Friday, May 26, 2017

Thoughts On Creating EHRs That Clinicians Are Actually Reasonably Happy To Use And Don’t Burn Them Out.

We had two relevant articles (and an extra) appear this week. First we had:

Physicians dream up a better EHR

May 22, 2017
When the American Medical Association (AMA) last year announced study results that found physicians spend nearly half their office day entering data into electronic health records (EHRs) and handling other administrative deskwork, the organization said poorly designed EHRs were part of the problem.
“If you were to start from scratch, you wouldn’t come up with the systems we have today,” said Jesse M. Ehrenfeld, MD, MPH, an associate professor of anesthesiology, surgery, biomedical informatics and health policy at Vanderbilt University School of Medicine who was elected to the American Medical Association Board of Trustees in 2014.
The AMA developed a list of eight items it believes vendors need to improve or develop to make EHRs better for physicians and their staff.
The list starts by saying systems should
1.     enhance physicians’ ability to provide high-quality patient care;
2.     support team-based care; and
3.     promote care coordination.
The AMA also asks vendors to
4.     offer product modularity and configurability;
5.     reduce cognitive workload;
6.     promote data liquidity;
7.     facilitate digital and mobile patient engagement; and
8.     expedite user input into product design and post-implementation feedback.
“If all vendors took these to heart, things would really improve,” Ehrenfeld said. “We want tools that help us provide high quality care and make the process of care easier and more efficient. Mobile technologies, voice recognition, imaging and sensing are all things we see in the world around us, but we don’t see that happening in the EHR space yet.”
Every physician likely has his or her own thoughts about how to improve EHRs. Ehrenfeld and others offered several additional ideas, from practical improvements to solve today’s problems to visionary suggestions that could dramatically change how they practice:
 Lots more here:
Second we had this covering the same material:

Want a better electronic health record system? Ask a doctor

May 17, 2017 12:35pm
Doctors have plenty of ideas for how to improve electronic health records.
Poorly designed electronic health records (EHRs) are the bane of many doctors’ existence.
They’re blamed for an increase in physician burnout and a decrease in physician satisfaction.
“If you were to start from scratch, you wouldn’t come up with the systems we have today,” Jesse M. Ehrenfeld, M.D., an associate professor of anesthesiology, surgery, biomedical informatics and health policy at Vanderbilt University School of Medicine, told Medical Economics.
Yet those EHRs dominate doctors’ work hours. For every hour physicians spend in exam room visits with patients, they spend nearly two hours on EHRs and desk work during office hours, a study funded by the American Medical Association found.
So it’s no surprise that doctors say they can easily come up with ideas for how to improve EHRs to make them better for them and their staff.
More here:
Both articles are worth a look as they take slightly different looks at the same issue.
The link between HER use and clinician burnout is especially troubling.
A more detailed coverage of this issue is found here:

Workplace Factors Contribute to Burnout in Family Physicians

Diana Phillips
May 10, 2017
Family physicians who work in a hectic or chaotic environment, those who report high rates of job-related stress, and those who spend time at home working on electronic medical record (EMR) tasks may be particularly vulnerable to burnout, researchers report.
In a study designed to assess workplace factors associated with burnout among family physicians, Monee Rassolian, MD, from Michigan State University, Flint, and colleagues administered an abbreviated burnout survey to a random sample of family physicians applying to take the 2016 American Board of Family Medicine Certification Examination. They report their findings online May 8 in JAMA Internal Medicine.
Twenty-five percent of the final survey sample of 1752 physicians reported symptoms of burnout on the basis of the 10‑item Zero Burnout Program survey, also referred to as the Mini Z survey, developed from the Maslach Burnout Inventory. The Mini Z survey enables the assessment of burnout with a single item that correlates with the emotional exhaustion subscale of the Maslach Burnout Inventory.
Although substantially lower than physician burnout estimates in studies using the Maslach Burnout Survey, the burnout prevalence in this study is similar to that observed among academic general internal medicine physicians using the Mini Z survey, the authors note.
Of those with burnout (n = 441), 57.1% reported working in a hectic, chaotic atmosphere compared with 26.5% of those without burnout, 91.4% reported feeling a great deal of job stress compared with 38.4% of the physicians without burnout, and 62.1% spent excessive time on EMR tasks at home compared with 38.7% physicians without burnout, the authors write.
The workplace factors addressed by the survey include:
·         job satisfaction;
·         job-related stress;
·         control over workload;
·         sufficiency of time for documentation;
·         the atmosphere of the work area on a 5-point scale, where 5 is hectic/chaotic;
·         alignment of professional values with those of department leaders;
·         ability of care team to work together efficiently;
·         time spent on the EMR at home; and
·         proficiency of EMR use.
Bivariate analysis identified associations between burnout and all the work-related factors except proficiency with EMR use, which was similar among physicians with and without symptoms of burnout, the authors report.
More here:
I wonder how the myHR would fit in here, given it is hardly user-friendly etc.


Anonymous said...

Well apart from the disregard by the business (owner ) needs of the clinicians (user) needs, there is fundamentally to many issues with the information design and interaction design, I reference it in this language because we have a CEO and an old consumer rep who is hell bent on the belief it is a visual design issue.

Surely the board must see this flaw in the leadership the transition steering committee delivered them? If the delay politics states it will shortly be their mistake.

Bernard Robertson-Dunn said...

I have a question for anyone attempting to architect/design/create a reliable Health Record system.

How do you keep the patient's health data accurate and up-to-date?

IMHO, unless you continually monitor a patient, their environment and their behaviour, and have the ability to correct diagnoses in the light of advances in medicine, you can't. You might while they are in a controlled environment like a hospital, but that won't apply to most patients/citizens.

At best a Health Record system can only be an unreliable source of information on a person's medical history.

There will always be an overwhelming need for current health data when treating a patient - that's what tests and diagnostic technology is all about. Historical data can add some data that show how a patient's condition has changed over time, but in comparison, today's health data matter far more than yesterday's, or last week's or last time the patient saw a health carer.

The promise of eHealth lies in measurement, diagnoses and treatment, not historical data.

To use an analogy, Health Records are the horses of the past. eHealth is the modern engines of today, i.e internal combustion engines and electric motors.

MyHR is like trying to develop a faster horse. OK if you like horses, not much use as the basis for a revolution in healthcare.

john scott said...

Bernard, I agree with your appreciation.
Our focus should be on organized purposeful collaboration to enable and ensure that the information needed at the point of care is there when it is needed, in the form it is needed and is meaningful.

Anonymous said...

Yes there are many other options depending on your need. Is your need to control all information, centralise and become a gateway for others who must first subscribe to use? Do you want to exchange on request? Or do you want an ecosystem underpinned by a culture of trust and sharing, where systems can co-exist..?

Which ever option you want, we are stuck with two who have a legacy of failed initiatives at the NHS, more than happy to encourage and facilitate the selling of data to pharmaceuticals and insurance companies, and one at least founded a career on a somewhat questionable health worker surveillance tool and scare tactics, along with some rather interesting sets of circumstances intertwined. We then have someone with a chip on their shoulder hell bent on destroying a mythical clinical mafia for reason I can only determine as not wanting to wait their turn in an American health system, or perhaps suffers flashbacks from the times sitting as a paid stakeholders on as many reference groups as could be found, and then the quiet one who is part of the labour NSW syndicate. Oh we also have two clinical folk because we have too.

Seem to be a large opportunity to replace with leaders with actual complex thinking abilities, organisational know know how, and experience.

Can Clinicians do this alone - no, no stakeholder group can on their own.

Bernard Robertson-Dunn said...

"es there are many other options depending on your need. Is your need to control all information, centralise and become a gateway for others who must first subscribe to use? Do you want to exchange on request? Or do you want an ecosystem underpinned by a culture of trust and sharing, where systems can co-exist..?"

Surely there are only two needs: More effective and efficient healthcare?

Everything else is the means by which you achieve these goals.

Unless you are the government trying to leverage off a large collection of personal data which turns out to have other, "secondary" uses?

Anonymous said...

Bernard, we have common agreement on the objective. Unfortunately, the all to familiar "this is complex" is true, and is one of the reasons that the health/medical industry has not made the significant advances in electronic information transfers that other, perhaps more ordered, industries have.

This is compounded in Australia by a tendency to regard the eHealth impasse as a technical or engineering problem awaiting a magic bullet solution from currently 'the ADOHA' or for a legislative blueprint from Government before we can move forward. This is a vain hope, because eHealth is part of the complex human system that delivers health care, and it has proved thus far, to not be amenable to simple technical solutions, especially bold and perhaps misguided large scale attempts that is now the GovHR, which even in its infancy was perhaps a bridge to far, is now, well perhaps become tyrannical.

Far better for the Government to adopt a simpler tack and approach eHealth (or Digital Health if you prefer), as a Complex Adaptive System and focus on promoting the evolution and adaption of eHealth systems to address local issues, rather than attempting to effect an enforced outcome (probably blinkered by past experience or vested interests) via bureaucracy, and monolithic rules and regulation.

At its most basic this means: a) creating the starting conditions for the evolution of e-health systems, b) providing simple rules and boundaries for participants, and c) by articulating a vision that encourages creativity at the local level.
A few dollops of money to stimulate (not underwrite) desirable activity would not go astray. This approach is neatly summed up I find in a one Dave Snowden's Children's Party story
There are long standing success stories such as that of electronic diagnostic result delivery is a good example of people seeing a problem, devising a solution, and delivering it, I believe we are starting to see emerge a raft of solutions focused on identifiable needs, satisfying clinical and consumer.

This is all perhaps to much to expect from ADHA or DOHAS, so in all probability it will have to be the e-health practitioners and vendors who will have to take the risks, maybe loose some skin, and just get on with doing it ( and hope to perhaps reap some of the benefits of being first movers).

There is a role for Governments at State and Federal. If I need to spell that out then it's is a journey of discovery they must first realise they need to take.

As a previous commentator highlighted, you first must admit you have a problem, before you can fix it.