Innovation case study: UC Davis Physician
Efficiency Program yields big gains for
EHR satisfaction, quality of life
Participants have seen a 24 percent increase in efficiency,
and a reduction of "pajama time" by a median of 25 hours
per physician.
Innovation can come in more forms that just technology -- and that's true even when IT plays a key role. Take the case of University of California Davis. Like many hospitals, UC Davis was struggling with physician burnout, a key issue in healthcare because, among other reasons, the ripple effect it causes affecting providers in terms of staffing, patient safety, quality and their system's bottom line. A leading cause cited for burnout is the much lamented EHR, which physicians have said leads to more work, more stress and less time with their patients.
Take the case of University of California Davis. Like many hospitals,
UC Davis was struggling with physician burnout, a key issue in
healthcare because, among other reasons, the ripple effect it causes
affecting providers in terms of staffing, patient safety, quality and their system's bottom line. A leading cause cited for burnout is the much lamented EHR, which physicians have said leads to more work, more stress and less time with their patients.
In an effort to thwart the damaging effects of EHR-related angst and burnout, UC Davis EHR Medical Director Scott MacDonald, who formerly practiced as a physician and was known to be computer savvy, put together a team and a program to help clinicians and staff become optimal users of the system's EHR, Epic. Called the Physician Efficiency Program or PEP, the initiative aims to reduce stress from EHR burden, increase job satisfaction, and give physicians more time to care directly for patients.
The mission is two-fold: make physicians and clinical staff the best users they can be by individually tailoring EHR training to each physician's needs and make meaningful changes to the EHR to eradicate functions that staff don't need and add or refine functions they do.
MacDonald said EHR's have taken a bad rap for a lot of the things that have happened over the years through the need for capturing metrics for quality, other regulatory issues and coding guidelines. Organizational leadership tends to use the EHR to solve problems because everything works through it.
"In modern medicine, the EHR is the most important tool in the physician toolbox. Everything or almost everything that is isn't face-to-time with the patient is mediated through the EMR-notes, orders, communication with patients and colleagues, referrals. The physicians blame the EMR for all the bad stuff they have to deal with in their day to day life. But it's not the EMR's fault that leadership asks them to do all these tasks. It's just that everything comes through the EMR so everybody blames the EMR."
This author who has been at the forefront of the change began blogging in 2004 on Health Train Express, and helped initiate one of the first and successful Health Information Exchanges, then called Regional Health Information Organization (RHIO) . The EHR interface remains a formidable obstacle, even when training has taken place and reinforced. It was at that time I rang a warning bell about premature implementation of the EHR. Training may just delay improvement in the EHR. There is no doubt that within ten years there will be rapid advances in artificial intelligence (deep learning, and natural language processing) which will obsolete present and near future EHRs.
PEP started as a pilot program after increasing recognition that EHRs contribute to burnout, costly staff turnover, with less direct linkage to patient satisfaction and quality. MacDonald said they "begged, borrowed and stole" a few staff members from their IT department and went out to 4 clinics with an informal version. After receiving highly positive feedback and the necessary funding, they were able to grow the program into full scale with the ability to reach every physician in their clinics, not just the "squeaky wheels that got the grease prior."
"There may be people suffering in silence or people in the middle that with a little effort could be really excellent performers and efficient users of the system," MacDonald said.
UC Davis hired a program supervisor, 4 trainers and two EHR builders so that per physician feedback, they could add to the EHR and fix things that didn't work well. That's something that IT was never able to get to because they were often busy with implementation of new projects.
"Putting those builders on the team is one of the more innovative things we've done," he said.
"At the beginning of each engagement with each clinic, the team sits down with clinic staff to evaluate the build menu, a list of things they can change for them. The clinic physicians decide what sounds good them and we build what they want."
Each physician has a PEP report issued before training. It's an individual efficiency program which includes an overview of what their turnaround time is for messages and refills, volume of messages, and an overview of what that doctor's work life is like i.e. are they doing work after hours, what they are frustrated with, what they might be wasting time on and other internally generated data. Participants complete a survey before they start and at the end of training rating their own progress. The survey asks about efficiency, satisfaction with EHR system and other metrics. Some who started at 1s and 2s on the five-point efficiency scale and moved up to 4s and 5s.
"Our Goal is to decrease the pajama time, which is the time doctors spend working on records while at home, and make people happy. Our tag line is finish faster so there is more time for the things that really matter."
So, far the results speak for themselves. Participants have seen a 24 percent increase in efficiency, and a reduction of "pajama time" by a median of 25 hours per physician in the first month after implementing. EHR satisfaction went up by 12-16 percent just by virtue of going through the program.
"We weren't expecting that big a change and when we break it down by how much time people were spending at the beginning, we also see that across the spectrum the people who only worked an extra 5 or 10 hours a month and the people who worked 30 or 60 extra hours a month, all those people improved. I was really pleased to see that we were really raising all boats."
The program is less than a year old and the plan right now is to get through all their clinics and specialities by or during 2020, then circle back and go and revisit other clinics. If they can get funding, MacDonald said they'd like to expand the team would keep circling back to reinforce the learning and make sure people don't fall back into old bad habits.
There's no word on financial gains yet but once they have a couple years' data under their belt, MacDonald said they want to look at rates of physician turnover to see what effect the program has had on that costly metric, as the price tag to replace a physician who leaves runs anywhere from $250,000 to $500,000.
The key takeaway here is that for the program to work, it has to be a serious system-wide effort. You need to commit resources and make it a priority--it can't be a part-time focus.
Another crucial point is that the success of this program is due largely to the approach to each physician being unique and individualized, and to make sure that the program includes every physician, not just the ones who are already showing signs of burnout or dissatisfaction.
"That's been a real benefit of our approach, that we touch base with everybody even if they have not been complaining. Everybody needs it."
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