Physicians weigh in: 5 keys to fixing the EHR inbox | American Medical Association

See what physicians suggest that EHR vendors and their health care organizations should change to cut physician burnout and improve patient safety.

It is no secret that physicians hate their electronic health records.  Perhaps you have noticed the past several years how often he turns his back to you looking instead at the computer monitor. Some physicians use an iPad or Surface notebook which they can place on their lap as they face you.  There some upsides to these arrangements, which can be found elsewhere.

On the other side of inputting data into the EHR, the electronic health record is morphing into practice management, messaging systems,  as well as for intra-office communication.

The much-maligned physician inbox

The much-maligned physician inbox—which the average primary care physician spends 49 to 85 minutes dealing with daily—is often difficult to use and filled with excessive and unnecessary messages that decrease face-to-face time and lead to stress that has been associated with physician burnout. It has become the replacement for the 'sticky note' taped to the wall or placed on the desk.

Looking for ways to make electronic health record (EHR) inboxes more physician-friendly, researchers went directly to doctors to get their feedback on what would make the tool more efficient and relevant. The qualitative analysis included interviews with 25 physicians at six large health care organizations.

The result:

Five key takeaways and 28 specific suggestions to improve the physician inbox, with the expectation that, in turn, there will be a reduction in physician burnout and an increase in patient safety. The original investigation, “An Exploration of Barriers, Facilitators, and Suggestions for Improving Electronic Health Record Inbox-Related Usability,” was recently published in JAMA.

Engage IT to prepare for restructuring your in-basket

Identify the types of messages that could be routed to other team members

Work with IT to restructure your EHR to direct messages to the right team members and declutter your in-basket

Create a team pool and team pool in-basket to help redistribute and streamline work

Empower staff to contribute by utilizing principles of team-based care

Develop workflows for common in-basket tasks

These are the takeaways

Cut the cognitive load
A customizable reminder or to-do lists that remind physicians to take action for a particular patient at a future date.
A way to assign priority to messages and enable sorting by priority to triage work.
Messages that allow added comments or tags to facilitate a subsequent review.
Flagging, sorting and filtering options for messages to enable prioritization and triaging.
A way for new messages to be easily distinguished from previously read messages.
Enable better team communication
A system to prevent messages from disappearing until the physician explicitly indicates that is desired, such as a complete button.
Read receipts to ensure closed-loop communication.
An out-of-office message to indicate when an inbox is not being actively monitored.
A function that allows one to manually forward inbox messages to others.
A way for physicians to automatically receive or otherwise review messages sent to other physicians whose patients they may be temporarily caring for.
A system to incorporate staff into the message triaging process rather than sending all messages to physicians.
Let tasks be distributed among clinical team members.
Cut the message volume
Reduce messages that do not affect care.
Educate staff to avoid sending messages to clinicians when the message does not affect the care the clinicians provide.
Prevent duplicate messages.
EHR Usability
Physician Burnout
Referencing JAMA Network™
Practice Transformation

How to accomplish these items:

EHR In-Basket Restructuring for Improved Efficiency
Efficiently manage your in-basket to provide better, more timely patient care

There is a handy outline for accomplishing these tasks and






Physicians weigh in: 5 keys to fixing the EHR inbox | American Medical Association:

Healthcare Innovation’s Top 10 Stories of 2019 | Healthcare Innovation

 This past year again offered a variety of fascinating developments in healthcare and health IT.

As it often is, this past year was one of new developments, emerging trends, and compelling stories of innovation. With that, here are the top 10 read stories from 2019.


Massive Rule Drops at HIMSS19: CMS, ONC Propose New Regulations to Transform the Future of Interoperability and Patient Access

Through two immense proposed rules released on the first day of the HIMSS19 conference in Orlando, federal health officials pulled an array of levers that fall under the core aim to improve interoperability and patient access to data. The two proposed rules—one from CMS and one from ONC are separate, but at the same aligned as the two agencies within HHS look to further advance the nation’s healthcare interoperability progress.

Apple Buying Epic Would Sure Be “Epic,” But is it Realistic?

Health IT observers surely raised their eyebrows upon seeing comments in January from CNBC’s Jim Cramer on why Apple should acquire EHR giant Epic Systems.

Cramer, the host of Mad Money, dropped a bombshell: "Apple should acquire Epic Systems,” he said. "Not only would this deal be good for the company, I think it's exactly what Apple's stock needs to get its mojo back." After reading Cramer’s remarks, Managing Editor Rajiv Leventhal reached out to a few industry sources who spoke about the possibility—or lack thereof—that this acquisition could actually happen.

Physician Groups Are Taking on Value-Based Contracts—and Learning Big Lessons

Even as some physician organizations are just now preparing to take the plunge into value-based contracting, others have been forging ahead into the tall grasses of the value-based healthcare world, and are racking up results. But the path forward is a complex and challenging one. What are those medical group leaders learning? Editor-in-Chief Mark Hagland takes a deep dive into this area for the January-February print magazine cover story.

The 2019 Innovator Awards First-Place Winning Team: Millennium Physician Group

Leaders of the first-place winning team in the 2019 Innovator Awards Program, Millennium Physician Group, discuss how they have cracked the code on success in the Medicare Shared Savings Program (MSSP), leveraging data to better care-manage their highest-risk patients.

First in U.S. Healthcare: UC San Diego Health Appoints a Medical Director of Cybersecurity

In July, senior clinician and IT leaders at UC San Diego Health broke new conceptual ground, when they appointed an emergency physician with accreditation in clinical informatics to be the health system’s medical director of cybersecurity—in their understanding, the first such appointment in U.S. healthcare. Christopher Longhurst, UC San Diego Health’s chief information officer and associate chief medical officer, and the newly appointed medical director of cybersecurity, Christian Dameff, M.D., spoke with the publication regarding the new role, and its context.

CMS Proposes New MIPS Framework for 2020

CMS announced in July that it would be making major policy changes to the Medicare Physician Fee Schedule and Quality Payment Program, in the form of a proposed rule, with the overarching goal to further reduce clinician burden. One key focus was to create a simpler way for clinicians to participate in CMS’ pay-for-performance program, the Merit-based Incentive Payment System (MIPS). The rule was finalized in November.

Epic, Cerner Continue to Dominate U.S. Hospital EHR Market, KLAS Finds

A report released in early May from KLAS Research revealed that EHR behemoths Epic Systems and Cerner continue to corner the U.S. hospital EHR market. For the second year in a row, Cerner signed the highest number of new hospitals, but large private sector hospitals are almost exclusively choosing Epic technology.

Walgreens, Microsoft Ink Strategic Deal to “Transform Healthcare Delivery”

Walgreens Boots Alliance Inc. and Microsoft Corp. announced in January they would be joining forces on a major seven-year healthcare partnership that will aim to “deliver innovative platforms that enable next-generation health networks, integrated digital-physical experiences and care management solutions.” The companies announced that they will combine the power of Microsoft Azure, Microsoft’s cloud and AI platform, healthcare investments, and new retail solutions with WBA’s customer reach, volume of locations, and outpatient healthcare services to accomplish their goals: to make healthcare delivery more personal, affordable and accessible.

Is CMS Making a Major Blunder on Physician Payment? Why Physician Group Leaders Are So Concerned

Shortly after the aforementioned MIPS proposed rule was released, Editor-in-Chief Mark Hagland wrote an in-depth commentary taking note of why the association representing the most advanced medical groups—the American Medical Group Association—spoke out against the proposal.

As part of the publication’s annual Top 10 Tech Trends package, this year one of the trends we examined was healthcare’s consumer-centric shift, and how the door has opened for non-traditional companies to disrupt industry norms.  The proposal calls for a simpler way for clinicians to participate in CMS’ pay-for-performance program, the Merit-based Incentive Payment System (MIPS), which is one of two payment tracks within the QPP. This new framework, called the MIPS Value Pathways (MVPs), beginning in the 2021 performance period, would move MIPS from its current state, which requires clinicians to report on many measures across the multiple performance categories, such as Quality, Cost, Promoting Interoperability and Improvement Activities, to a system in which clinicians will report much less, CMS officials contend.”

“Under MVPs, clinicians would report on a smaller set of measures that are specialty-specific, outcome-based, and more closely aligned to Alternative Payment Models (APMs). MVPs will connect activities  and measures from  the four existing MIPS performance  categories that are relevant  to the population they are caring for a specialty or medical  condition, according to CMS.”

Has Healthcare’s Consumerization Shift Already Begun?

For many patients—especially those in the baby boomer and Generation X cohorts—seeking medical care outside a hospital or physician’s office might seem blasphemous. In the traditional healthcare ecosystem, patients wait until they get sick to contact their care providers, then often wait days until they actually get to see said provider, then wait in his or her office to finally get face-to-face time. It’s a continuous cycle that has not changed much over time—until now.


Patients are beginning to realize that waiting days and sometimes weeks to make an appointment with a provider—a 2017 Merritt Hawkins report found that it takes an average of 24 days to schedule a new physician appointment in a large U.S. city, a 30 percent increase from 2014 data—is unacceptable and that other options do exist. What’s more, as healthcare costs continue to rise and patient payment responsibility increases, looking outside the traditional four walls for medical care has become more appealing.

“As millennials, Generation X, and baby boomers enter new life stages at the same time, there are simultaneous demands for both lower cost, convenient care delivery and better management of chronic illness and outcomes. The industry must evolve to meet the needs of these groups (and others)—both in terms of where they converge and where they deviate,” KPMG researchers wrote in the research and consulting firm’s “Healthcare 2030” report. Millennials have become the largest generation in the U.S. labor force, and the way they think of patient-provider relationships is different from how prior generations engage with healthcare.

Retail healthcare clinics, on the other hand, are becoming increasingly appealing to consumers as an alternative form of care delivery for certain conditions. A recent survey of 1,000 patients from Kyruus, a healthcare solutions company, found that nearly half of respondents said they sought care in a retail or urgent care clinic. And, 30 percent of those said they visited one of these sites after they were frustrated in their efforts to secure timely appointments with their primary care physicians.

Clearly, in many areas of the country, the traditional model for physician practice is no longer tenable. Despite the reluctance to join what many doctors consider the enemy they are forced by the reality of supply and demand to join the new model, sacrificing independence.  This is also a major factor in physician burnout, along with difficulty adapting to electronic health records.  Some will succumb to these pressure, and retire early or change careers.  This change is already showing as a physician shortage, especially in primary care, and less so in specialties.  Determinants are tied to location and demographics.  Each regional system is different.

Are providers adapting?

Of course, the other end of the healthcare consumerism spectrum is dependent on providers being able to meet patients’ shifting demands so they can keep them in their networks. But when asked how “consumer-centric” patient care organizations are today, on a 0 to 10 scale, John Matthews, principal, healthcare and life sciences strategy, at KPMG, says, “Broadly speaking, close to 0.”

Clearly, physicians are not adopting unless they are in a group or health system that markets for them. Physicians are not in a leadership role and have pushed back hard against alternatives such as Minute Clinics, CVS, and some free-standing Urgent Clinics.

The main attention getter for physicians is when their daily appointment schedules dwindle. At that point when they have empty spots in their schedule they have time to look up from their busy schedule

Only the largest health institutions such as Mayo Clinic, University systems, Cleveland Clinic and others such as MD Anderson Cancer Clinic have resources to build patient-centric models.




Healthcare Innovation’s Top 10 Stories of 2019 | Healthcare Innovation:

Validation key in digital health, but how do you get started? |

Today begins a series on how to validate digital health ventures.  Is there a set of metrics to judge the worth of investing or developing a digital health application, mobile or computer-based?

Last night at a Partners HealthCare Pivot Labs event, industry players discussed the ins and outs of how to validate a digital health product, regardless of funding.

Once a promising futuristic industry, digital health is merging into mainstream medicine. Now in the limelight, conversations around how these digital tools should be validated are starting to take place.

But for startups, getting validation often means securing money and partners, creating potential barriers for young startups. Last night at Partners HealthCare Pivot Labs digital health event, industry experts dished on the why, when and how of validation.

Why get validation?
It’s no secret the app market is now flooded with digital health products. Many of those apps remain unregulated and unvalidated. However, validation is one way for developers to set their products apart.

“A fun fact is that every day at least 200 apps get added to the app store. Just in the mental health space, there are 1,500 apps,” Dr. Ramya Palacholla, a research scientist at Partners HealthCare Pivot Labs, said at the event. “We are so passionate about validating solutions because when there are so many different apps —1,500 different apps that claim to do the same thing — then what separates me from the others?"

But validation isn’t just about setting a product apart on an app store — startups seeking to work with big names in the medical world will need to show data, according to panelists.

“For the program that I run, validation is so critically important because we connect later stage and middle stage startups — entrepreneurs that have solutions ready to go — we connect them with organizations like Mass General, Brigham and Women’s, and they want to see the data, right? They want to know this actually works and it is really solving a real problem,” Nina Kandilian, director of operations of Vertical Programs at MassChallenge, said.

When it comes to validating technology money matters, according to panelists, stakeholders need validation that the product can produce a return on investment.

“You could do all these amazing things and to solve all these problems but at the end of the day if there is no financial incentive tied to it there is only so long you can work on it,” Kandilian said.

Different validation for different stakeholders
Validation doesn’t always mean a standard clinical trial. It could mean a lot of different things depending on the users and the purpose.

“I think we should define what validation is. So there is clinical validation, but there is validating what is a useful tool and even earlier than that validating if it is needed,” Dr. Mark Zhang, medical director of the digital innovation hub at Brigham and Women’s Hospital, said during the panel. “We see ideas and concepts at all stages.”

Validation expectations also differ significantly depending on the end-user.

“Value looks different to different stakeholders. As a clinician, the value I look for is better workflow efficiency, decreased workload and just improving patient outcomes,” Palacholla said. “As a patient, I may look for increased convenience or just a pleasant experience. So I think it is really important to determine what value you are looking for and the type of stakeholder also determines the type of value you are looking for.” 

Validation on a budget
Validation can be expensive — posing a potential hurdle for unfunded startups. But there are options for these companies, according to panelists. 

“So early-stage entrepreneurs, what the VCs really want is the data,” Kandilian said. “They want to know that it works, and it is really hard to do that when you have no money. So I have found a lot of startups in our program that are earlier stage have mastered the art of finding grants.”

Seeking venture dollars might not be the best course of action for every young startup, Kandilian said. 

“There are so many other alternatives to regular VCs," she said. "Do you really want to give up all of your company at the beginning? A lot of the angel VCs you want to find are people with money that can also help you with your business."

Partnerships are another avenue for startups to validate their tools. However, panelists stressed the importance of pitching to the right clinicians. 

“It’s a lot easier to make a connection if there is a target," Zhang said. "It’s a lot harder if you have a solution and you want to connect with [for example] neurology …  that can be harder. We may have a contact, but we may not. So if you’ve already done the leg work that is always helpful.”

Another resource for emerging companies is new professional guidelines, which Palacholla said could help shape the future. 

The CMO of SalesForce, a large customer relations management platform had this to say,

“I think we are heading in a positive direction there are a lot of frameworks and guidelines that are being put out by different organizations, whether it is the NIH or AMA or even the World Health Organization, that two days ago released some guidelines,” Palacholla said. “So all of these guidelines are moving from infancies, from where we just cited products and great products for different users, to actually forming a body of evidence and standardizing and coming up with all of these different guidelines.”

Last decade’s cutting-edge tech is moving into the boring, but productive, part of the hype cycle

Most of you are probably familiar with the Gartner hype cycle, a useful conceptual framework that describes how new technologies move from a “peak of inflated expectations,” to a “trough of disillusionment,” to the “slope of enlightenment” and, finally, the “plateau of productivity.” Several times speaking with stakeholders at JP Morgan, it was striking how many technologies seem to be in the last two of those stages.


Virtual reality and augmented reality is a strong example — the wow factor of VR is finally starting to fade. Neither of the two startups we spoke with at the show who use this technology described themselves as VR startups. Instead, they casually mentioned the way their solution deployed VR the same way they might drop in a reference to the cloud or a mobile app. The technology itself is no longer eliciting excitement — or trepidation — about a product. And there are signs of blockchain, until recently the ultimate tech hype punchline, moving in this same direction.

Other technologies, like AI or digital therapeutics, have hype cycles that seem destined to be longer and are still offering some unrealistic promises and hype-driven pitches. In fact, it’s hard to imagine a better example of the trough of disillusionment where, as Gartner says, “interest wanes as experiments and implementations fail to deliver,” than the recent spat of public digital therapeutic partnership failures. Or, for that matter, some very public AI algorithm foibles.

More digital health-specific investor firms and funds will emerge

We predict the investor pool will mature and continue to specialize. Due to the relative newness of the digital health industry, investors have come from a variety of backgrounds including tech, biopharma, and general health. However, industry insiders have continued to stress the importance of understanding the health ecosystem.

“It is vital in digital health to have people not just on the venture side, but also on the boards and management of digital health companies, that come from different genders, economic backgrounds, ages and different perspectives,” Luba Greenwood, lecturer at Harvard and former Verily business development manager, told MobiHealthNews in April. “The best return on your investment is going to be in companies that are going to do that by working with payers, provider groups, pharmaceutical companies, and diagnostic companies. Because you have such different types of companies, you need different perspectives as an investor. You need to understand how the consumer world works.”

As the industry ages so will the experience level of investors. We also predict to see an increasing number of digital health-focused firms, like 7Wire Ventures, Rock Health and StartUp Health, and targeted investment funds such as Flare Capital’s sophomore health tech fund.

Asian digital health markets will continue to rise. Our eyes are on the Asia/Pacific market for 2020. Last year Beijing topped the list of the most digital health funding in a non-US city, coming in with $855.4 million, according to Startup Health’s 2019 funding report. While this is number is about $100 million less than last year, it pulled ahead as the clear leader as the international funding hub over London (which it was tied with last year), and we expect this trend to continue. Mumbai, Bangalore, Shanghai, Singapore, Guangzhou, and Delhi also made the top ten list.

“In 2018, the total amount of venture capital that was invested in the Asia Pacific amounted to about $6.8 billion. To put in context, in the US it is $8.2 billion and $2 billion for Europe,” Julien de Salaberry, CEO & founder of Galen Growth Asia said at the SFF x SWITCH conference in Singapore in November. “So clearly Asia Pacific is the number two in the world with some four-and-a-half to five thousand startups in the region that are growing from strength to strength and raising more money, getting more FDA regulatory-type approvals,."

We expect Asia's funding growth and digital health maturity is already becoming evident. For example,  China’s Tencent Trusted Doctor platform raised $250 million in a fundraising round in April. Additionally, the Indonesia-based health-tech platform Halodoc raised $65M in Series B funding and Chinese medical AI startup Synyi raised $36.3M in Series C funding in early July.

China, by far the economic powerhouse in the region, is expected to continue to lead the funding. This is particularly true following the kickoff of Healthy China 2030, the nation’s first long-term strategic health plan since 1949. This means there is now a government mandate that makes healthcare policy a priority. However, India and the Middle East will also likely continue to crop up on the radar.

China will become a major player in health care apps if the fear of cyber attacks and/or spying can be overcome. The United States has banned Huwaii from selling its smartphone chips in the U.S.

 2020 will be a banner year for digital health commercialization and distribution

As more digital health products hit the prime time, we see a splintering in the path each is taking to market — especially within the realm of digital therapeutics. Among many of the other major takeaways following last fall’s digital-pharma breakups is an understanding that these products are unlikely to follow the traditional drug development and distribution model.

“The traditional medicine models, I don’t think that’s where we should be as digital therapeutics,” he said during a late September event. “I don’t think we’re ever going to demonstrate value to patients in the way digital therapeutics really can … unless we make big bets, unless we say traditional medicine not only may not be the answer, is very likely not the answer, and we need to invest and stumble a little bit, experiment [with] putting out creative models.”

Also fueling change is the FDA’s PreCert Program, an experimental regulatory pathway that could substantially lower the burden for digital health companies hoping to more rapidly release their products. The program’s one-year pilot came to an end with the calendar year and the agency is promising the publication of a report card similar to what it put out around the half-year mark.

Should the FDA like what it sees and moves to fully implement the new pathway, participating companies will (for better or for worse) have free rein to launch and relaunch their digital health products much more easily than ever. This would stand as a major benefit for software-based products in particular, which could begin pushing out updates of their algorithms or other underlying systems at a rate that traditional biologics could never hope to match.

But these points aren’t to say that tried-and-true distribution models are unable to accommodate large-scale digital health commercialization, and the payer side of the industry, in particular, has made some major crossroads here. One clear development has been pharmacy benefit managers like Express Scripts and CVS Health's work on digital health formularies and similar resources to help their clients select vetted digital health products from third-party vendors.

These major market players are making a major effort to corral digital health products into an offering that’s more palatable for their longstanding businesses. And it should go without saying that those companies taking part in the PBMs’ opening salvo are viewing the traditional-yet-novel pathway for reimbursement and distribution as an important part of their long-term strategy.

“We [at Propeller Health] believe this is a really good step in the process of making digital health and digital therapeutics more traditional in terms of reimbursement and distribution,” Chris Hogg, CCO of Propeller Health, told MobiHealthNews after announcing his company as part of the Express Scripts formulary’s inaugural cohort. “For us, we view this as a mechanism to provide access and reimbursement for many more patients, for a product that we have clinically validated.”

The takeaway here is that 2020, in particular, is poised for convergence of contrasting go-to-market strategies. The success of one won’t necessarily disqualify another but expect the digital health players of tomorrow to follow the most successful examples on display throughout the next 11 months.

In a final precautionary note, Mercom reports digital funding dip in 2019.

Digital health funding is on the decline, according to yet another funding report, this time from Mercom Capital Group. According to the company’s latest report, in 2019 digital health funding came in at $8.9 billion with 615 deals — a drop from the $9.5 billion and 698 deals recorded in 2018.

“After three consecutive years of growth, venture deals, and dollars for digital health companies declined in 2019," Raj Prabhu, CEO of Mercom Capital Group, said in a statement. "After a long dry spell, there were four US IPOs, but their performance so far has been underwhelming. M&A activity also declined in 2019. The big winners were telemedicine companies, with a 55% percent increase in funding YoY while digital health products that were powered by AI, brought in over $2 billion."

However, the report's executive summary notes that the average funding deal size in 2019 was up to $14.4 million, whereas in 2018 it was $13.6 million. Consumer-centric companies brought in the most cash with $5.3 million in 2019, followed by practice-centric companies, which brought in $3.6 billion.

WHY IT MATTERS 

Mercom isn’t the only investor report pointing to lower funding numbers in 2019. Last week Rock Health released its annual tally, which recorded $7.4 billion in digital health deals in 2019. This was also down from 2018 when they recorded $8.2 billion in deals. MobiHealthNews' own year-end accounting held to this trend as well.

While each report varies in calculations, due to the scoop and definition of digital health, both are reporting a dip in numbers this year.

THE LARGER TREND

2019 may have slid back in terms of funding totals, but over the last decade digital health funding deals are trending up. When Mercom first started the reports in 2010, it recorded $211 million in funding. While some years like 2015, dropped slightly from the previous year, overall they are increasing. 

Ditch the “stupid stuff” that drives doctors crazy

Physician administrative burdens can take a toll on well-being. This health system is changing that by eliminating “stupid stuff” from daily requirements.

The entire EHR is not to be blamed for physician burnout. Much of the EHR is irrelevant to some specialties. CMS seems to have encouraged meaningless information in certified EHRs, or the software vendors have just not caught on.

A urologist is not going to record an ophthalmoscope examination as a routine field. Neither will an ophthalmologist record the size of the prostate. These are small things that add up to much wasted time and energy.

Have you ever performed a daily task and wondered, “Why do I even bother to do this?” You are not alone. Increasing administrative tasks for physicians means they have less time to focus on what is important, such as interacting with patients and delivering care. One health system in Hawaii is tackling physician administrative burdens by eliminating “stupid stuff” to free up time for doctors and other health professionals.

Hawaii Pacific Health, a nonprofit health system in Honolulu, has launched a program called “Getting Rid of Stupid Stuff.” In just a year, the system’s physicians and other clinicians have nominated more than 300 time-wasting EHR activities for the chopping block.

Committed to making physician burnout a thing of the past, the AMA has studied and is currently addressing issues causing and fueling physician burnout—including time constraints, technology, and regulations—to better understand the challenges physicians face.

The AMA Ed Hub™—your center for personalized learning from sources you trust—offers CME on professional well-being using the STEPS Forward™ open-access platform that recommends innovative strategies that allow physicians and their staff to thrive in the new health care environment. These toolkits can help you prevent physician burnout, create the organizational foundation for joy in medicine, create a strong team culture and improve practice efficiency.

Melinda Ashton, MD, executive vice president, and chief quality officer at Hawaii Pacific Health, is the brains behind ditching the dumb things. In an essay published in The New England Journal of Medicine, Dr. Ashton wrote that the EHR in and of itself may not be the reason for burnout. Instead, it is the approach to documentation that has been adopted in the U.S. she wrote in the essay, titled, “Getting Rid of Stupid Stuff.”

“The EHR makes it really easy to click on things and it also makes it very easy for us to think, ‘I have a great idea, let’s just get them to click on this or click on that,’” Dr. Ashton said.

The “stupid stuff” nominations from physicians and other staff members fell into three different documentation categories, she said.

Never meant to occur. One example Dr. Ashton referenced involved a urologist who completed a pre-op physical on a patient, which included a complete fundoscopic exam.

“I joked with the audience that I should have asked the urologist to see his ophthalmoscope—I’m not sure that there was an ophthalmoscope in his office,” she said. “I’m pretty sure the EHR is full of this stuff. It’s not OK because it cheapens the documentation.”

When unintended documentation requirements were reported, the health system made quick changes to the EHR. In several cases, requirements were being applied to patients of different ages than originally planned.

For patients who require briefs for incontinence, drop-down options asked whether the patient was incontinent of urine, stool or both. This required three clicks. However, a nurse who cares for newborns clicked three times for each diaper change. Single-Click documentation was created for children appropriately in diapers.

Needed, but could be more efficient. Even in cases when documentation was needed, it could be completed more effectively. An emergency physician questioned printing an after-visit summary, having the patient sign it and scanning it back into the system.

After querying other health systems and the legal team about the value of the signature, the requirement was removed.

“The physician was delighted that he had been able to influence a practice that he believed was a waste of support-staff time,” said Dr. Ashton.

A feature called “the rounding row” monitored hourly rounding implementation, which also led to repetitive clicking. After removing the row, about 1,700 hours of nursing documentation time were saved per month at four hospitals, Dr. Ashton said. The EHR should not be used as an enforcement tool.

Required, but not understood. Several requests from physicians asked about sorting and filtering capabilities that already existed. A physician-documentation optimization team was available to help, but doctors reported a lack of time to meet with the team.

While not formally submitted, 10 of the 12 most frequent alerts for physicians were removed because they were being ignored.

“It appears that there is stupid stuff all around us, and although many of the nominations we receive aren’t for big changes, the small wins that come from acknowledging and improving our daily work do matter,” said Dr. Ashton.

Needed but interruptive and time-consuming with needless repetitive typing.

Simpler logins, voice recognition ease click fatigue at Yale

 ID safelok card CAC

Facial recognition

Voice Recognition

Use of Natural Language Processing in lieu of type input and mouse

The benefits of these actions resulted in substantial time saved. Due to the limitations of the keyboard-and-mouse user interface, Dr. Hsiao implemented speech recognition for physicians. Through voice-recognition software that connects directly to the EHR, physicians have experienced a 50 percent reduction in the time it takes to complete and close encounters. Of Yale’s 300 ambulatory sites across six hospital campuses, 60 percent have implemented the new system.  Between 30 and 40 percent of Yale physicians are using voice-recognition software, and about 100 new clinicians each week are signing up to use it. 

Because the voice-recognition technology is three times faster than previous options and has improved quality for physicians, the average time to close an encounter is down by eight hours a week.  

Dr. Vender also recommends physicians use voice recognition while the patient is in the room. This real-time note-taking allows the patient to understand what the physician is writing in their notes and provides instant feedback. This can be reassuring and a confidence builder for patients.

The third major initiative is a pilot using virtual scribes in which 50 physicians are participating. With voice recognition and the virtual scribes, physician time on the computer on nights and weekends has significantly lessened, Dr. Vender said.

Ditch the “stupid stuff” that drives doctors crazy | American Medical Association: