EPtalk by Dr. Jayne 9/30/21

Due to critical shortages of healthcare personnel and ICU beds, several states have declared “crisis standards of care,” including Alaska. As if they don’t need one more thing to worry about, a new virus has been detected in the state. Dubbed “Alaskapox” by the media, the virus was found in two additional patients who sought treatment at a Fairbanks urgent care clinic. The symptoms include skin sores, fever, joint pains, and swollen lymph nodes. Both patients recovered within a few weeks, but it’s worrisome as these cases are similar to an initial case in 2015 and another one five years later. The virus has been identified as one from the same family as smallpox and cowpox. Epidemiologic investigation linked the virus to outdoor cats who may have picked it up from cows or other mammals, including voles. Just goes to show that public health was important before COVID-19 and will continue to be important in the future. Let’s hope governmental entities show up with their pocketbooks to fund the kinds of investigations needed to tackle emerging illnesses.

A new report from AHIMA, AMIA, and EHRA asks for consensus on the definitions of “electronic health information” and “designated record set” to better help organizations operationalize the requirements found in the 21st Century Cures Act. The organizations had formed a task force last year in preparation for key compliance deadlines. The task force will be asking stakeholders for feedback on the report and will continue to refine their work as the 2022 deadlines for compliance to the information blocking portions of the Act approach. The health information export portion of the Act kicks in at the end of 2023.

I’m glad to see that EHRA is participating since its members are the ones that actually need to incorporate the definitions in the systems we use each day to care for patients. Especially given the need for interoperability and portability for patient data, it’s critical that vendors use a common set of definitions. Having worked with dozens of healthcare organizations over the years, there are so many other definitions that are nebulous, including the definition of the legal medical record. I’ve got some clients that think that the final “visit notes” that you can print from the EHR are the legal medical record, completely disregarding the idea that there is a lot of other information in the system that becomes part of the legal medical record. I can’t count how many hours I’ve spent trying to educate clients on this, but until recognition of the concept is required, there will continue to be confusion.

Looking back to 2019, physicians were already exhausted trying to do everything they needed to do to care for patients – managing in-office visits and managing non-visit encounters including telephone messages, patient portal messages, refill requests, pharmacy communications, insurance communications, and more. Throw 18 months of a pandemic on top of that and we’re seeing some serious burnout. A number of my close colleagues have left the clinical trenches, choosing to either retire early or leave medicine altogether. Someone sent me a recent article from the Journal of the American Medical Informatics Association that looked specifically at objective EHR measures (including time, volume of work, and proficiency) and whether they are associated with exhaustion and cynicism. The study was done in 2018 within the primary care clinics of a large academic medical center. It found that over a third of clinicians had high cynicism and more than half had high emotional exhaustion. Those that had the highest amount of after-hours EHR documentation time and those that had the highest volume of messages had greater odds of high exhaustion. No specific measures were associated to high cynicism.

I would think that cynicism is more likely to be associated with factors that can be difficult to quantify, including having to jump through regulatory hoops, having to deal with administrators that don’t have solid experience but are trying to push the latest and greatest thing they heard in their master’s program despite never having worked in healthcare, and having to deal with the moral injury that stems from not being able to deliver the care we were trained to provide.

As far as exhaustion being related to having high volumes of patient messages, I’ve seen it first hand. A while ago, I worked with a large national organization that was looking to optimize its EHR. Whenever I start one of those engagements, I begin with a current state assessment where I observe a variety of users – extremely proficient ones, middle of the road ones, and those that are struggling. I also observe providers at various visit volumes and across various subspecialties.

The first thing I found was that the organization had different policies depending on whether you were part of the “northern” medical group or the “southern” one. One set of clinics allowed their staff members to do preliminary triage of all messages and handle all the back and forth, while the other required the licensed clinicians to handle every single message in the inbox queue. It’s not difficult to figure out which clinicians were less satisfied and felt more overworked. The organization had never looked at whether it made sense to have different policies for the different regions, it had just evolved over time due to lack of overarching governance. I tried to engage them in a discussion of how modifying the policies could be helpful far beyond any optimization we might do with the EHR, but they weren’t interested.

They also weren’t interested in strategies that have been proven to enhance their patients’ ability to adhere with medication regimens – simple things such as providing refills through the next scheduled visit or providing medications for a year in stable patients. They absolutely refused to consider the idea of a delegated refill policy, where nurses or other clinical staff could check various parameters defined by policy then refill accordingly. They were perfectly happy to push the work up to the physicians rather than to embrace change.

After numerous discussions, it was clear that they just wanted to demonize the EHR. I left them with a lengthy report that included some changes they could make in their system that would help micro-level workflow on the screens, but the vast majority of changes that needed to happen were operations and cultural. They weren’t thrilled with my recommendations, but frankly their technology was in pretty good shape, although their people and processes were not.

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