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Creating Joy in Medicine™ in a Boston, MA Health System: A Case Study

Physician well-being is critical to both patient care and organizational success at Atrius Health, a Boston area delivery system, with approximately 900 physicians and another 300 advanced practice providers across 36 sites. The leadership agrees that the path forward includes a deliberate focus on improving professional satisfaction.

The operational initiatives to achieve this strategic aim are organized around three reciprocal domains of physician well-being

  • Practice Efficiency

  • Culture of Wellness

  • Personal Resilience

Practice Efficiency

By developing greater efficiency of practice, Atrius Health intends both to improve the quality of care a physician can provide and to explicitly return some personal time to the physician's day.

Atrius Health is focused specifically on shortening the physician workday. As in many organizations, Atrius Health knows that its physicians, particularly in primary care, typically spend an hour or more of their personal time after hours each day completing documentation or working on their inbox.

To address this, leaders are introducing workflow redesign to ensure process reliability. Initial efforts at improving the micro-environment for the care team focus on adult primary care and consist of enhancement of nursing and support roles, routinization of core processes (e.g. rooming patients, refills, referrals, forms, patient onboarding, chronic disease management) and reduction of inbox items in primary care, including reductions in copied (CC'ed) notes to physicians and reducing the influx of messages in certain folders (results, telephone encounters, and media manager). A team in internal medicine spearheaded CC'ed chart changes. 90,000 CC'ed messages are sent each month at Atrius Health. To reduce this clutter, specific guidelines were set and adopted in the entire practice. Referral management has also been substantially removed from the primary care physicians' task lists via a Navigator Center. On behalf of primary care physicians, Navigator staff help patients with referrals and are able answer routine questions and offer guidance, including having difficult conversations when the proposed referral is different than what the patient might have requested.

A technology team has been deployed in primary care practices to re-engineer the EMR to reduce clerical tasks performed by clinicians (e.g. adult wellness visits, medication reconciliation, routine diagnostic orders) and to optimize EMR use among physician users. These efforts are estimated to have already saved hundreds of clicks per clinician per day across the enterprise.

Because visit note documentation consumes substantial physician time, physicians are given the option to pay for clerical assistants (scribes) to assist with documentation. One small study suggests that this form of team documentation has reduced physician burnout while at the same time significantly increasing patient confidence in the physician as well as patient satisfaction with the amount of time spent with their physician. The study indicates that patients are also more likely to recommend the individual physician and the overall practice. In addition, the study authors found that physicians with clerical assistants are more likely to add on patients to their schedule on short notice. Physicians reported fewer after-hours documentation and clerical burdens. To reduce the burden of lower level clinical and clerical tasks while on call, Atrius Health has strengthened its 24-hour clinically-staffed call center and fortified its capacity for urgent care 365 days per year.

To help physicians deliver higher quality care, as both a means of efficiency and of driving satisfaction, via our VNA Care home health subsidiary, Atrius Health has expanded its capacity to provide same day evaluation at home for patients who cannot come to the office and would otherwise go the ED (reducing likelihood of admission and associated work for physician).

The organization also facilitates prompt referrals across specialties, guaranteeing same day consultation in many sub-specialties while also establishing e-consultation as a mainstream method for acquiring sub-specialty guidance for primary care. Similarly, geriatric and palliative care physicians are available to either provide direct care or to guide primary care clinicians as they care for frail, elderly patients, increasing the scope and competency of the primary care workforce, which in turn enhances professional satisfaction. Finally, Atrius Health is beginning to use advanced predictive analytics to identify patients at high risk for hospitalization, thus enabling the team surrounding the physician to proactively recognize patients who require specialized in home or in office support.

Culture of Wellness

Atrius Health envisions a shift toward a culture of compassion, one that encourages physicians to extend to themselves and to their colleagues the same natural compassion they show to their patients.

One component of this cultural shift will entail modifying the annual physician review process away from traditional metrics and performance criteria and toward a reflective conversation between physician and chief, focused on individual professional growth and core well-being. This conversation will be used as a pivot point away from “physician who does it all” thinking and toward team expertise and compassion for all team members. Recognizing that facilitating these novel conversations doesn't come naturally, Atrius Health will conduct specific leadership development activities. These will support this shift in culture and the acquisition of new leadership skills to promote physician well-being.

Atrius Health is also working to rejuvenate, support and expand teaching, learning, and research opportunities through its Academic Institute, with an eye toward rekindling the intellectual and social ties that knit together a community of physicians.

Personal Resilience

While strides in physician well-being are driven by organizational and cultural factors, Atrius Health also recognizes the importance of individual efforts toward improving personal resilience. Atrius Health has launched a coaching program, available for individuals and teams, to build the skills, behaviors, and attitudes that contribute to well-being and the prevention of burnout. To date, 30 primary care and specialty doctors are enrolled in individual coaching. Furthermore, a half dozen more have signed up for our first “team client.” This will involve group coaching within a department to facilitate practice improvements. The coach is trained in both psychosocial and individual/team based practices. The goal is to help heighten the workplace environment and improve the clinician's day-to-day activities.

In addition a two-day Personal Wellness event at a local hotel is being planned. Clinicians will be able to use CME funds to attend this meeting and earn CME credits.

Lessons Learned

Improving clinician wellness through the three domains has presented challenges and barriers. In an effort to reduce inbox clutter, regulatory issues were uncovered. Efforts were undertaken to remove normal routine mammograms from the primary care physicians' inbox, but our compliance office interprets federal regulations to mandate that all results must be communicated to the ordering physician. Furthermore, medication reconciliation of recently hospital discharged patients presented further regulatory issues. Our compliance office interprets that physicians need to sign off on the medication reconciliations although nursing staff actually perform them.

Internal resistance to change has created challenges. Some physicians had difficulty accepting practice efficiency changes and thus, in the past, projects were abandoned. Now, within the Internal Medicine Department, changes are implemented based on majority impact; if most clinicians get a meaningful benefit, the practice efficiency takes precedence and will be implemented.

There is a lot happening, some underway, some in design. Responsive change will take time. Right now, many physicians do not yet “feel” the changes already underway as much as we would like. It is up to leaders to convey hope and uncover incremental opportunities, even as the changes are nascent.

Future Vision

As a core component of its strategy, Atrius Health intends to become a destination medical practice, attracting physicians regionally and nationally due to its success in making practice life better. It will do so by succeeding in the three domains: practice efficiency, fostering a culture of wellness, and the development of personal resilience among its staff. Atrius Health's legacy--a prepaid group practice that pioneered quality improvement, managed care acumen, process improvement, and brought clinician training into the ambulatory practice---makes it distinctly suited to succeed in this new realm challenging all of American medicines.

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