Clinician burnout: a hot topic and getting hotter. Are electronic medical records fuelling the fire? Mike South , Paediatrician & Chief Medical Information Officer
Clinician burnout: a hot topic and getting hotter. Are electronic medical records fuelling the fire? 1. Clinician Burnout 2. The impact of computers 3. The impact of Electronic Medical Records 4. What can we do as players in the Health IT space?
Participant poll 1 A. Doctor B. Nurse C. Allied Health D. Manager E. Hospital/Primary Care: IT / EMR / Informatics F. Industry G. Other
Burnout: a brief history 1961
Burnout: a brief history 1971 US air traffic controllers were commonly reporting “ vocational ‘burn out ,’ a form of exhaustion, which is manifested in a decline in quantity and quality of work production.” After several fatal mid-air collisions due to human error the FAA commissioned a study of 416 air traffic controllers over 3 years Rose RM, Jenkins CD, Hurst MW. Air traffic controller health change study. Reportprepared by Boston University School of Medicine for US Dept of Transportation, FAA Office of Aviation Medicine: 1978. Report No. FAA AM-78/39.
Burnout: a brief history More competent individuals Burnout was not simply a failure of personal resilience: most air traffic controllers had experienced military service and had dealt with extremely challenging conditions. The paradox here: workers who strive hardest to meet internal and external professional ideals may increase their risk of burnout, which then contributes to them falling short of these professional ideals .
Burnout: a brief history Particularly pertinent to caring professionals. Still conceptualised as particularly affecting those in emotionally demanding professional roles Herbert Freudenberger
Burnout: in the literature Last 12 months: “Burnout” 123 Million hits “ Burnout - "car“ ” ~125,000 hits “Burnout” 18,700 articles Medline
2019 Medline Examples Effects of a resiliency program on burnout and resiliency in family medicine residents. Clinician burnout and its association with team based care in the Emergency Department. Physical discomfort, professional satisfaction, and burnout in vascular surgeons. The Relationships between Problem-Solving, Creativity, and Job Burnout in Iranian Occupational Therapists .
Burnout: a medical diagnosis? No DSM-5 No mention of burnout ICD11 (2022) “Factors influencing health status” Notes Framing it as a medical diagnosis may be counterproductive Not a diagnosis therefore not accepted in workplace compensation / insurance claims
Participant poll 2 A. No burnout B. Under stress C. Feeling burned out sometimes D. Feeling burned out most of the time E. Completely burned out
Burnout: so what is it? No 100% agreed definition Many descriptions Common definition:
Prevalence Higher in women Higher in younger doctors Higher in high acuity specialties
Is clinician burnout a big topic in Australia?
2013 n= 14,000 2% attempted suicide
Participant poll 2 A. No burnout B. Under stress C. Feeling burned out sometimes D. Feeling burned out most of the time E. Completely burned out
RCH Burnout Survey
Burnout: Discussion
Clinician burnout: a hot topic and getting hotter. Are electronic medical records fuelling the fire? 1. Clinician Burnout 2. The impact of computers 3. The impact of Electronic Medical Records 4. What can we do as players in the Health IT space?
Don’t just sit there!
? Alternate sitting / standing
Death By 1,000 Clicks: Where Electronic Health Records Went Wrong The U.S. government claimed that turning American medical charts into electronic records would make health care better, safer and cheaper. Ten years and $36 billion later, the system is an unholy mess. Inside a digital revolution that took a bad turn.
The Doctor 1891 Luke Fildes
Is clinician burnout a big topic in Australia? Is the use of EMRs commonly cited as a contributing factor in Australia?
USA RCH
Abraham Verghese, New York Times Magazine , May 16, 2018
11.5
Large international benchmarking survey ~100,000 clinician respondents All EMR systems RCH 1,067 respondents (23% active users)
RCH Staff Satisfaction Satisfied / highly satisfied 92% – All 93% - Nurses 92% - Allied Health 89% - Doctors 85% - Consultants 94% - Trainees
RCH in top 10% for many items Net EMR experience RCH the top non-US hospital for overall user satisfaction
So what is going on here? Same EMR system
So what is going on here? “Note Bloat”
Documentation - clinics
So what is going on here? USA RCH Problem: Abdominal pain Abdo pain • RLQ The problem has been getting • Sharp worse. The pain is in the Right • getting worse Lower Quadrant. The pain is • Now 8/10 currently at a severity level of • Febrile 8/10. The quality of the pain is sharp. Associated symptoms currently include fever We actively encourage this style Epic Note Writer tools reconfigured
So what is going on here? “Time - saving” tools Transcription Voice recognition Scribes Copy Forward into notes
So what is going on here? USA - Documentation driven by something other than clinical care?
So what is going on here? Compliance Documentation Revenue Anticipating litigation Perfunctory
So what is going on here? C ompliance Documentation R evenue A nticipating litigation P erfunctory
What is the documentation in a note for? Australia USA Clinical care The documentation seems to serve many non-clinical purposes. At RCH – no staff other than clinicians look at the outpatient Clinical care often seems to be a notes. secondary purpose (Patients and families) There are strong drivers for There are minimal drivers for clinicians to document more clinicians to document anything more than what is needed for good clinical care
It’s not just documentation Inbasket Messages
It’s not just documentation We also do much less Ordering Linking orders to diagnoses Co-signing orders Attesting trainees notes Marking things as “reviewed”
It’s not just documentation We also do much less Alerting – drug and other warnings Average US Epic hospital displays drug alerts 6 times RCH rate (RCH 1/11, some US hospitals >1/1) US Many more non-drug alerts +++
New drug analogy Method A Method B Good theoretical basis Good theoretical basis Introduced into practice Pilot studies promising No monitoring Randomised trials Outcome Outcome Efficacy unknown Efficacy found to be limited Headache Headache Chronic fatigue Chronic fatigue
? Something missing
? Now you're in New York These streets will make you feel brand new Big lights will inspire you Let's hear it for New York, New York, New York
So – what is to be done? Maintain the clinical focus for notes Avoid attempts to drive CRAP documentation Hands off our medical record!!! Encourage concise clear clinical note keeping Only ask clinicians to do tasks that add value in their eyes Be very careful about alerts etc Rigorous informatics methodology Clinicians involved +++
Conclusion
Scribes Private Practice software 24/7
Medical Records in Mesopotamia Iraq and parts of Iran, Syria and Turkey. >5000 years ago. Scribes ICD -5000BC ?
24-50% error rate
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