As hospitals and health networks struggle to implement EHRs and comply with federal regulations, medical laboratories have their own struggles fulfilling orders while dealing with physician burnout
Ever since 2009, when the federal government’s electronic health record (EHR) adoption initiatives first became law, hospital medical laboratory managers have watched their parent healthcare organizations struggle to implement behemoth information systems and comply with new federal adoption and data reporting regulations. In most instances, not entirely successfully.
Ten years and billions of dollars in incentives later, not much has improved. EHRs still lack a common interoperability protocol. And health networks still struggle to comply with federal information exchange requirements, while simultaneously engaging with Medicare data reporting schemes that treat patient data as a form of currency.
However, during that same ten years, clinical
laboratories and anatomic
pathology groups have been successful in implementing interfaces with
physicians’ EHRs to support lab test orders and results reporting.
EHR Costs and
Physician Burnout Increasing
In the current climate of acquisitions and mergers in the
healthcare industry, health networks often find themselves patching together a
mix of disparate, incompatible EHRs. All while the cost of implementing EHR
systems is increasing.
And medical laboratories that must maintain APIs
(application programming interfaces) for data exchange with these changing
systems are finding themselves between two front lines: hospitals and EHR
developers.
Tragically, there’s also growing evidence that EHRs
contribute to physician burnout, a well-known industry problem that Dark Daily reported on in multiple
e-briefings.
For example, a 2017 study published in the Annals of Family Medicine (AFM) found that primary care
physicians spend more than 50% of their time working on tasks associated with EHRs
instead of caring directly for patients.
A similar 2016 study published in the Annals of Internal Medicine (AIM)
found that “For every hour physicians provide direct clinical face time to
patients, nearly two additional hours are spent on EHR and desk work within the
clinic day. Outside office hours, physicians spend another one to two hours of
personal time each night doing additional computer and other clerical work.”
“In addition to the cost of procurement and deployment,
we’re also seeing subsequent increases in higher IT operating costs, higher
departmental operating costs. We’re also seeing lower productivity and lower
employee satisfaction,” Scott
Kolesar, Americas Health Technology
Innovation and Digital Leader for multinational professional services firm Ernst and Young, told Modern Healthcare.
This may be an understatement.
“Where the debate about EHRs still comes in is doctors changing the way they practice and spending an awful lot of time doing data entry type of things,” Michael Burger, a senior healthcare information technology consultant specializing in both clinical and administrative systems and processes at health IT management consultants Point-of-Care Partners, told Modern Healthcare. “They push back to say, ‘We’ve made this enormous investment, and in the end, I’m not sure the care I’m providing is any better or less expensive than if I were doing it on paper.’” (Photo copyright: Point-of-Care-Partners.)
Massive Amounts of
Money
The news, however, isn’t all negative. Some health systems
are reporting efficiency gains—particularly in areas of billing—and perhaps
surprisingly, in faster clinical laboratory test turnaround times.
A recent report from Allied Market Research (AMR) seems to predict future growth in the EHR industry. “The global EHR market was valued at $23.6 billion in 2016, and is expected to reach $33.3 billion by 2023, growing at a CAGR of 5.0% from 2017 to 2023,” noted an AMR press release.
Nevertheless, the lack of true interoperability could be
responsible for a possible reduction in EHR sales as well.
“However, high cost of EHR and increase in concerns
regarding the patient data safety and security are expected to impede market
growth,” the press release also stated.
So, that’s confusing. One thing is certain, EHRs are not
going away.
Indeed, some experts suggest health networks and hospitals
view EHR implementation, maintenance, and upgrades as they would any other
investment. “If you think of EHRs like any other capital system—a phone system,
for instance—they are indispensable, so you have to just put them in your
capital plan,” Jon
Ivins, Vice President, Partner, and attorney at Hirschler Fleischer who specializes in
healthcare disputes, litigation, and regulation, told Modern Healthcare.
For better or for worse, EHRs are here to stay. Hospital and
independent clinical laboratory managers and stakeholders will want to note
this fact and become even better prepared as the EHR industry continues to
develop.
Pathologists might be able to help overburdened doctors by adding medical laboratory support services that assist providers in selecting the right tests and identifying the best therapeutic options for patients
In a new Stanford University School of Medicine study published in the July 9, 2018, issue of Mayo Clinic Proceedings, researchers indicate that physician burnout may be as big a cause of medical errors as unsafe healthcare environments. This highlights an opportunity for clinical laboratory professionals and pathologists to help physicians improve both diagnostic accuracy and the selection of the most appropriate therapies.
The study found that exhausted providers were twice as likely to report making a medical error. However, it’s a complex problem with no easy solutions.
“Just trying to fix the setting of healthcare environments in order to prevent errors is not sufficient,” Stanford University’s Daniel Tawfik, MD, MS, the study’s lead author, told Reuters Health. “We also need to address the actual underlying human factors that contribute to errors—specifically looking at physician burnout.”
Nevertheless, while there is no one-size-fits-all solution to physician burnout, clinical laboratory managers and pathologists potentially could help overburdened providers reduce burnout and fatigue by adopting new lab testing support services designed to assist physicians in selecting the right tests and identifying the best therapeutic options for their patients.
Medical Errors Third-Leading Cause of Death in America
Stanford researchers wanted to learn how physician burnout contributes to medical errors which, according to Johns Hopkins, is the third-leading cause of death in the US. They surveyed 6,695 physicians from across America. Of the respondents:
More than 54% reported symptoms of burnout;
33% experienced excessive fatigue;
Nearly 7% had thoughts of suicide; and,
Roughly 4% reported a failing safety grade in their primary work area.
Even in medical units judged to have excellent safety records, the study found rates of medical errors nearly tripled when physicians working in those units had high levels of burnout. The prevalence of errors became similar to a non-burned-out physician working in a unit with a safety grade of “acceptable” or “poor.”
“We found that physicians with burnout had more than twice the odds of self-reported medical error, after adjusting for specialty, work hours, fatigue, and work unit safety rating,” Tawfik noted in a Stanford news release. “We also found that low safety grades in work units were associated with three to four times the odds of medical errors.”
According to the study, overall, 10.5% of physicians surveyed acknowledged in the prior three months making:
An error in judgment;
A wrong diagnosis;
A technical mistake during a procedure;
Prescribing a wrong drug/dosage; and/or,
Ordering medication/intervention for the wrong patient.
While more than half of mistakes (55.4%) did not affect patient outcomes, or only caused a temporary problem (22.6%), more than 5% of errors did lead to major permanent health problems and 4.5% resulted in a patient death, the study found.
Radiologists, neurosurgeons, and emergency medicine specialists had the highest prevalence of error rates, with more than 21% of providers in each of those fields acknowledging recent mistakes.
Physicians reporting errors were more likely to have symptoms of overall burnout (77.6% versus 51.5%), as well as fatigue (46.6% versus 31.2%), than error-free providers. Physicians reporting recent errors also had a higher prevalence of suicidal thoughts (12.7% versus 5.8%), the study found.
Ted Hole, MD, a family practice physician in Ventura, Calif., is not surprised by the correlation between medical mistakes and overall well-being. “If your brain isn’t working right, you’re going to make errors,” Hole told the Ventura County Star. “That’s what burnout does. It makes your brain not work right.”
Stanford Connects Physician Burnout and Poor Workspace Safety Ratings
In their paper, the Stanford researchers argue a “combination of physician-targeted burnout interventions and unit-targeted patient improvement measures” are needed to tackle the problem of medical errors. Physicians who gave their work units an excellent, very good, or acceptable safety grade were less likely to make a medical error than those who described workplace safety as poor or failing.
Of the physicians who reported a poor or failing work unit safety grade, nearly 25% reported a recent error. Errors were incrementally lower for work units with higher safety grades regardless of physician burnout levels.
“This indicates both the burnout level as well as work unit safety characteristics are independently related to the risk of errors,” Tait Shanafelt, MD, Director of the Stanford WellMD Center and Associate Dean of the School of Medicine, noted in a Stanford statement.
“Today, most organizations invest substantial resources and have a system-level approach to improve safety on every work unit,” he said in the Stanford news release. “We need a holistic and systems-based approach to address the epidemic of burnout among healthcare providers if we are truly going to create the high-quality healthcare system we aspire to.”
Tait Shanafelt, MD (above), is Director of the Stanford WellMD Center, Associate Dean of the School of Medicine, and an author of the Stanford study. He maintains the “epidemic of burnout” among healthcare providers should receive as much attention as safety issues. Shanafelt became Stanford Medicine’s first Chief Wellness Officer in 2017. (Photo copyright: Stanford School of Medicine.)
Burnout Among Physicians Increasing
Other studies, including Medscape’s “Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout,” confirm an upward trend in burnout rates among US physicians. In the Medscape study, 51% of physicians surveyed reporting being “burned out,” defined as a loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. Since the Medscape Lifestyle Report first queried physicians about burnout in 2013, the number of providers reporting burnout has increased 25%.
Physician burnout has been attributed to a variety of factors, including:
Excessive workloads;
Financial stress;
Extra hours spent on clerical work or EHR-related tasks; and,
Loss of human-to-human interaction between physician and patient.
Robert Lum, MD, an Oxnard, Calif.-based radiation oncologist, blames the shift to corporate-owned medical practices for some of the reported increases in burnout among physicians. Lum told the Ventura County Star he stays upbeat by never losing sight of why he became a physician.
“If you focus on the reason you went into medicine in the first place, which is to help people and marvel at the miracles modern medicine is able to do, then you’ll have less burnout,” he said.
Nevertheless, other solutions also can help. Clinical laboratories play a key role in maximizing physician/patient encounters. By extension, physicians and laboratories are linked in unique ways that enable labs to reduce physician burden and ensure positive healthcare outcomes.
New study published in the Annals of Family Medicine (AFM) indicates that despite efforts to improve EHR usability and efficiency, primary care physicians continue to spend more than 50% of their workdays on computerized physician order entry (CPOE) and other clerical tasks instead of engaging in direct patient care
Do electronic health record (EHR) systems improve or degrade the productivity of physicians? That question has been the subject of robust debate. Now comes a new study in a peer-reviewed journal with a surprising finding: physicians spend up to 50% or more of their workday on EHR-related tasks.
In theory, EHRs offer a wealth of benefits over traditional paper-based systems. In practice, however, between interoperability concerns and implementation costs, they have proven a daunting undertaking for even the largest healthcare systems.
While EHRs might offer easy access to patient data—including medical laboratory records and anatomic pathology reports—this information doesn’t enter itself into databases or make itself instantly accessible. That requires human interaction, which is time consuming and prone to errors.
Thus, research from the American Medical Association (AMA) and the University of Wisconsin revealing that the time it takes to enter data, address communications, and perform other clerical tasks adds up to more than 50% of a physician’s workday is of paramount importance. That’s because physician dissatisfaction and departures from medical practice have increased each year since the EHR revolution began, and reports are the situation is getting worse.
Researchers validated their data through direct observation of 14 nonresident family medicine physicians from May through June of 2016. This observation showed similar findings. During clinical hours, 60% of physician time related to non-EHR tasks, with 40% of time devoted to EHR tasks.
Documentation Burden Leads to Physician Burnout, Dissatisfaction
“Our family medicine physicians spent 44% of their workday (157 minutes) in the EHR doing clerical and other administrative tasks,” study authors reported. “Computerized physician order entry accounted for 12.1% of their clinic hours (43 minutes) in the EHR. The burden related to order entry has been associated with clinician burnout, dissatisfaction, and intent to leave practice.”
Researchers tracked various tasks and assigned them to categories. Of the tasks tracked, only 32.1% fell under the heading of “medical care.” Reviewing chart notes, chart medications, and problem lists topped medical care tasks.
Review of clinical laboratory results in charts ranked near the bottom, with only 2.5% of the total time spent performing medical care tasks. These tasks, however, could offer opportunities for medical laboratories to help physicians identify opportunities to optimize reporting and test-ordering processes and improve productivity for clinicians who are responsible for most of the data entry burden associated with EHRs.
One potential solution to EHR burnout involves the use of medical scribes who work with physicians during and after a patient’s visit inputting encounter data. Alan Bank, MD, cardiologist at Allina Health, and medical scribe Jaeda Roth, are shown above during a patient visit. Bank told the StarTribune that he’s convinced scribes help doctors get more done and reduce billing errors. (Photo and caption copyright: Elizabeth Flores/StarTribune.)
Researchers also questioned the EHR’s role as a communication or telemedicine hub. “There is insufficient evidence that such asynchronous care improves health outcomes, cost, and overall healthcare use,” they noted.
However, even for intra-practice communications between healthcare professionals, EHRs may not be the most efficient approach. “Face-to-face communication is associated with increased efficiency,” the researchers noted. “Whereas more electronic communication among team members leads to greater clinician and staff dissatisfaction, as well as poorer clinical outcomes and increased healthcare use among patients with coronary artery disease.”
EHR Cost/Benefits Generate Debate
This latest study is not the first to suggest that EHRs are creating problems for clinicians. While there appear to be no trends between studies, multiple researchers have highlighted the workload created by EHR systems in recent years.
In a study published in the Annals of Internal Medicine (AIM), Christine A. Sinsky, MD, of the American Medical Association, et al, analyzed data from the observation of 57 US-based physicians in family medicine, internal medicine, cardiology, and orthopedics.
Comparing data across 430 hours of observation, researchers concluded, “For every hour physicians provide direct clinical face time to patients, nearly two additional hours are spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another one to two hours of personal time each night doing additional computer and other clerical work.”
While medical laboratories and diagnostic specialists—such as anatomic pathologists—can work with physicians to streamline ordering and reporting processes relating to EHRs, much of the burden comes from how EHR systems are designed and used.
In a 2016 New England Journal of Medicine Catalyst Panel on EHRs, Tait Shanafelt, MD, Director of the Mayo Clinic Department Program on Physician Wellness, noted that one of the most contested features of EHR systems in the US, according to the AMA and Mayo Clinic, is computerized physician order entry (CPOE).
Later in the discussion, Sinsky discussed a recent trip to the UK, where she observed general practitioners (GPs) at the National Health Service (NHS). She noted that most GPs loved their EHRs. However, those EHRs were designed with GP input to best work with an NHS GP’s typical workflows and procedures. She also noted that overall usage is different in the UK, as EHRs there are not tied into billing systems.
As Dark Daily has reported, up to 70% of data stored in a patient’s electronic health record is clinical pathology laboratory related. As newer EHRs replace outdated models, it will remain critical for healthcare professionals—including clinical laboratory professionals who generate most of the data stored in EHRs—to assess, track, and report on what is working with various platforms and what is not.
Communicating this end-user data to EHR developers is essential to designing EHRs that reduce unneeded burden and clerical load on physicians, rather than increasing it.
Clinical laboratories tat wish to take proactive steps might contact physicians and other professionals in their workgroups to tailor data generation, reporting, and ordering processes to the EHRs in use at those practices.
No clear trend in pathology industry as to the demand for services versus the supply of pathologists
Healthcare providers often describe themselves at being part of a family of caregivers, and right now, one member, the physician, is under extreme pressure. So much so, experts are calling on other members of the family, such as pathology groups and clinical laboratories, to seek ways to proactively ease the burdens on America’s doctors.
A survey by the Physicians Foundation reveals that 80% of physicians reported being overextended or at capacity, with no time to see additional patients. And the number of physicians considering an early exit from patient-centered roles is increasing. If allowed to continue, such a trend will negatively impact patients’ access to care. (more…)
‘Care Studio’ is designed to give physicians a ‘single, centralized view’ of patients’ records that are spread among multiple disparate databases within a healthcare system
Lack of interoperability between electronic health records (EHRs) has been a thorn in the side of healthcare providers—including clinical laboratorians and pathologists—who have to search multiple healthcare organizations’ databases to pull together medical records on individual patients. Google Health claims it may have the answer to the longstanding issue of siloed patient records.
Google Health and St. Louis-based Ascension, one of the largest healthcare systems in the US, have announced the clinical pilot of their new Care Studio platform. The software tool, according to the Care Studio website, “leverages Google’s expertise in organizing information to help clinicians find health record information faster.
“The tool’s Clinical Search feature,” Google Health continues, “enables nurses and doctors to simply type what they’re looking for and quickly find the specific information requested—which might otherwise require significant time and effort to uncover.”
Essentially, Care Studio complements existing EHR systems and enables healthcare providers to quickly search and organize previously siloed patient healthcare data stored on multiple EHRs within a health system. If successful, such a tool would clearly help streamline physicians’ workflows and shave hours off their daily patient research.
According to Google Health, Care Studio is a cross-platform EHR tool that gives clinicians a “single, centralized view that brings forward a patient’s hospital visits, outpatient events, laboratory tests, medications and treatments, and progress notes.”
Gathered data then can be visualized in tables, graphs, and other formats.
“Using Google’s expertise in organizing complex information, Care Studio (above) provides a unified view of patient records, making them more accessible and useful for clinicians,” Peter Clardy, MD, Senior Clinical Specialist at Google Health, said in the launch video. “In Care Studio, you can browse and search through patient information.” Clinical laboratory test results will be included in these screen views. (Photo copyright: YouTube/Ascension.)
According to Medical Device Network, Google and Ascension originally introduced Care Studio to a small number of providers at Ascension’s Nashville and Jacksonville, Fla., locations. They are now expanding the pilot to more nurses and physicians working in clinical settings.
“So, why Google?” David Feinberg, MD (above), VP, Google Health, asked in a video announcement. “Google is really, really good at organizing information, and these electronic health records have amazing amounts of information. But they are unusable. So, we want to bring the functionality of Google—the way to kind of organize information—so doctors can spend more time holding your hand, looking into your eye, and having the difficult conversations with you instead of being data clerks. Part of that is allowing them to find the needle in the haystack in your medical record in seconds, instead of days.” This, of course, would include clinical laboratory test results, which make up 80% of all medical records. (Photo copyright: YouTube/Google Health.)
In a blog post, Eduardo Conrado, Executive Vice President, Strategy and Innovation at Ascension, wrote, “In current EHR systems, clinical information too often is buried in siloed records scattered across hospitals, clinics, urgent care centers, pharmacies, physician offices, labs, and other sites of care, making it challenging for physicians and caregivers to efficiently deliver coordinated and precise care.
“When information is finally retrieved from these disparate EHR systems,” he added, “it is usually poorly organized and fragmented. Most clinicians work in an environment where data is incomplete, inaccessible, and delivered in disjointed bursts of information without context.”
COVID-19 Accelerates Need for Improvements in Data Access
Conrado notes that the ability for clinicians to quickly retrieve and organize a patient’s complete clinical history is “the essence of delivering effective and efficient care.” He wrote that the “once-in-a-generation” COVID-19 pandemic has accelerated the need for improvements in public health infrastructure, health technology services, and care delivery models and “reinforced the significant impact that complex and often confusing EHR systems, and the fragmentation of patient health data, have on delivering effective care.”
While the collaboration between Ascension and Google began in 2018, Conrado said “remarkable” progress was made on Care Studio this past year.
Conrado did not state how long the clinical pilot of Care Studio would last but emphasized that the technology will be enhanced with additional features and improvements based on feedback from pilot clinicians. Ultimately, the clinical search tool will be made available to all caregivers across Ascension’s 2,600 sites of care, including 145 hospitals and more than 40 senior living facilities in 19 states and the District of Columbia.
Clinical laboratories should welcome this development. Any software tool or information technology that allows clinical laboratory test data to move across different EHRs will help interoperability.
