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The Killing Paradox:EHRs, Burnout, and Paradoxes of Choice
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Seung Park, MD // Emily Webber, MD
CHIO, IU Health // CMIO, Riley Children’s Health
DISCLAIMER: The views, opinions and images expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Session #PE3, 9 March 2020 // Session #337, 13 March 2020
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Meet Our Speakers
Seung Park, MD Emily Webber, MD
Conflict of Interest
Seung Park, MD and Emily Webber, MD have no real or apparent conflicts of
interest to report.
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Agenda: One Story, Five Chapters
• Prologue / Chapter 1: More Is Less
• Chapter 2: You Get What You Govern
• Chapter 3: Beyond The EHR
• Chapter 4: Less Is More
• Epilogue / Chapter 5: This Is Our Story
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Learning Objectives
• Define the Paradox of Choice and enumerate its consequences on EMR/EHR
design and end-user acceptance
• Illustrate the importance of C-suite buy-in and advocacy in large-scale
cultural change
• Analyze the positive and negative characteristics of the culture around the
EMR at your institution, and create strategies toward a fully standardized,
end-user-accepted build
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Prologue / Chapter 1
More Is Less
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Our Story: Where We Were
• In 2017, IU Health had:
• The single slowest EHR install (according to the vendor) in the entire world
• Regular unplanned downtimes
• Extreme variability of EHR governance, to the point where individuals could submit
tickets detailing major EHR enhancement projects and have them accepted
• The highest burden of alerts in the entire world
• 967 required data elements in the standard nursing intake assessment
• Epidemic-level clinician burnout
• Clearly this is an undesirable state
• But how did we arrive at such a state to begin with?
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What Do Blue Jeans Have To Do With It?
More (or less) than you’d think …
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VS
Trust Loops and Burnout
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Broad Agreement in the UX-Related Literature
• Alerts
• Testing methodologies, especially with multiple choice tests
• Study-in-a-vacuum vs. study-as-a-system
• EMR optimization projects as reported in the Informatics literature
• Google and its homepage UX studies
• The purchasing characteristics of those who build their own computers vs.
those who buy computers off the shelf
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On Clinician Burnout
• What “lacks” contribute to clinician burnout in relation to the EMR?
• Lack of adequate “player trust loop”
• Lack of best known ways or known good ways to accomplish clinical tasks, leading
to workarounds
• Lack of adequate elbow support
• What “too many’s” contribute to clinician burnout in relation to the EMR?
• Too many alerts and interruptions
• Too many EMR actions required to perform a single clinical action
• Too many points of cognitive burden
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This All Boils Down To Too Much Choice Within The EMR!
I was the poster child for the perpetually frustrated, demoralized practitioner, and if I’m being completely honest, was finding it harder and harder to see any kind of long-term future with IU based on the sacrifices that I was making in my personal life to get work done.
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Wyatt Horsely, MD
Primary Care Physician, IU Health Physicians
Chapter 2You Get What You
Govern
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Shared Vision,Shared Goals
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Marie Kondo™
Everything
Refocus, Exnovate, Innovate
Let Clinicians Drive
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From Reactive Governance …
Change requests overwhelmed capacity; IS saddled with
prioritization
Default to customization
solution
Lack of accountability to outcomes
Individual preference
… To Governance Focused on Alignment and Reduced Variation
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Clinical + Informatics + IS
leadership
Reversion to model EMR settings
Clear “No” when capacity or conflict
with guiding principles
Identify warranted variation and true
gaps
Governance focused priorities,
change management and
implementation
Consistent
outcomes, more
agile change!
An Example In Alerts
• Objectives
• Decreased volume of alerts
• Increased measurable outcomes of alerts
• Increased alert acceptance
• Processes
• Remove or curate alerts: EXNOVATE
• Disciplined review of alert performance and taxonomy: DECREASE REQUESTING BODIES
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VS
Methods And Process
• Alert reduction strategy was deployed beginning in 2017
• Alerts were inactivated after evaluation of clinical workflow impact
• Overall alert efficacy was monitored for overall acceptance rates
• Specific alert efficacy (desired behaviors) monitoring:
1. Dose range checking
2. Situational awareness alerts
3. Medication reconciliation reminders
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• Decreasing the average
number of alerts each provider sees correlates with increased
alert acceptance
• The “right” alert is a
combination of consideration of
the venue, the patient, and the
actions being provided – one
size does not fit all
• No alerts without a SMART goal
A Moment To Reflect
It’s much better than two weeks ago when I thought there was no chance. It’s been faster as time goes on.
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Wesley Ratliff, MD
Pulmonologist, Southern Indiana Physicians
Chapter 3Beyond The EHR
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What’s Good for the Goose …
• A ruthless minimization of the EHR will only take you so far
• Our interactions with our work – and with our healthcare systems – largely
take place outside of the confines of any one given system
• It is the aggregate of these systems that defines the experience
• ERP
• RTLS
• Two-factor authentication and other Information Security systems
• Secure Text Messaging
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On Text Communications
• While the industry has been moving toward pager replacement, this has
been slow
• There are at least 5 different pathways at play here:
• One-way communication
• Point-to-point two-way communication
• Team-based provider-centric communication
• Team-based patient-centric communication
• Blast communication
• Traditionally we’ve done all of these pathways without much oversight!
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Our Road Paved With Good Intentions
• Massive proliferation of systems both explicitly and implicitly associated with
paging and texting
• Too many choices, all of which were honored
• This is how a certain waste management vendor somehow got involved in our
secure text messaging strategy
• “It all just works” via a web of non-secure and non-hardened systems that no
one could catalog or understand
• Then, in 2019 …
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Clawing Our Way Back
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Define the Battlefield Govern the Troops Win Hearts and Minds
total replacement of pagers,
text messaging, and all
homegrown systems with a
single enterprise solution
and
development of a taxonomy of
message-driven workflows, and
a promulgation of Ruthless
Minimalism™ in that taxonomy
utilization of our CC-TC-TT
governance councils to drive
the pathways, and to lead
change control
and
everyone gets a voice, but no
one gets a choice when the
mission and the strategy make
the direction clear
focus on the drops in patient
care, as well as time spent by
clinicians and ancillary staff
alike in figuring out just how to
get ahold of individuals
and
accentuate every positive
while reminding of the clear
and present danger to patients
The beauty of [our unified secure messaging system] over pager numbers is operators can easily look up [messaging IDs] for new docs – we don’t need anyone to send us that info. You can’t even imagine what an improvement this is over chasing down pager numbers.
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Greg Willett
Director, IU Health Revenue Cycle Services and Transfer Center
Chapter 4Less Is More
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Our Story:EHR Speed
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Average Transaction Response Time (ATRT)
IUH Benchmark Top 20%
Our Story:Adoption of the Cutting Edge
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0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
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90.00%
100.00%
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Documentation Method
Clinical Notes Dynamic Documentation PowerNotes Transcription
Our Story:Alert No More
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65.00%
70.00%
75.00%
80.00%
85.00%
90.00%
95.00%
-
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
Alerts
Alerts Fired Override Rate
Our Story:Text Messaging
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Oh, And Three Last Things
1. Physician burnout (as measured by the Mayo Clinician Wellness Index) went
down from 2.37 to 1.99 (a 40 basis point drop)
2. In September 2019, we converted a major Ambulatory EHR build (major
vendor) to our enterprise EHR build (other major vendor)
• … with high end-user engagement and satisfaction
• … with many end-users approaching baseline productivity 2 weeks after go-live
• … with charges and bills appropriately dropping over 98% of the time, 2 weeks
after go-live
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Yes, I still get behind at times, but there has been such a dramatic improvement. My patient care has improved, my marriage has improved, my relationship with my kids has improved, I feel hopeful and excited for my future with IU.
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Wyatt Horsely, MD
Primary Care Physician, IU Health Physicians
Epilogue / Chapter 5This Is Our Story
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The End Is Not Yet Written
• We are happy to make all of the artifacts of our journey to date available to
you
• Just come up and ask!
• We are stronger together
• Partner with us and let us share the burdens of this road together
• We are not yet where we want to be
• We would love to learn from you
• The endless and malignant victim loop must end
• This is our story and we get to decide how it ends
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Questions
• Seung Park, MDChief Health Information Officer
Indiana University Health
• Emily Webber, MD
Chief Medical Information Officer
Riley Children’s Health
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