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EPtalk by Dr. Jayne 2/21/19

February 21, 2019 Dr. Jayne 9 Comments

We’re officially post-HIMSS, because the emails have started arriving thanking me for my interest in various vendors’ products after I stopped by their booths at the show. Folks have had time to decompress and begin sorting through various business cards that were traded and notes that were made about follow up. 

I have my own stack of cards to go through, following up on new connections and seeing what opportunities might arise from the conference. As summer approaches, I tend to start putting together my strategic plan for the upcoming year. I’ve had some tempting offers to go back into the hospital trenches as well as some interest from the vendor side, so this might be a year full of change.

Normally I don’t spend a lot of time reading things from Healthcare IT News, but their interview with Judy Faulkner caught my eye. Part of the conversation was around physician burnout and relative happiness (or unhappiness) with EHRs. She brought up some good points that many of us in the trenches already know, but that large organizations seem to tune out at times. One of those points is that although EHR use can be associated with physician burnout, it’s not necessarily causal. There are burned out physicians that are happy with their EHRs, and EHR-haters that aren’t burned out. Other factors influence burnout including administrative burden, leadership issues, patient load, and work-life balance issues.

She also notes that clients need to stay current with their EHRs, installing the latest versions so they can benefit from usability enhancements that followed the post-Meaningful Use programming era. I’ve found that to be true with nearly all the vendors I’ve worked with, not just Epic. Once they cleared the certification hurdles, vendors often went back to customer enhancement request lists and started making good on old promises.

Another point she made was around training. Physicians that tend to do better with EHR adoption are likely to have had better training. That doesn’t always mean more hours of training, but it could mean more focused training or role-specific training, using the physicians’ time wisely and training them on the tasks they are most likely to perform in their work.

She calls for physician subspecialists to train their peers. That’s great in theory, but it’s not very easy to find physicians who want to dedicate themselves to learning how to train other physicians how to use the EHR. I’ve worked to mentor multiple CMIOs in this regard and not everyone has the aptitude or personality to be a trainer even if they want to do it, even when the hospital is willing to compensate them appropriately. In too many cases the compensation, isn’t remotely adequate, so it becomes a non-issue.

Faulkner does mention the idea of EHR personalization as a positive factor towards EHR happiness. She notes that it’s a challenge to convince health systems to do that for their physicians. My take on it is that it’s not just an Epic issue, but happens with most vendors and most health systems. It can also vary based on the degree of autonomy held by physicians outside the EHR.

One hospital I work with keeps its employed physicians on what many would consider a short leash. They’re fanatical about quality and reducing unnecessary variation, so physicians are expected to use order sets and standardized workflows. They’re incented on following the rules. Generally, people comply or they leave. The users tend to be satisfied with the EHR because they know what to expect and they know the rules of the game they’re playing.

At other organizations where there may be lots of competition for attending physicians’ patient volumes, I’ve seen hospitals bend over backwards to customize the EHR on an individual physician basis for fear that someone will take their surgical business elsewhere. This can lead to redundancy and confusion in order sets and workflows and costs more to maintain, but the organization feels it’s worth it. There’s definitely a need for vendors to make their systems easier to personalize and to allow user-level configuration rather than having to have IT teams involved in making small adjustments.

She goes on to note some data from KLAS that looks at EHR happiness and whether the health system is “agile,” meaning “If a physician wants a change made and talks to an IT person, how many committees does it have to go through? And if the answer is zero, that’s good.”

I understand the sentiment, but for those who haven’t waded into the muck that is EHR or IT governance, it’s an oversimplification. I’ve done hundreds of hours of work for hospitals and health systems “undoing” various changes that were made without any level of approval (and often without any documentation). Oversight isn’t a bad thing, but has to be crafted carefully to support the needs of the user and the goals of the organization. There should be a decision matrix that shows what kind of changes need what kinds of approval, and from whom. Simple things that don’t have downstream ramifications should happen quickly, where more complex issues that might have far-reaching consequences might need multi-level oversight.

Assuming the interview is a relatively straight transcription and didn’t go through much editing, it shows the level of understanding and insight that Judy Faulkner has into some of the issues her clients are facing. I’ve interacted with C-levels at many vendors and some of them don’t seem to have as much understanding of the challenges their clients are facing and how it impacts the end users. Many of them are good at using sound bites, but when it comes to getting into the details, they become quiet.

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I’m approaching a milestone reunion for my medical school class, and one can’t help but think about how much it cost to get here. Some of my classmates are still paying off their loans. A recent planning committee get-together led to some conversation about free tuition being offered at some medical schools. The brand new Kaiser Permanente School of Medicine in California has announced that it will waive tuition for all years for the school’s first five classes of students.

This led to quite a bit of discussion on the fact that Kaiser Permanente is opening its own medical school, unaffiliated with any university. Depending on how much influence Kaiser Permanente has on the students and what facilities they rotate through, there may be significant difference from the educational opportunities received at other schools. The first class will be relatively small (48 students) and the school names three academic pillars: foundational science, clinical science, and health systems science (which they describe as focusing on care delivery including population health, quality improvement, and social inequality). Students will participate in longitudinal clerkships starting in year one, hosted in Kaiser Permanente hospitals and clinics along with community health centers. It will certainly be interesting to see how this plays out.

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I was in the office yesterday treating lots of folks with influenza. At one point, all nine of our exam rooms were occupied by people receiving IV fluids. The flu is hitting people hard. I had a great team working with me. However, at one point, I noticed that probably all of them were young enough to be my children.

This thought came back to me later in the day, when one of them was using the EHR to print a label for a blood draw and asked aloud, “What did we do before we had Dymo printers?” They looked at me like I was from Mars when I started to tell them about the Addressograph machine, with which we used to print headers on patient chart pages and various labels. One of my jobs as a Candy Striper on the mother-baby unit was to stamp new chart pages for all of the patients on the floor. It’s funny the things you forget as technology moves on, but I think I can still smell the ink when I think hard enough.

What’s your favorite piece of extinct technology? Leave a comment or email me.

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Currently there are "9 comments" on this Article:

  1. I enjoyed your comments about Epic and their CEO Judy. In watching and being in the industry over the years as Epic has sprawled through Health Systems and shown advantages do medical professionals in many areas their success is undeniable since this undeniable and noteworthy. I do however feel the Judy’s comments are definitely biased based on an antiquated workflow on Epic’s front end for physicians the nurses alike. At the end of the day any of us who goes to see a provider utilizing Epic as a patient will notice the unbelievable amount of typing they are performing at point of care. It is definitely not the preferred way nor the way they were trained in medical school. So I would definitely think that providers being forced to be data entry techs would be a major factor in contributing to burnout. Too many providers are seeing fewer patients and staying later to complete their charts to ignore the reality of burnout and it’s connection to EHRs. Epic is great when it comes to sharing data in between care settings within a single Health System but by no means they make it easy two important consume a ccda at the user level and she be on that Healthcare or Health Systems silo. Epic can be effective for a provider committed to macros and investing the time to create those macros for documentation purposes, and combined with good speech recognition may be effective. Just to reiterate, providers I have communicated with are not particularly impressed with Epic as far as physician documentation and it does not seem to be better than any of the other “”run of the mill “”systems in the marketplace.

  2. I enjoyed your comments about Epic and their CEO Judy. In watching and being in the industry over the years as Epic has sprawled through Health Systems and shown advantages to medical professionals in many areas their success is undeniable since this undeniable and noteworthy. I do however feel the Judy’s comments are definitely biased based on an antiquated workflow on Epic’s front end for physicians and nurses alike.

    At the end of the day any of us who goes to see a provider utilizing Epic as a patient will notice the unbelievable amount of typing they are performing at point of care. It is definitely not the preferred way nor the way they (providers) were trained in medical school. So I would definitely think that providers being forced to be data entry clerks would be a major factor in contributing to burnout.

    To many providers are seeing fewer patients and staying later to complete their charts to ignore the reality of burnout .

    Epic can be effective for encounter documentation for a provider committed to macros and investing the time to create those macros for documentation purposes. Just to reiterate, providers I have communicated with are not particularly impressed with Epic as far as physician documentation and it does not seem to be better than any of the other “”run of the mill “”systems in the marketplace. No where near the hype…

  3. “Physicians that tend to do better with EHR adoption are likely to have had better training.”

    I have always been amazed at how different users experience their software. Over the course of my career, I’ve seen numerous situations where 2 people, sitting close to each other, in the same department, and ostensibly doing the same job. One person thinks the software is great and has no issues; the other person says the software is “terrible, sucks, and should never have been chosen!”

    Whenever you dig into these situations, you invariably find things like:

    – their jobs, even if close, invariably diverged in subtle ways;
    – lots of times the personal history, interests, favorite complaints and obsessions of the people involved matter;
    – expectation levels matter. People with high expectations are difficult to please. Low expectations people always make do. Ironically, low expectations people are often happier!
    – job history matters too. Anyone who experiences a system that “does it right” and conforms to their way of thinking, typically will be unhappy with any other system;
    – there is some personal responsibility. I’ve lost track of the number of users I’ve encountered who seemed to get as much out of complaining about a problem, as fixing that problem.

    IT is a great ally to have on your side, no doubt. But my ironclad rule is, no one cares more about your job than you do. It’s not realistic to expect IT (or anyone else) to invest more into fixing your job issues than you are willing to invest yourself. If you demonstrate that you are invested it becomes much easier to recruit allies.

  4. I wonder/wish if there was a way to quantify how much of Epic’s perennial higher ratings comes from the fact that they made extensive training with proven methods a mandatory part of their contract and implementation?

  5. My favorite piece of extinct technology?

    I’m gonna go old-school on this one. The Ditto machine and process. Used for school handouts and tests back in my youth.

    https://www.youtube.com/watch?v=Uu3iCvAQCHg

    What was it about that smell? It wasn’t nice exactly, but it was compelling. Like a menthol drop or something. And the images on the page, in fuzzy purple.

  6. The rotary telephone. Even as my kids were growing up in the late 90’s, early 00’s, some of their friends were stumped on how to call home. But you couldn’t break ’em







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Reader Comments

  • Billy Bonka: I find it interesting that you pick on Epic for Share Everywhere and Lucy, while completely ignoring the impact of Care ...
  • JeanneC: Much of health care is driven by a "Show me the Business Case" model, not a "What is the best way to employ information ...
  • Fred: Epic does this from time to time; puts out apps it doesn't really care if anyone uses or solves any real problems, so th...
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