Clinicians are experiencing a burnout crisis that stems from several factors — one of them being EHR burden. Here, executives from 12 hospitals and health systems across the country share their thoughts on how to best address EHR burnout.
Editor's note: Responses have been lightly edited for clarity and style.
Michael Restuccia. Senior Vice President and CIO for Corporate Information Services at Penn Medicine (Philadelphia): A first step is to recognize that EHR burnout is real and must be addressed, particularly in today's environment where front-line caregivers are often stretched to meet the ever-growing clinical demands of the population. A key contributor to EHR burnout focuses on the need for superfluous amounts of clinical documentation to ensure appropriate reimbursement as well as clinical care support. The combination of organization and government requests to gather this data has resulted in the unintended consequence of burdening clinicians to respond to and document a never-ending set of inquiries.
Although we are not yet perfect at this and with the guidance of our clinical committees, our approach to reduce this burden is multifaceted. Our efforts include validating the purpose of additional clinician documentation prior to building it within the EHR, eliminating extraneous documentation requirements, leveraging/pulling preexisting patient data to populate required documentation and providing patients with the ability to enter data via the patient portal that can be validated by the clinician have been introduced. Simply put, the need for less documentation will result in less EHR burnout.
B.J. Moore. Executive Vice President and CIO at Providence (Renton, Wash.): In close collaboration with clinical leadership, and in addition to ongoing targeted optimization work, we have made investments and established partnerships that enable us to make improvements that ease our caregivers’ burden with speed and in a sustainable way.
In the spring of 2022, we will have completed our EHR standardization, one of the largest Epic implementations in the world. This will enable us to optimize workflows for the entire system and respond with greater agility to feedback and evolving needs. In addition, our strategic partnership with Nuance plays an important role through their ambient sensing technology including DAX (Dragon Ambient eXperience), which enables doctors and nurses to focus on the patient encounter instead of taking notes.
Zafar Chaudry, MD. Senior Vice President and CIO at Seattle Children's: Helping to ease clinician burnout requires a multipronged approach. Providing quality training and "at-the-elbow" support is essential. Look at interventions designed to optimize technologies and workflows. Maintain constant communication directly with clinical leaders about EHR usability issues. Consider live or virtual scribes for certain high-volume medical specialties, and make voice recognition available for all clinicians. Ensure that the EHR team has both clinical and technical competencies.
Jon Manis. Senior Vice President and CIO of Christus Health (Irving, Texas): EHR blame for physician burnout is likely masking bigger, more complex issues. The real challenge is the requirement to use a new, digital tool within an old, analog care model. It's like being required to go to a video store to stream a movie or visit a banking branch to upload a check. The problem is exacerbated by the physician compensation model. Most physicians are compensated for seeing individual patients face-to-face, historically in-person. Though virtual visits have helped, traditional care and compensation models need to evolve into the digital age.
Physicians should be fairly compensated for leveraging digital connections to keep healthy individuals well, and compliant, well-managed patients from utilizing costly, in-person clinic, hospital and emergency department services. Today, physician mental health and job satisfaction are threatened by the requirement to use a digital tool within an analog care model while maintaining the one-to-too-many relationships necessitated by large patient panels and the closely monitored productivity metrics that drive most physician compensation models.
To alleviate stress and reduce physician burnout, a modern, digital care model should incorporate a data and communication triage capability, an EHR, and a care team capable of remotely managing and coordinating care for individuals and patients by leveraging wearable, implantable, and ingestible sensors; connected monitors and self-service diagnostic tests; automated, from-home check-ins and check-ups; automated health status, trends and alerts; compliance and progress reports; and the provision of in-person care by a physician only as required by exception.
Adopting modern care and compensation models that utilize available technology tools and digital channels will increase access, improve satisfaction and reduce costs. It should also help to reduce physician burnout and improve job satisfaction. How would physicians feel about their profession if they were able to work regular hours and maintain both their status and standard of living by spending more high-quality time with fewer patients — the clinical exceptions — that actually need to be seen in-person?
R. Hal Baker, MD. Senior Vice President and Chief Digital and Information Officer at WellSpan Health (York, Pa.): We believe that the key to reducing EHR-related burnout for clinicians is to focus on the time and attention of caregivers as precious resources. Since our major EHR implementation in 2017, we have concentrated on caregiver time as a measurable resource and sought to reduce the amount of time EHRs demand of our care team.
By recognizing that every nine to 15 seconds is 1 percent of the time for an office visit, we emphasized reducing the time spent with the computer to allow more time to focus on the patient. We also identified administrative tasks that could be removed from the workflow of our providers so that the physician can focus more attention on the needs of the patient.
Perhaps the most exciting tool we have implemented is ambient voice technology in the office setting. By letting ambient technology document the conversation in the exam room, our providers can focus on engaging with their patient. A note follows a few hours later in the EHR and requires only a minute or two of edits, dramatically reducing the amount of a provider's time taken for documentation. Since adding ambient technology, our physicians are sharing that they enjoy their work much more and feel more connected to their patients during visits.
Tom Barnett. Chief Information and Digital Officer at Baptist Memorial Health Care (Memphis, Tenn.): I had a physician relay to me once that each irritation in the EHR or workflow is like a tiny stone in your shoe — it doesn't hurt that much at first (you might not even notice it) but after a full day you literally could be limping from the pain! The EHR is consistently cited as one of the main drivers of physician burnout. It's a complex issue — is it the EHR that's burdensome or the tedious regulations behind it that are simply being expressed through the EHR? Perhaps a suboptimal workflow could be to blame?
I think one area that can add dramatic improvements to the provider experience is optimization. By that I mean every organization should have an optimization team composed of workflow specialists, trainers, clinical personnel and a few EHR build folks. This team can work directly with providers, watch how they practice, and then help streamline and automate key areas of physicians' overall workflow.
It might be that EHR modifications are necessary, but it might also be a quick conversation with coding or compliance about a specific rule or regulation and how it is being interpreted, maybe a change to the "click count" on a screen to explore ways to automate and reduce the effort — there are numerous ways that an optimization team could help deliver some solid improvements for the physician work day and directly help with physician burnout in the process.
Jim Feen. Senior Vice President and CIO at Southcoast Health System (New Bedford, Mass.): There is no singular approach to this critical problem. Clinician burnout now transcends the EHR as we (hopefully) move past the pandemic, but the EHR will continue to be the harbinger of pain and inefficiency in baselining how well an organization coordinates care and designs work effort among staff.
How easy is it for patients to navigate your system and receive access to information or access to care? Have we refined advanced provider-to-provider telehealth workflows that can accelerate care plan decisions and follow-ups, reducing burden for providers and staff? The questions are numerous, and all have an impact on stress and burden of work.
As for what can be done: Focus on incorporating the voice of the provider and clinician must be a continuous improvement effort with established support mechanisms/resources for your clinicians. This is the path to meaningful change. Coming out of the pandemic, this is where we must refocus our time, energy and resources. Our clinicians need us more than ever.
Will Weider. Senior Vice President and CIO at PeaceHealth (Vancouver, Wash.): The combination of regulatory, quality and organizational data collection requirements that get added into the EHR are primary contributors to burnout. Organizations must be vigilant regarding what caregivers are required to collect and document. Adding any new EHR documentation requirements should require approval by a governance committee staffed with people that highly value caregiver time. Organizations also need ongoing efforts to streamline EHR design. EHR changes should be bundled into periodic releases to reduce change fatigue.
Ray Gensinger, MD. CIO at Hospital Sisters Health System (Springfield, Ill.): EHR burnout is a well-researched and scientifically documented phenomena that certainly needs addressing. Short of burning the EHRs to the ground and starting over while at the same time removing all of the documentation accessories (elements needed to respond to every CMS, Joint Commission, registry and compliance reporting requirement) we have to optimize, optimize, optimize!
Optimization is a very tight and closed loop partnership that includes the vendor, an organization’s informatics and EHR staff and appropriate subsegments of clinical partners. Many of us built generic tools and workflows out of an abundance of speed and budgetary constraints and thus made everyone’s job harder. While "standardization" has its upsides from a support perspective, it also came with a downside of care provider inefficiencies that have been feeding the departure of our nurses, doctors and other clinicians.
Taking a measured approach to the EHR features is essential. We have been assessing usefulness and effectiveness through face-to-face assessments, vendor reporting tools and standardized surveys and benchmarking. We are assessing all provider groups, not just our physicians.
The results of those assessments allow us to: segment our users into clinically relevant and like user groups; refine "smart" tools that more smartly represent specialized user groups; eliminate or push to the background those clinical decision support functions that are ignored consistently; produce focused education, in multiple formats, that address optimized skills and workflows; and provide ongoing "at-the-elbow" personalization.
To battle burnout, optimization needs to be the logical and well-funded phase following implementation. The term of the optimization phase should be in perpetuity.
Joel Klein, MD. Senior Vice President and CIO of University of Maryland Medical System (Baltimore): There’s lots of things that healthcare organizations can do around EHR burnout: implement better, more user-friendly systems; enable personalization; make dictation easy; offload tasks like answering messages into office pools; turn on mobile platforms; empower clinicians visibly in decision-making and governance; get rid of clutter; pay formal attention to usability; profile users and offer help to those who are struggling; improve training; aggressively eliminate unnecessary alerts; have available enough working hardware like desktops; and communicate changes rather than have them just appear.
In our organization, we have done a lot of work in all these areas. But there's even more that the industry and its regulation can do, like reducing redundant or unnecessary documentation requirements, moving away from documentation-driven billing and reimbursement, making ambient documentation better and more affordable, and taking a harder look at workforce needs, compensation and training. In the end, EHR burnout may be a symptom of larger disaffection with the hard work of caring for our patients, and to make it better will mean doing many things from many directions — not any one single thing.
Ash Goel, MD. Senior Vice President and CIO at Bronson Healthcare (Kalamazoo, Mich.): Clinicians have been at the forefront of managing incredible demands on their time while dealing with the increasing cognitive burden and complexity of care that has been making this a near impossible task. There are several aspects of the clinician burnout that are contributed to by the technology that is used in delivering clinical care — including the EHRs.
There are many actions that are being taken that need to continue and others that need to develop and be put in place as soon as possible, especially given the current and future resource shortages. Starting with a continued focus in the regulatory space to reduce documentation burden and to a shift in processes that enable team-based care documentation, we have had some success in the amount of time clinicians spend in the EHR on a daily basis.
Programs designed to remove unnecessary clicks, redundant data and views to reduce clutter — as well as continuous loop process improvements by working with the clinicians — have been instrumental. Integrating natural language processing technology to provide contextual interaction tools (to search for data, to input data and capture peripheral device information), mobile device integration, medical (including nonradiological) imaging integration and use of artificial intelligence and machine learning to anticipate and present relevant data to clinicians are areas to continue to explore. In the end, we have to design processes and systems that enhance, enable and speed up work — not stop, hinder and slow it down.
Rick Keller. Senior Vice President and CIO of Ardent Health Services (Nashville, Tenn.): To address, and hopefully prevent, clinicians EHR burnout within our organization, we provide support to clinicians from our clinical and physician informatics support teams. The support is a hybrid approach where informatics staff work "at the elbow” as well as "at the ear" virtually. We recently finished our last 10 hospital Epic implementations, so now our entire enterprise is using the platform.
Part of our process is to provide personalization and training for clinicians to use the platform for smart text and phrases and streamlined order sets that minimize clicks for the users. We provide access to information from the system that measures "note bloat" so clinicians can learn to document more efficiently. We also have deployed a voice recognition solution for documenting within the chart.