SANTA CLARA – At Health 2.0 on Monday, National Coordinator for Health IT Dr. Don Rucker listed a litany of challenges faced daily by physicians and nurses, and contributing to the ongoing scourge of clinician burnout: onerous documentation requirements, boilerplate electronic health records and the “monster burdens” of prior authorization and compliance with too many overlapping quality measures.
A lot of people single out suboptimal EHR experience as as root cause of the burnout epidemic, and it certainly is one of them. But “burnout is multifactorial,” said Dr. Michael Pfeffer, chief information officer at UCLA Health.
It can be caused by EHR frustrations, admin burdens, regulatory headaches, malpractice concerns and the rise of consumerism: Pfeffer says he hears often from physicians dismayed by poor online reviews from patients that they’re powerless to fix.
Ultimately, burnout is about “loss of control,” added HIMSS Chief Clinical Officer, Dr. Charles Alessi. The EHR may have become the “epithet to hang everything on,” he said, but this deep satisfaction among so many clinicians has a wide array of contributing factors.
Technology is one of them. But it can also be a “force for good,” said Rucker.
So Glenn Winokur, managing director of Healthbox asked his co-panelists: “If you could wave a magic wand, what do you think could be the biggest technology solution to the clinician burnout problem we’re facing?”
Alessi pointed to tech that could enable the concept of “precision health – and by that I mean the obverse of precision medicine,” he said.
“That means creating a situation where we’re managing wellness as well as we’re managing illness – precisely, digitally and directly with individuals,” he said. “Because that way, we’ll have a really activated population, into which we then deploy the single thing, which is clinical decision support systems right inside the EHRs, and right inside the clinical flow.”
For his part, Pfeffer said that, “given where we are today” with the realities of documentation requirements, his pick would be “really accurate voice transcription tools.”
He set the scene: “You have a device in the room. You’re having a conversation with the patient, and it writes the note. So you can be face to face, but talking to the electronic health record.”
Some of that exists now, of course, but truly hands-free, comprehensive, error-proof voice documentation is “still years and years away,” he said. “It’s very, very complex. But that would be such a huge win for the physician-patient relationship, which is the key to all of this. Anything we can do from a technology standpoint to bring that relationship back, is so key.”
Lisa Grisim, RN, associate CIO at Stanford Children’s Health, meanwhile, also put “great voice recognition and natural language processing” at the top of her list.
“The physician would be talking to the patient and the note would be documented for them: they could talk about the orders they would have and the orders would be placed for them, they could be talking about a follow-up visit and what time would be best for that patient and a visit would get scheduled for them.”
Another pie-in-the-sky wish, she said, would be “the ability for a provider to just quickly get the clinical history of a patient. If they’re seeing someone they haven’t seen before, just having some way to pull together that clinical history: the pertinent thing a clinician would like to have right in front of them. EHRs have a ton of data, and surfing through that data to try to get to the story of the patient.”
Rethinking the EHR for a networked era
Rucker, for his part, said more can be done to capitalize on network effects to improve the lives of providers and patients alike.
“Our world has been transformed by networks,” he said. “Metcalfe’s law is the law of future generations in healthcare, getting that seamless integration. I’m in a lucky position to be working on APIs at ONC, moving that along and making it truly seamless, across sites of service, across vendors. It should not just be big expensive delivery systems sharing information with themselves. There should be something that is truly pro-consumer, pro-competitive. So moving that along is atop my wish list, and I’m pleased as punch to say I think we are making measurable and rapid progress.”
As for EHRs, which are great for automating billing but not so much for developing patient and clinician workflow, Winokur asked whether they should be “completely reimagined, reenvisioned, somehow, some way, from a completely different paradigm.”
EHRs have indeed evolved over the past 30 years as a “tool for billing and documentation,” said Rucker. “There’s been piecework automation, computerized provider order entry being the most notable. But, frankly, if our automation is what it is – that we slap ourselves on the back that we can get lab results back, or maybe an image – y’know, to be able to retrieve a fact from a database is sort of a yawner in the rest of the economy. That’s sort of a given, rather than the blessed event it seems to be in healthcare.”
He said we need starting think instead about EHRs – “and again, maybe this means new vendors, new APIs, new modes of thinking about it” – as something more akin to enterprise resource planning systems.
“Things need to be instrumented, automated – and there is tons to automate,” said Rucker. “A lot of our lack of automation now is handled by the telephone. When I was at Ohio State, we had 130,000 phone calls a day. Of those calls, half were one minute or left, with a median duration of 27 seconds. So, 65,000 calls a day where one fact was exchanged in a 27-second call. Much of this activity was centered on the nursing units.”
In other words, “there is a vast opportunity,” he said. “If you’re exchanging one byte of information, as it were, that can almost certainly be a rich and ripe target for automation, with all the safety, cost and consumer value that brings. So I think one of the next-generation activities is going to be to think of EHRs as ERP systems, and we are doing our darndest (at ONC) to take the incentive to use them as documentation and billing adjuncts out of the equation.”