Reduce burnout by putting more doctors in leadership roles: Physicians Foundation

Last month, Medical Economics published an article summarizing the results of a study performed at the Palo Alto Medical Foundation examining the link between the number of EHR-generated messages doctors receive and job satisfaction levels and burnout.

As a follow-up to that story, we recently interviewed Gary Price, MD, president of The Physicians Foundation, about its efforts to combat burnout and train doctors for leadership positions in healthcare. Price is a plastic surgeon practicing in New Haven, Conn., and is on the clinical faculty of the Yale School of Medicine.

Excerpts from that interview appear below, edited for length and clarity.

Medical Economics:  How long have you been using electronic health records?

Gary Price, MD: I’ve been using one now for 7 or 8 years. 

ME: What system do you use?

GP: In my office, we use Nextech, which was originally designed for plastic surgery practices. And, in fact, when they were doing their design they actually came to my office and talked to me before they developed their beta version. And they were already doing our bookkeeping software and our practice management software, so we went with them. At the hospital, I have to use Epic.

ME: You have first-hand experience coping with EHR algorithm-generated inbox messages. Can you tell me more about that?

GP: My frustration is the constant interruption and inefficiency it puts into my daily workflow. Just last week, I spent a day at the outpatient surgery center and I estimated at the end of the day I had wasted an hour and a half doing unnecessary documentation or fighting with the system so that it would allow me to discharge a patient or even to get started.

There are some frustrating and unnecessary things one has to do in Epic just to allow a patient to go to the OR. And as I’m waiting for them to take my first patient in there, they informed me that they can’t start the case because I’m not “green.” I’d never heard that before, but they explained to me that on the schedule board, each case has a red or a green little figure for the surgeon indicating whether or not the surgeon’s available. I was a little dumbfounded about that since there wasn’t anyone at the entire surgi-center who hadn’t known I was there for the last 45 minutes.

So I said fine, just show me how to do it. There wasn’t anyone who really knew how to do it but I did find a resident and I had to not only log in but go through multiple menus, none of which were intuitive whatsoever to get to the spot where I could just click that I was there, despite the fact that I’d been on the computer for a half an hour before that. It was only perhaps 10 minutes that it consumed, but I know the employed hospital physicians get very upset about not seeing a patient and being done in 10 minutes.

That same day, on two separate patients, the system detected a disagreement in medication dosages patients were on before they came in for their outpatient surgery that had absolutely nothing to do with what we were doing that day. At some point in the past, the dosages of medications these patients were taking had been changed. And  the computer had two different versions of the same medication with different dosages. There was no intuitive way to take just one out or just to say take what you were taking before. It literally took me half an hour to get the computer to accept their discharge.

ME: As a surgeon, what sort of EHR-generated messages turn up in your in-box?

GP:  I’m fortunate. Most of the messages I get in my in-box have to do with chart completion or notification of a copy of a chart being forwarded or a lab result. That part isn’t too onerous for me, although it’s at the office where I would get the messages about prior approvals for medications and things like that. But as a plastic surgeon, at least up until recently, that hasn’t been a big problem.

But the issue that they’re studying in Palo Alto, looking at in-box messages, I would view that as a proxy for how deeply a physician is involved with using the EHR in their work. The physicians who have to use it the most are going to be the most frustrated. Almost 40 percent of physicians say that the EHR is the most frustrating part of their practice. And of course we know there have been several studies that show for every hour you spend working with patients there’s about two hours of documentation time, which is pretty ridiculous. 

ME: Does that jibe with your experience?

GP: Absolutely. In fact, the way I’ve coped with it is I’ve had to get more efficient about what parts of the EHR in my office that I’m not going to complete, that are unnecessary. That’s helped a little but I’ve still got hours of data entry at the end of a patient day. This system is just not designed efficiently enough.

ME: Is The Physician’s Foundation trying to do anything about this?

GP: We are, in a number of ways. I think surveys of the country’s physicians are a big part of what we do. That’s a way of defining the [EHR] problem and measuring it. We think the most important part of solving the problem is to get good physician leaders who can get involved in the decision-making that goes in to not only choosing but designing these systems and making them work better.

So we fund leadership programs all over the country as well as a national program every fall to try to develop the kind of leadership skills that will make the voice of physicians more effective on the national landscape.

We’re also interested in certain determinants of health and how they impact health outcomes. We think that’s part of the frustration that’s leading to the burn-out issue, in that physicians are now held accountable for patient outcomes and the new quality measures that are coming out. But physicians really have very little input into some of the things that can drastically affect a patient’s health outcome, such as poor nutritional status or not being able to afford prescriptions or not being able to actually get to an office visit, things like that. So we’re looking at that from multiple directions.

ME: What do you do with the results of your surveys? Do you send them to the EHR manufacturers, CMS, Congress? 

GP: We have distributed it to the Congressional offices in the past, although we’ve found it’s a little more effective to target it by making sure it’s online. We release it to the national press, and as you know, it’s been quoted in many national outlets.

But we make sure that the results are easily available to physician leadership in each state and we even break the data down state by state for them. And we try to make it available to all the leading thought and research groups that are involved in this as well. And of course we encourage our state medical societies to use that data when they’re interfacing with their own congressmen.

ME: Do you think it’s ultimately up to Congress to fix this?

GP: My personal opinion is that the only way to fix this has to be a top-down revamp. The way our system works, unless a healthcare system realizes that they have a strong incentive to make the EHR work better for their physicians, I don’t think it will happen.

The EHR as it exists right now, I’m convinced is the largest and most efficient billing machine that the human race has ever designed. However, it’s a terrible impediment to taking good care of patients at the physician-patient level. There are lots of good things about it with availability of data and things like that. However, because it works so well as a billing machine, I think everyone in the market for the EHRs doesn’t have a lot of impetus to help make it better for physicians.

I think that what we really need is a way to objectively measure how an electronic health care record works in clinical practice: How efficient it appears to the physicians using it, how frustrating it is, and have that measured on the hospital level and also on the platform level and seeing it becomes publicly available. I think [hospital] systems that do a great job of making their EHRs work better could actually use that as a recruiting tool for physicians, and physicians would really like to know which systems have the worst EHRs before they consider working in them. I think that would be the kind of incentive that would make the system change.

There is also a role for government. Part of the frustration comes from quality measures and just a slew of other checkboxes that really have never been shown to improve outcomes or even decrease costs. And that creates a tremendous amount of inefficiency and also frustration on the part the physician. 

ME: I wonder if part of the answer lies in making the qualities that you talked about, the desirable qualities, part of the EHR certification process? Then the manufacturers have an incentive to design systems that are more user-friendly and actually help improve patient care, rather than just being, as you say, glorified billing machines.

GP: That certainly would be one way to approach it. But remembering the history of how that certification first got developed and implemented,  I’m a little pessimistic about that. 

ME: In your opinion, is there any significant difference among [EHR] systems?

GP: I don’t think that I can tell you that any one system is better than another. It’s very interesting to me that if you use Epic in one setting, like Yale New Haven Hospital, you could go to another place using Epic and it wouldn’t look or feel at all the same. And then within a system, parts of it could work very well for certain specialties. And other parts wouldn’t.

For instance, when Epic was introduced at Yale, the first day of operation, nobody had really paid any attention to outpatient surgery. And I was trying to do an outpatient operation and I couldn’t even pull down a help menu or anything with those words in it. There just hadn’t been much attention given to that.

ME: And the difference is that the way different hospital systems configure their EHR systems so that, as you say, Epic in one place will work very differently than in another?

GP: Yeah, they can be configured differently and they can be given different looks. There’s sort of a nascent ability to customize windows now to some degree to speed things up, but I find it woefully inadequate to speed up what I do. I think the systems are so broad and they cover so many different ways of providing care that they can look very different to two different physicians in the same system or going from one system to another.

ME: I want to go back to what you said about the Foundation training physicians for leadership roles. You’re referring to leadership roles within health systems?

GP: Not just health systems but within their medical societies, within their specialty societies, anywhere that the voice of physicians can be brought to the forefront.

ME: Aren’t physicians always leaders in medical societies?

GP: They are, but we want them to become more effective leaders so that the physician’s voice can become better heard throughout the policy-making sphere and also the sphere of decision-making within their hospital systems. You know, when the EHRs were introduced, the perspective of physicians who had to use them was pretty much largely ignored.

ME: And now we see the results?

GP: Exactly. We think one of the barriers to solving our problems in healthcare is that the physician’s voice has not been heard. Physicians are dealing with patients on the front lines of healthcare every minute of every day and their perspective is not only very clear but it’s very important.