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Curbside Consult with Dr. Jayne 4/5/21

April 5, 2021 Dr. Jayne 4 Comments

A major part of my consulting practice involves trying to help physicians become more proficient EHR users. As I evaluate their current state workflows, I usually discover a number of operational processes in their practices that are adding to their workload. Often the perception is that the EHR is causing more work when it’s really a combination of poor EHR implementation, poor EHR configuration, and continuing to try to use processes that were designed for paper even though the paper is long gone.

Increasing practice-related stresses contribute to physicians feeling like they’ve lost control of their work lives, which can ultimately result in burnout. I’m always on the lookout for strategies to help my clients beyond optimizing their EHRs and their office processes. Sometimes this involves referring them for executive coaching to discuss work-life balance and their willingness (or lack thereof) to alter their work schedules to try to reduce stress. Other times, physicians are resistant to any advice that advocates for work habits different than what they’ve grown to accept.

I ran across an article from the AMA this week that advertised four approaches to reduce the mental workload that physicians face. This was presented as a strategy for reducing burnout. Cognitive workload is a real phenomenon that a lot of organizations don’t think about. I’ve had many conversations with EHR designers and UX experts about it over the years, and certainly systems can be designed in a way to make things easier on the user. However, what users see on the screen is only a small part of the stressors they face each day.

The article cites a recent webinar with Elizabeth Harry, MD, who is senior director of clinical affairs at the University of Colorado Hospital. The first point that the article makes is that an individual’s attention is a limited resource, and that we need to “have space to actually give proper attention to things” in order to avoid making mistakes. She suggests that people use a task-based approach, where they focus on a single task for a period of time in order to saturate their working memory. An ideal time for focused attention would be 25 minutes, followed by a break during which the cognitive load would be discharged.

That sounds well and good from an academic perspective, but I’m not sure how to apply it to the typical workflow physicians face in the outpatient setting, where they’re bouncing from 10- to 15-minute visits with “breaks” in between, during when they are expected to finish documentation, field telephone messages, address medication refills, and perform numerous other tasks.

Dr. Harry goes on to suggest four strategies to address systems issues that contribute to burnout.

The first strategy is to increase standardization. She cites Steve Jobs and his standardized wardrobe as an example. She notes that building intentional habits can reduce stress and that organizations should try to standardize as much as possible across medical care unites.

I wholeheartedly agree with this idea. My urgent care employer has more than 30 locations, and all of them are built on the same blueprints except for three locations. I work at two of the three non-standard sites from time to time and find them incredibly frustrating. One site was acquired from another urgent care organization and has different cabinetry, so the drawers are laid out differently and the rooms have different configurations, which results in the physician opening random cabinets trying to find things. I’m sure that doesn’t build confidence for patients, and it definitely injects a small amount of stress into your day. The other site has the standard layout in the rooms, but the doors to the exam rooms all open opposite of how they should, resulting in some shimmying and dodging of trash cans and exam tables as you enter the room. It also makes you try to grab for a handle on the wrong side of the door as you exit, which just makes you feel foolish as well as slowing you down.

The second strategy she advocates is decreasing redundancy so that organizations have a single high-reliability process for completing a task rather than having multiple ways a process can run. She uses the example of notifying a physician regarding lab results. We need to receive results the same way each time rather than a different way each time we order labs. I think most organizations are doing a fairly good job with this, although there are some levels where redundancy is important, especially where critical patient safety situations are involved.

The third anti-burnout strategy involves consolidation of clinical data. This is where she cites EHR design as an example, setting up the workflow so that key information is located in a single space rather than requiring users to bounce around to find the information they need. Disease-specific workflows are an example of this, where users can find relevant patient history, clinical indicators, and labs all in the same place. This approach builds on the concept of reducing split attention as well as creating routines and habits.

The fourth strategy involves reducing interruptions. Dr. Harry notes that physicians need to have agreements with their support staff about what merits an interruption and what doesn’t. Interruptions can disrupt important thought processes, and she again advocates for physicians to have blocks of time where they can focus.

This may be a possibility for outpatient visits in certain subspecialties that are allowed longer appointments for complex consultations, and might be even more of a possibility where physicians own their own practices and can control their own schedules. However, I can’t see how it would be much of an option for specialties where physicians are expected to juggle multiple patients who are having acute problems simultaneously, such as in the emergency department or in the intensive care unit. In those settings, our attention is constantly drawn away from what we’re looking at and towards something that is potentially less stable or more serious.

The reality is that inability to focus doesn’t just lead to stress for physicians and caregivers, but it also leads to poor care when patients don’t have our complete attention. Having time to focus has become a luxury and our patients deserve better.

What are your organizations doing to help physicians achieve greater focus, and is it helping reduce burnout? Leave a comment or email me.

Email Dr. Jayne.

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Currently there are "4 comments" on this Article:

  1. In primary care at least, so much easier when the horse brought doc to the house where he–with rare exception, she–stayed until the crisis resolved. Physician was not interrupted at all.

    As a country doc by training, I knew we were going down a slippery slope when consultants started saying that all patients needed to be in gowns before doc would encounter them.

    And now, it is all about productivity first rather than quality.

  2. We support an ambulatory EMR that is very configurable to each provider’s workflow (a blessing and a curse). Some dictate, some use Dragon, some use scribes, and some like to click and type. The biggest issue is that <10% of our doctors take the time to learn the system or configure it to their liking. They get in, start working and then complain about it. We continually offer 1:1 training (no additional cost) when we hear someone is struggling, and on demand when someone is stuck, but rarely get taken up on that offer. This makes their charting onerous and often times not up to coding standards.

    How can we help doctors who don't want standardization, and won't accept any help? It has been demonstrated over and over again that clinics with strong, standardized policies perform better for providers, staff, and patients.

    When a doctor tells me they need a new EMR because their current one is not meeting their needs, my first question is how much training did you get at implementation? How much follow up training and workflow reviews have you had with your EMR vendor or a consultant since go-live? Not to say that there are not sub-par EMRs on the market, but many clinics toss the products out for another one hoping it will save their day, yet they put themselves back in the same boat by not doing a content build that meets their practice workflows.

    I want to be part of a solution, not a nag. I'd be interested to know how others are supporting the providers in their wake. I certainly don't want to hear our doctors complaining about charting after hours because the system doesn't work for them. Our well trained providers are done with all their notes by the end of clinic, not working into the night. I want that for all providers.

  3. Keep fighting the Good Fight, Dr. Jayne! I like your messaging on EHR design and implementation. I’m from the IT side, rather than the Clinical side. But these are the messages we need to hear, and send.

    Also, this is particularly apropos: “…an individual’s attention is a limited resource…”

    I didn’t fully get this until I joined a shop that had a lot of automation already in place. Man, does that make a difference! You now have time to really solve problems properly, rather than continually band-aiding them.

    Prior to that, we’d tell ourselves: “We need to maintain control. Keeping this process manual gives us that control. Therefore, don’t automate it.”

    Sure, you have control, but at what cost? And what exactly is the point of maintaining the flexibility of human intervention, when you never actually exercise that flexibility?

    Standardize and automate. Do as much of this as you can, and no more.

    • There is a story that came from that high automation shop, I thought I would share.

      We created an automated interface between 2 clinical apps. The primary purpose was to save time for the Clinical personnel. That worked fine BTW.

      No, this story is about a downstream consequence of that interface. You see, those clinical transactions? They wound up sending costing transactions to our General Ledger. So, we offered Finance the option of automating those too.

      “No!” said Finance. “We must maintain control over posting to the G/L. There is an important principle at stake and we will not violate that principle!” Being a responsible IT department, we obeyed their wishes and did not automate that component.

      That interface ran for something like 7-8 straight years. Uncountable thousands of transactions went through it. And not once, in all that time, did Finance do anything but post every single transaction.

      Our Finance department never used the flexibility offered by human processing. It was a wasted opportunity. They instead used their people as biological robots, doing the exact same thing, every day.

      What seemed like the right thing to do, to them, was in fact the wrong thing.

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