physician activity, and these are proposed core electronic health use measures that hopefully would be applied across all vendors so that we can have, we can compare, and we can see what the total EHR time is. Work outside of work for eight, compared to eight hours of patient care time, and time on prescriptions inbox and the use of teamwork for entering orders, as well as identifying and measuring the amount of undivided attention we can give to our patients because that's what patients want. They do not want to see the back, our back, while we're struggling with the electronic health record. This is all about delivering quality patient care and the patient experience.

Very quickly, I'm going to review what burnout is, and it is a stress reaction characterized by these three things. Sometimes it comes in the form of depersonalization, referring to a patient not as their name, but the train wreck in room one, emotional exhaustion, I just can't take it anymore, or feeling that the day you spent was not what you were trained to do, that you spent most of the time doing meaningless work and feeling like what's the point, all I did today was click buttons and document for billing.

We know that many are exiting practice or doing part-time work. Hopefully not having family problems at home or suicide, but the effects on the patients, the teams, and the organizations are significant as well. When a physician is burned out, patient satisfaction, trust, adherence, goes down, and we know that a burned out physician is more likely to write more referrals, order more tests, make mistakes, and the people around them will have more staff turnover, and it costs organizations. A very effective way to decrease burnout and to manage the documentation burden is to go part-time. So, many physicians are going from five days a week to four for clinic, and then so they're working 0.75%. What are they doing on that day off? The documentation required by the EHR to give good quality care for the other four days.

So, if an organization looks at this, and on average, many of their physicians are going part-time, if you have 600 physicians and they're all on average 0.75, you lost 150 physicians, but you're paying full benefits for all those physicians. So, that's something to think about when we want to invest in some of these time-saving tools that we're talking about. And what brings joy to a physician? Really pride in their work, at the end of the day, we're not afraid of hard work. We wouldn't have gone through medical school and residency. If at the end of the day, I saved lives and everything I did today, I needed my training and my skill set to do. It's when we're doing meaningless work, that is so frustrating.

We think of the relative causes of burnout as the organizational culture, only 20%, maybe personal resilience, and I'm going to focus today on the efficiency. So we're going to focus on the clerical burden and taming the EHR. And to do this work, this kind of efficiency work, it's important not to think like a doctor. Now that may sound strange, but we are trained to think of the exception. We are trained to think that every headache comes in is not a tension headache, but is a brain tumor or subarachnoid hemorrhage until we do a history and a physical, and prove otherwise. If we didn't think like that, if we weren't trained to think like that, then we're going to miss that one patient who comes in with an unusual diagnosis, but to do this work, we need to think like an efficiency expert. So, if we're working on something that would save two hours a day, but it'll only work for 50% of the people, your patients, then you're only going to save an hour a day, not two hours a day.

So, this is one, one of the biggest take-home points I'd like to leave you with. And quite often we blame the vendor for our concerns and some of the unnecessary work we think we're forced to do. However, we have seen around the country that the compliance department, or your IT department, risk management, or coding are actually overinterpreting the regulations. So, you may have much more control than you think, and working closely with the compliance department and these other committees to make sure that they're accomplishing what they need to accomplish, but with the understanding that the user experience should be incorporated into any decisions that they make. Here's an example, in each patient chart, I can go to my patient care team and I can turn off notifications of tests that I have not ordered, and it's simple to do, you can do it with each patient and you can turn them on if you want to follow what a specialist or somebody you've referred to is doing, or how they're doing in the hospital. But for most of my patients, I trust my specialists, I trust my hospitalists, and I'll look at that chart and review everything when I see the patient. I do not need, as it's ongoing, to have all of that information when I am not in charge of that patient, I don't need to see what my other colleagues are doing. When I turned off these notifications, my inbox decreased by almost half. And it's also a patient safety issue, if you're getting notifications of orders that another doctor wrote, for instance, a cardiologist ordered a electrolytes and your potassium, and that patient's potassium comes back low, the cardiologist ordered it, it's coming into your box, because they copied it. Do I address the low potassium or does the cardiologist? And she may think I'm doing it, I may think she's doing it, and that's where patient safety and attention to that abnormal test may be missed.

Your in-house IT team can default all of your patients to either notifications for admissions, discharges, and transfers, to being off or on. At one hospital, the IT, the CMIO told me that for the primary care doctors, they turned it on, the default was on, and for all the subspecialists it was off, but they said they were rethinking that. Again, you can always turn it on if you want to watch closely what other doctors are doing for your patient, but I found that it was not necessary. I reviewed them when I saw the patient. There are also examples of security issues. In one hospital here in Chicago, a popup notifying the physician or the user about the privacy concerns of the hospital popped up every single time that the doctor logged on. This would maybe occur a hundred times a day.

Now you delete it, or you hit “okay,” and it goes away in less than a second. However, this was brought by the EHR, not by the EHR vendor, but the hospitalist compliance officer, and if the compliance officer's job description and what leadership wants that compliance officer to do and only do is be sure that security is intact, then this is what you're going to get. But if leadership directs the whole hospital to also be sure that the time required, the necessity of the alert is part of their job description, then this may not happen as often. When it happens a hundred times a day, that could be 10 minutes a day, an hour a week, that's 52 hours, that's six day, that's a week of work for you. And we know that when you see this, it distracts you from the task at hand, and it can take up to 24 minutes after a distraction to regain focus on a task.

So, the first thing we encourage you to do is stop doing unnecessary work in the electronic health record. So, I've already alluded to getting rid of copies that you don't need to see the things that come to your inbox should only be things that you need to attend to. We have a STEPS Forward® toolkit called “Getting Rid of Stupid Stuff.” This was written by Melinda Ashton, Dr Ashton, after she wrote a piece in the New England Journal and was kind enough to author this toolkit. It shares how she went about finding things, asking physicians and nurses, the clinicians doing the work, what are they doing that clearly does not add anything to the experience or the physician health, or to the patient health? And sure enough, they found wonderful opportunities that saved hours throughout the organization. In the toolkit are opportunities to show how to roll this program out in your organization with templates and emails, and how to sort them after you get recommendations or suggestions from the workforce.

She suggests sorting them into, just do it, it's simple, simply turn it off, or the IT department turns something off, like I just mentioned with notifications, and that could take less than a week. When I first went to Rush University, every time I ordered a non-controlled substance, I had to enter my username and password. Dr Dan Dunham, who came from another hospital, said, well, we don't do that across town. Took him a few weeks to find the right person to call, but once he did, they turned off that requirement. That one phone call probably saved thousands and thousands of hours for the physician and clinicians throughout the organization. And then there'll be some that take longer, maybe redesign or re-education, maybe two weeks, and some things that simply are not able to be done. And these are, there are many examples in the toolkit. I mentioned some of them. Another one that is very common is how quickly you, the computer, automatically logs you off.

And this is not vendor specific. This can vary in location within your organization. So, in the ER, where the computer is very public, we'd want it to automatically sign off for security in a very short period of time. However, if you're having a visit alone with the patient in an exam room where we don't have to worry about security, it should not be as quick because while you're trying to talk to the patient and give them your undivided attention, you're trying to remember to move the mouse so that it doesn't automatically sign you off. So, there's many opportunities to stop doing unnecessary work, or get rid of stupid stuff, and many of those can save you hours each day. And just last month, the AMA published a de-implementation checklist. This is also housed on the resource page of the “Getting Rid of Stupid Stuff” toolkit.

And you can share this with your compliance department, IT department, to stop doing things that are unnecessary. And we know that physicians themselves are often in the best position to recognize those unnecessary burdens that don't bring any benefit to the experience of the patient, the coding, or the physician experience at all. So, it's broken up into EHR, compliance, and quality assurance. The compliance allow verbal orders in low-risk and in crisis situations, we've seen that in the COVID crisis, but verbal orders can be allowed in low-risk settings. We need to reduce clicks as often as we can, and eliminate unnecessary requirements like attesting to a possible pregnancy in a man or woman over 60, and reduce all those inbox notifications, and I'll share with you what one group in Boston did successfully. They set out to save time, the technology solutions include included widescreen monitors, dictation in-basket reduction efforts, and they were very successful. Just wide screen adoption alone saved 60 million clicks, and they estimated that the click savings was 1,500 per day per provider.

And if you average that out to maybe five seconds of seeing something that pops up that you have to accept, or hit next, or get rid of, on average, maybe five seconds, that's two hours a day per provider. So, that's an enormous amount of time saved. They eliminated ADT admissions, discharges, and transfers, and got rid of 300,000 messages a year. In some organizations, paper is still coming over, and we have to sign those papers, the home health, physical therapy, durable medical equipment. Then that paper is sent to be scanned. In some organization that scanned document comes back into my- to their inbox to be checked off again. Well, if it's already been signed, you've already reviewed it, it simply does not need to go back in to be reviewed once again, that's double the work. And if we talk to our specialists and work together as a team across the medical staff, copied charts were necessary when we didn't share the electronic health record. Now, if I want to see what the cardiologist did, I have access in the computer. So do we really need a routine referral to a dermatologist, a cardiologist, a pulmonologist, especially if they're following the patient along with you, do we really need to see that, or would it be more efficient to look at that chart in preparation for when I'm going to see that patient maybe next week. So, it has been done and it can be done.

There's opportunities to eliminate notifications, duplications, copied charts, anything that's FYI, because it all leads to burnout, and wasted time, and time away from your patient most importantly, and of equal importance, away from your family. We can add standing orders, and protocols, and standing labs, and I'll highlight that we can refill meds for one year, having the refill burden for your nurses and your staff. There are many quick wins. I've mentioned some of them, and implementing dictation. I know I started dictating when dragon first came out years ago and found it very awkward. I picked it up again a year ago and was amazed at how far the technology had come. So, if you haven't used it recently, you may want to try it again. And I found it was very effective, rarely got anything I said incorrectly, and in fact, I found it quite time saving, because I would put in the plan- I would look at the patient and discuss the plan. So, while I was telling the patient what the plan was, getting a lab, going to physical therapy, whatever, I was dictating it into the chart at the same time, and the patients loved it, my documentation improved, and I closed the chart when I left, before I left the room.

We have several toolkits on EHRs. I'm going to highlight a few, EHR in-basket for improved efficiency, and again, these are open access, written in a very conversational tone, usually takes, you know, 20 or 30 minutes, there's videos and resources that you can use associated with it, adopting open notes, we have one on telemedicine, and one on optimizing the patient portal. And then there's electronic health record strategies for thriving, which you'll see much of what I'm talking about here. There are some simple things that we can do, according to standing orders, that a physician doesn't really need to have that MD or DO to sign off on. So, we can make standing orders or protocols that test strips, glucose test strips can be refilled by an MA, depending on your state rules, or your nurse.

We can get rid of discharge summary notes, especially when they say that when you open it up and it says no notes of this type exist for this encounter, because this is very, very frustrating and completely unnecessary. One of the benefits of the electronic health record that I greatly appreciate is being able to postpone a laboratory result. If it's not emergent, like a slightly low vitamin D level, I could talk to that patient the next time I see them, maybe next week or two weeks. So, I can, instead of calling that patient today, I'm going to have that discussion with them next week. So, I'm going postpone this lab, so that'll come into my inbox the day before I'm about to see that patient. So, with one click, I have addressed it, I haven't ignored it, and I'm going to be able to have a much more efficient conversation with the patient, face-to-face, about a slightly abnormal lab.

I also especially like the opportunity to use the electronic health record to remind me of something very important that the patient may- that I want to be sure that the patient follows up on. Perhaps it's an incidentaloma on a CT scan for lungs that was done for some other reason, and I want to be sure that they get another lung scan to make sure it's stable in six months. So, I can send a reminder not only to myself, but to my MA in six months. So, it'll pop up again in six months. I sleep better at night, knowing that I'm going to be reminded as is somebody else, to be sure that that patient did follow up so that we don't miss a growing malignancy or some such medical problem.

We also can streamline our problem lists. This is a- there's an example of wanting to put obesity in the problem list, but putting in the BMI and whether it's associated with other comorbidities is very time consuming. With a few minutes, you can save these, and you can find a way to streamline it so that you're not clicking four or five different ways and frustrated, to simply want to document that a person has a BMI of 35, and has obesity. Similarly with the problem list, we have to associate it with a- when we order tests, in some electronic health records, you can click the top of where the diagnosis is, and it will auto check all the labs that you have, that you want to associate with that diagnosis.

So one click replaces four clicks, and these are simple tools and tricks that take time to get to learn, but 10 minutes can save you 10 hours in the long run. Another tool that I found helpful, that meant that, actually a patient of mine shared with me who also used Epic was to type in “.risk” and what will automatically populate is the atherosclerotic cardiovascular disease score, so that you know the risk score, so that you have a calculation of whether the patient is eligible for statin, for example. And what I found with patients, is I would frame the discussion about whether they needed a statin or not, and what their risk was, if we were trying to get them to stop smoking or get their blood pressure under control, I would say that if it's less than 5%, this is what we need to do, if it's five to 10%, here's the conversation, if it's over 10%, that means you have a 10% risk, and that would be probably a time we'd want to definitely put you on a statin.

And then I would have the patient, I would type “.risk,” and I'd have the patient actually press the enter button, and then would pop up a number. And I was surprised if it came up like this, you know, 20 or 30% they go, oh, I guess I need, I would benefit from the statin. And if it came out at 2%, they'd say, oh, this is great, I'll, I'll keep doing what I'm doing, and we'll, we'll calculate this every year. So, I think the patient engagement was very helpful here as well. We can also improve adherence and improve our experience and the patient's experience by using indication prescribing. If you set up your electronic health records, so that your top 10 drugs that you most commonly use, you can add into the instruction, for instance, you're ordering atorvastatin, you could add into it that this is to lower your cholesterol and prevent heart attack and stroke, so that the patient understands why they're taking it. You don't have to write that over and over again every time you order atorvastatin, that's what will pop up, and patients and families really appreciate that, and that's called indication prescribing.

We also have a toolkit on medication management, talking about or teaching how to move chronic med refills from 90 times one for six months, to 90 times four, call me no more. And clearly this saves and we've- I did it in my practice, I've facilitated other organizations doing that, that one little change in six months can result in an hour or two savings for doctors and nurses. The patients like it, actually, they love it, because they only have to worry about getting it filled once.

And if you can synchronize them so that all the meds come due on the same day, that's even better. Now, every physician knows and is thinking of the one patient where they won't come in. So, you continue to see the patient as often as you need, but you don't punish all of the patients who would come in anyway, by making them have their, come in twice refill, double the refills twice a year, instead of once a year, and you're not punishing yourself and your staff. You free up an hour or two a day, so that you can reach out to the patients who are missing their appointments or who you were using the prescription to hold them hostage so that they could come in. So, streamlining that is very helpful and you can default. So the default is 90 times four, and you can change it to three, or two, or one, or 30 times one but the default is the time-saving benefit.

And again, saving an hour or two a day, night calls, weekend calls, patient satisfaction goes up. And, of course, you continue to see the patient as often as you need to, but imagine a day when you're not writing or responding to a phone call, a fax, requesting a refill for chronic med. Another one of the tools that I found in Epic, extremely helpful, is similar to what you all have if you have an iPhone, autocorrect. So, these are not smart lists or embedded links, or text macros as some of the vendors call it. This is simply replacing your shorthand. So, you know how you write a quick note to yourself? It might be a 60-year-old with c/o BR BPR, short - SOB. So it'd be, that would turn into a 60-year-old woman complaining of bright red blood per rectum with shortness of breath and dyspnea on exertion.

And this is going to be extremely important now that all the patients will receive and have access to all of their notes. So if you use jargon one time, you need to put in your specific to your specialty, what you abbreviate things. PAD, you know, peripheral artery disease. If you put that in once every time you write PAD and then hit the space button, it will write peripheral arterial disease. So this was a huge, this probably saved me a good hour a day and made my notes much more readable for my colleagues, as well. When we are prescribing, we can also write a note to the pharmacy, so that in addition to 90 times four for a whole year, we can synchronize them so that we- I wrote S-Y-N-C, and that automatically populated to a note to the pharmacist to sync the medicine. So, all the chronic meds come due on the same day, once a year, and disregard all prior prescriptions for this medicine. Many of the pharmacies are trying to do this. One retail pharmacy calls it “save-a-trip,” and patients love it, their families love it, and it's a great time saver for you as well.

Another concern is trying to find the correct order, especially for an MRI of the spine or brain- something a little unusual. But if you know that there's only a few of these- once you find it and put it into your favorites, you're not going to have to waste that 20 or 30 minutes, or worse, get the wrong test preauthorized and waste everybody's time, including the patient, and put it in your favorites. And this is, again, take 10 minutes to ultimately save 10 hours.

So, turn off the notifications, communicate with your subspecialists regarding copies, consider asking or if there's subspecialists on the call, changing the way you format your note. Instead of the old-fashioned SOAP, subjective, objective, assessment, and plan, put the assessment at the top with the plan underneath, and if the referring doctor wants more information, they can scroll down further for the subjective and the objective. I've seen physical therapy appointments in my inbox with, you know, 20 that are clearly unnecessary. So, talking to physical therapy or having your IT people make sure that anything that goes into your inbox needs action. And use autocorrect, favorites, smart list tests, max rows, whatever your vendor provides. With that, you can easily save three to five hours a day. For the toolkits that we have, I'm going to highlight just two, prescription management and pre-visit planning, and with pre-visit labs which can be protocolized and done with your team.

So the patient has the lab's done, completed your A1C, your BMP, within the week of seeing you, so that when you see the patient, you have everything you need so that you're not playing phone call, getting the test that day, and then calling them back with escalation or de-escalation of therapy, because it's difficult to get a hold of patients now. When an organization did that, phone calls went down 90% as did letters. Patient satisfaction went up and nurses and physicians had much more time to care for their patients, rather than trying to track them down. It can save eight weeks per year with synchronized prescription renewals, and that is an enormous savings, and most of the nurses that I speak with do not want to spend the time talking to every retail pharmacy in the city.

It is not a good use of their training, and it can save money. If you save an hour a day, of your staff, it can be, perhaps replace or have an opportunity to hire additional staff to do this work. We really want to be enabled. We are engaged. We didn't go through all this training. There's no question that we're engaged. We want to make sure that our IT department provides training on the clock, or give RVUs for the training, at least make somebody whole. If you're involved in committee work, don't be, don't have the physicians that you need to talk to the compliance team or the IT team to be penalized because they're not in clinic, and they're losing RVUs, at least make them whole and measure work after work.

In Epic, it's called signal. Other vendors have similar ways to track that. We have to get away from the physician. There I am with my patient playing on the phone and I'm trying to find, I'm the billing collect pharmacist. I'm trying to find medical records, a transcriptionist, it's not sustainable. So, team documentation is critical. University of Colorado has provided, in their family medicine residency, an increased ratio of medical assistance to even people in training so that they get used to this teamwork. And we also have a tool kit called medical assistance, recruitment, and retention. And we've done a webinar on that as well. Strongly encourage you to look for a lot of this information on stepsforward.org. Again, it's open access. They're all the goals of the STEPS Forward® program is to really help eliminate waste from our workflow, so we can get back to face-to-face time with our patients and improve patient care.

So the take home points are these, the burden of the EHR leads to physician and team burnout. It really affects the cost for the entire organization, as well as quality of care. We can stop overinterpreting the regulations at the local level and stop doing unnecessary work. Improving personal resilience, meditation, eating right, maybe 20% but it is really the efficiency of the workplace and the culture in which we work that is 80% of the causes leading to burnout. Team documentation saves time and money and improves patient care. So, I hope that that has been of some help to you. I know it was vendor specific because this is the one I use, but most of the vendors have similar programs. And I hope that we will all be able to tame our EHR and get back to doing only meaningful work so that we can give the best care to our patients and improve health outcomes.

Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.

Audio Information

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Disclaimer: AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward® content.


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