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Reclaiming Your Joy:
Strategies to increase
professional satisfaction in your
clinical practice
American College of PhysiciansNew Mexico Chapter Meeting
November 2, 2018
Suja Mathew, MD, FACPGovernor, ACP Northern Illinois
Practice Transformation Consultant,American Medical Association
Chair of Medicine,Cook County Health
Objectives
• Define burnout
• Identify the prevalence of burnout among
American physicians and the factors
correlating with low physician satisfaction
• Recognize consequences of physician
burnout on individual physicians,
organizations, and society
• Identify possible strategies to combat
physician burnout
No relevant financial
disclosures
Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life
balance in physicians and the general US working population between
2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613.
Percent of Physicians Who
Report “Burn-Out”100% ---------------------------------------
0% --------------------------------------
45% 54% ?
in 2011 in 2014 in 2018
Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance in
physicians and the general US working population between 2011 and 2014. Mayo Clin
Proc. 2015;90(12):1600-1613.
Physician vs Population
28 28
45
54
0
10
20
30
40
50
60
2011 2014
Burnout% 2011-2014
Population Physicians
55
63
49
41
0
10
20
30
40
50
60
70
2011 2014
Satisfaction% withWLB
Population Physician
Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance in physicians and the general US working
population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613.
Dissatisfaction
Disengagement
BURN
OUT
Not Quite the Same as Dissatisfaction or Disengagement
“I don’t like this”
“I don’t want to do this”
I Can’t Do This!
Three Components of Burnout
1. Emotional exhaustion*
2. Depersonalization, cynicism, or
dehumanization
3. Inefficacy, diminished sense of
personal accomplishment
Maslach C, Schaufeli WB, Leiter MP. Job burnout.
Annu Rev Psychol 2001;52:397-422.
Burnout in Action
• High turnover
• Difficulty recruiting
• Disruptive physician
behavior/complaints
• Lack of engagement in
QI/strategic projects
• Poor attendance at
staff meetings
• Flat refusal to see
patients
• Angry complaints about
work environment
• Disengagement with
low patient satisfaction
scores
• Demand for
compensation
DeChant, Paul, and Diane W. Shannon. Preventing Physician Burnout:
Curing the Chaos and Returning Joy to the Practice of Medicine.
CreateSpace Indepedent Publishing Platform, 2016.
Burnout May Cost US Healthcare
Physician burnout is associated with…
o More Referrals
o Increased Testing
o Fewer PCPs
o Higher rates of self-reported errors
o Longer post-
discharge
recovery time
http://petersonhealthcare.org/sites/default/files/images/media_library/Pet
erson%20Center%20on%20Healthcare_Stanford%20Overview.pdf
Social Science and Medicine 1999; (48):547-557
Family Practice doi:10.1093/fampra/cmt060.
Arch Intern Med. 2011;171(17):1582-1585
http://content.healthaffairs.org/content/29/5/835.full
Anagnostopoulos, F., et al. “Physician burnout and patient
satisfaction with consultation in primary health care settings:
evidence of relationships from a one-with-many design” J Clin
Psychol Med Settings, 2012.
Patient Safety
• Surgeons– Shanafelt (2010) found that 9% of surgeons
reported a major medical error in preceding 3 months, and they were significantly more likely to have symptoms of burnout
• Trainees– West (2006) showed that burned out residents
were more likely to make medical errors, by self-report
– Fahrenkopf (2008) found increased risk of medication errors among residents who were depressed of burned out
Burnout Costs Organizations
Physician burnout is associated with…o ↑ Malpractice risk
o ↓ Productivity
o ↑ Part time
o ↑ MD and staff turnover
Replace PCP costs $250,000 o (1999)
Shanafelt et al. Physician Burnout and Reductions in Professional Work Effort
Mayo Clinic Proc 2016;911(4):422-431Am J Man Care Nov 1999:5(11):1431-1438
Am J Man Care Jul 2001;7(7):701-713
BMC Health Services Research, 14(325).
Health Serv. Res. Oct 2004;39(5):1571-1588
Med. Care Mar 2006;44(3):234-242
Journal of Applied Psychology, Vol 73(4) Nov 1988, 722-735
http://psycnet.apa.org/?&fa=main.doiLanding&doi=10.1037/0021-9010.73.4.727
Health systems can’t perform well with widespread burnout
On organizational vitalityFreeborn DK. Satisfaction, commitment, and psychological well-being among HMO
physicians. West J Med 2001;174(1):13-18.
Williams ES et al. The relationship of organizational culture, stress, satisfaction, and
burnout with physician-reported error and suboptimal patient care: results from the
MEMO study. Health Care Manage Rev 2007;32(3):203-12.
Hinami K et al. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen
Intern Med 2011;27(1):28-36.
Hakanen JJ et al. The Job Demands-Resources model: a three-year cross-lagged study
of burnout, depression, commitment, and work engagement. Work & Stress
2008;22(3):224-41.
Dewa CS et al. How does burnout affect physician productivity? A systematic literature
review. BMC Health Serv Res 2014;14:325-35.
Dewa CS et al. An estimate of the cost of burnout on early retirement and reduction in
clinical hours of practicing physicians in Canada. BMC Health Serv Res 2014;14:254-63.
More Consequences of Physician Burnout…
Burnout affects Patients
Physician burnout is associated with…o Decreased Patient Adherence
o Less empathy
o ↓ Patient satisfaction
o Increased risk of patient changing providers
Sources: Dyrbye. JAMA 2011;305:2009-2010.; Murray, Montgomery, Chang, et al. J Gen Intern Med 2001;16:452–459.;
Landon, Reschovsky, Pham, Blumenthal. Med Care 2006;44:234–242.
Is the professional satisfaction of
general internists associated with
patient satisfaction?
Haas, J.S., Cook, E.F., Puopolo, A.L. et al. J GEN INTERN MED (2000)
15: 122. https://doi.org/10.1046/j.1525-1497.2000.02219.x
MAIN RESULTS: After adjustment, the patients of physicians who rated themselves
to be very or extremely satisfied with their work had higher scores for overall
satisfaction with their health care (regression coefficient 2.10; 95% confidence
interval 0.73–3.48), and for satisfaction with their most recent physician visit
(regression coefficient 1.23; 95% confidence interval 0.26–2.21). In addition,
younger patients, those with better overall health status, and those cared for by a
physician who worked part-time were significantly more likely to report better
satisfaction with both measures. Minority patients and those with managed care
insurance also reported lower overal satisfaction.
CONCLUSIONS: The patients of physicians who have higher professional
satisfaction may themselves be more satisfied with their care. Further research will
need to consider factors that may mediate the relation between patient and
physician satisfaction.
Burnout Costs Physicians
Physician burnout is associated with…
o ↑ Divorceo ↑ Substance abuseo ↑ Accidentso ↑ Death (Suicide 2-4 x)
Suicide Compared to Other Causes of Mortality in Physicians
Torre, Dario M.; Wang, Nae-Yuh; Meoni, Lucy A.; Young, J. Hunter; Klag, Michael J.; Ford,
Daniel E.
Suicide and Life-Threatening Behavior, v35 n2 p146-153 Apr 2005
Physicians frequently are early adopters of healthy behaviors based on their knowledge and
economic resources. The mortality patterns of physicians in the United States, particularly
suicide, have not been rigorously described for over a decade. Previous studies have shown
lower all-cause mortality among physicians yet reported conflicting results about cause-
specific mortality such as suicide. In this study, we compared all-cause and cause-specific
mortality in a sample of physicians to the age-gender matched general U.S. population from
1948 through 1998. We also compared the mortality experience across medical specialities.
The risk of all-cause mortality was 56% lower than expected in men,
and 26% lower in women, compared to the general population. Standardized mortality ratios (SMRs) were markedly lower for diseases strongly linked to
smoking, e.g., cardiovascular diseases, respiratory diseases, and lung cancer. Suicide
was the only cause of death where risk was greater than the general
population. Overall, we found that physicians are at substantially lower risk of dying
compared to the general population for all causes of death except suicide. The findings for
suicide are strikingly different than other causes of death and should provide impetus for new
research on the mental health of physicians.
More Consequences of Physician Burnout…
On Physician HealthWest CP, Tan AD, Shanafelt TD. Association of resident fatigue and distress with occupational blood and body fluid exposures and motor vehicle incidents. Mayo ClinProc. 2012;87(12):1138-1144.
Firth-Cozens J. Individual and organizational predictors of depression in general practitioners. Br J Gen Pract 1998;48:1647-51.
Frank E et al. Self-reported depression and suicide attempts among US women physicians. Am J Psychiatry 1999;156:1887-94.
Graham J et al. How hospital consultants cope with stress at work: implications for their mental health. Stress Health 2001;17:85-89.
Sargent MC et al. Stress and coping among orthopaedic surgery residents and faculty. J Bone Joint Surg Am 2004;86:1579-86.
Hakanen JJ et al. The Job Demands-Resources model: a three-year cross-lagged study of burnout, depression, commitment, and work engagement. Work & Stress 2008;22(3):224-41.
Ruitenburg MM et al. The prevalence of common mental disorders among hospital physicians and their association with self-reported work ability: a cross-sectional study. BMC Health Serv Res 2012;12:292-8.
The Doctor 1891 Fildes
The Doctor 2016
Why Does Burnout Happen?
• Result of Interaction
between
– the worker and
– the workplace
• Highly motivated
professional into a
dysfunctional workplace
where unable to succeed
without constant vigilance
and focus
• Unstainable => Toxicity
Worker
Workplace
Adapted from Maslach, 2001
Maslach’s Burnout-Engagement
Spectrum
Negative Positive
Burnout JOY
(Work Engagement)
Exhaustion Energy
Depersonalization Involvement
Inefficacy Efficacy
Adapted from Maslach, C. Engagement research: Some thoughts from a
burnout perspective. European Journal of Work and Organizational
Psychology, 2011;20(1): 47-52.
Quadruple AimExpanding theTriple Aim
Bodenheimer and Sinsky. From Triple to Quadruple
Aim: Care of the Patient Requires Care of the
Provider. Ann Fam Med 2014
Mark Linzer 2016, personal communication
Burnout Spectrum
Clinica Family
Health Services
Group Health Olympia
Multnomah
County Health
Dept
South Central
Foundation
Univ of Utah-
RedstoneNewport News
Family Practice
Cleveland Clinic-
Strongsville
Quincy, Office of
the Future
West Los Angeles-
VA
La Clinica de
la Raza
Clinic Ole
Sebastopol
Community
Health
Martin’s Point-
Evergreen Woods
Harvard Vanguard
Medford Brigham and
Women’s
Hospital
North Shore
Physicians GroupMedical Associates
Clinic
Mercy Clinics
ThedaCare
Fairview Rosemont
Clinic
Mayo Red Cedar
Medical Center
Allina
Site visits to 23 high-
performing practices
(most PCMHs)
Mass. General
Hospital
Joy in Practice
Workflow
Task distribution
Physical space
Technology
Shanafelt TD, Boone S, Tan L, et al. Interventions to prevent and reduce
physician burnout: a systematic review and meta-analysis. Lancet.
2016;388(10057):2272-2281.
Drivers of Burnout
Work overload
Chaotic work environment
Time pressure
Loss of Control
Insufficient reward
Breakdown of community
Absence of fairness
Conflicting valuesLinzer, M: J Gen Intern Med. 2014 Jan; 29(1): 18–20.
Maslach, C., & Leiter, M. P. (1997). The truth
about burnout: How organizations cause
personal stress and what to do about it. San
Francisco, CA: Jossey-Bass
6
3
0
Medscape 2018
How Ambulatory Physicians
Spend Our Time
27% Direct clinical face time
73% Administrative, non-clinical tasks
38.5% EMR
documentation and review
19.1% Administrative
tasks related to
insurance or biling
10.7% EMR review
of test results,
medication and
other orders
6.1% Logistical
arrangements,
clinical planningSinsky C. et al, “Allocation of Physician Time in Ambulatory Practice:
A Time and Motion Study in 4 Specialties.” Annals of
Internal Medicine, 165. 11 (2016): 753-761.
Save 3-5 hours/day
• Team doc/dictation to transcription 1-2 hr
• Expanded rooming/discharge 1 hr
• Pre-visit lab ½ hr
• Prescription management ½ hr
• Optimize physical space 1 hr
• Automatic log in ¼ hr
• Paper/verbal order entry ½ hr
3+ hr/d
ER
• 10 hr shift
• 44% data entry
• 4000 clicks
• 28% patient
PCPs
• 11 hr day
• 50% computer– COE, inbox
• 20% patient– 1/3 screen
gaze*
4000 Clicks per day
Am J Emerg Med 2014;31(11):1591-1594
*Int J Med Inform 2014; 83: 225–34.
EHRs (esp. CPOE) Burnout
• 44% dissatisfied with EHR
• 63% “EHRs make my work less efficient”
• Nearly half: “Spend too much time on clerical tasks”
• 41%: “EHRs did not improve care”
• EHR/CPOE use assoc with burnout (59% v 45% p <0.005)
• http://www.mayoclinicproceedings.org/article/S0025-6196(16)30215-
4/pdf
“American physicians have become the
most expensive data entry work force on the
face of the planet.”
https://www.youtube.com/watch?v=RbWgJIOWQmQ&feature=youtu.be
Work after Work:Evidence From PCP Utilization of an EHR System
Brian Arndt, MD; John Beasley, MD; Jon Temte, MD PhD; Wen-Jan Tuan, MS MPH; Valerie Gilchrist, MDUniversity of Wisconsin Department of Family Medicine and Community Health
Context
There is growing evidence related to EHR systems adoption and their impact on quality and safety of healthcare services
Less is known about EHR-related workload impact on primary care physicians (PCP) including:
When do physicians complete their work in the EHR (i.e., during work hours or after hours)?
How much physician work in the EHR is related to face-to-face vs non-face-to-face patient care?Objective
To assess usage patterns of PCPs interacting with an EHR system during and after work hours (“workhours” = 8:00 am – 6:00 pm Monday - Friday)
Design
Retrospective cohort study from 1/1/13-6/30/15
System access logs were extracted to compute PCP time spent on various face-to-face and non-face-to-face tasks
A fuzzy matching model was used to restructure physicians’ tasks into events, segments, and sessions in a hierarchical manner to depict each physician’s EHR interactions:
Conclusions
For most patient care activities there is substantial time spent by physicians in the EHR after hours
Physicians spend most time in the EHR doing documentation (33.9%)
Physicians spend at least 23.5% of EHR time doing non-face-to-face work
The study did not account for the additional physician time spent on EHR systems outside UW Health
Future analysis is needed to examine the association between EHR workload, job satisfaction, work RVUs (or other measures of efficiency), quality outcomes, and care team function including communication style (in-person vs electronic)
This research enhances understanding of PCP workload and may influence development of policy, reimbursement models, and primary care redesign
Results
The EHR access logs of 130 family physicians from 18 primary care clinics were analyzed
Physician time spent on EHR differs between face-to-face and non-face-to-face patient care activities
Average Time per Individual Encounter TypeAverage Time by Encounter Type per Month
(NORMALIZED 1.0 FTE – 100% CLINICIAN)
Physician time spent on EHR differs by task type and day of the week (weekday vs weekend)
Category Level N %
Sex Female 55 54.5
Male 46 45.5
Residency Clinic No 66 65.3
Yes 35 34.7
Years of Practice 0-5 4 4.0
6-10 23 22.8
11-15 16 15.8
16+ 58 57.4
Direct Clinical Care FTE 0.90-1.0 27 26.7
0.70-0.89 26 25.7
0.50-0.69 21 20.8
0.30-0.49 19 18.8
<0.30 8 7.9
Precepting No 70 69.3
Yes 31 30.7
Over 160,000 unique patient records analyzed
Category Level N %
Sex Female 85,279 51.6
Male 80,115 48.4
Age Group 0-5 7,622 4.6
6-17 20,069 12.1
18-64 119,803 72.4
65-79 13,844 8.4
80+ 4,059 2.5
Race/Ethnicity White, non-Hispanic 137,377 83.1
Black, non-Hispanic 7,283 4.4
Hispanic 7,273 4.4
Native American 567 0.3
Asian 4,454 2.7
Other 8,446 5.1
Payer Category Commercial 101,754 61.5
Medicare 17,829 10.8
Medicaid 12,224 7.4
Uninsured/Unknown 33,592 20.3
Language Preference English 161,462 97.6
Spanish 2,614 0.8
Other 1,323 1.6
-
2
4
6
8
10
1 4 7 10 13 16 19 22
% o
f to
tal
acce
ss
Hour of day
Average Time by EHR Task per Month
(NORMALIZED 1.0 FTE – 100% CLINICIAN)EHR Usage Frequency by Time of Day
Date Time Metric Type Metric
ID Metric Name Description Patient Name
12/17/2014 9:05:10 CONNECTION EVENTS 14010 Login
12/17/2014 9:08:01 PATIENT CLINICAL INFO 20620 AC_VISIT_NAVIGATOR AUTAUD,TEST
12/17/2014 9:08:02 PATIENT CLINICAL INFO 17133 MR_VN_CONTACTS Visit Navigator Contacts section initialized. AUTAUD,TEST
12/17/2014 9:08:03 PATIENT CLINICAL INFO 17124 MR_CHIEF_COMPLAINT Visit Navigator Chief Complaint section initializ AUTAUD,TEST
12/17/2014 9:08:03 PATIENT CLINICAL INFO 17117 MR_ENC_SMARTSETS Smartsets activity selected for patient. AUTAUD,TEST
12/17/2014 9:08:03 PATIENT CLINICAL INFO 49008 FLOWSHEET VN Flowsheet section is accessed. AUTAUD,TEST
12/17/2014 9:08:03 PATIENT CLINICAL INFO 17104 MR_ENC_ENCOUNTER A Navigator for a patient encounter opened. AUTAUD,TEST
12/17/2014 9:08:04 PATIENT CLINICAL INFO 17106 MR_MEDICATIONS Medications activity accessed. AUTAUD,TEST
12/17/2014 9:08:15 PATIENT ORDERS 17108 MR_ENC_ORDERS Order Entry activity accessed. AUTAUD,TEST
12/17/2014 9:08:40 PATIENT CLINICAL INFO 17148 MR_COMM_MGT Communication Management Section of the Visit AUTAUD,TEST
Study Clinician Characteristics
Note: Clinician statistics were based on UW Health’s December 2014 panel
data.
Note: Panel statistics were based on UW Health’s December 2014 panel
data. Patients had a PCP at the study clinics.
More than 63.6 million EHR system accessing log records were extracted
# of
Encounter
s
# of
Sessions
Total EHR
Duration –
Workhours and
(%)
Total EHR Duration
– Afterhours and
(%)
3,493,423 277,497274,957 hr
(83.6%)53,335 hr (16.4%)
Study Panel Characteristics
Office…
Phon…
Hosp…
Char…
OBv…
Order…
MyC…
Medr…
Off-s…
Clinic…
Letter…
Workhours
Afterhours
- 1 2 3 4 5 6 7 8 9 10 11 12 13
Avera
ge h
ours
per
month
Wo…90
>
15%
15%41%
21%14%25%21%11%31%18%36%
83.515.2
Office…
OBv…
Hosp…
Off-s…
Clinic…
Phon…
Order…
MyC…
Char…
Medr…
Letter…
Workhours
Afterhours
- 5 10 15 20
Avera
ge m
inute
s
W…
15%12%
41%33%
17%14%22%19%18%11%27%
Docu-me…
Chartrev…
In-Basket
Order
Entry
Chartrev…
MyChar…
Systems…
Problemlist
Chartrev…
Admin-istr…
Phonecall
Chartrev…
Lettercre…
Clinicalr…
Billingand…
Workhours
Aferhours
- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Ave
rag
e h
ou
rs p
er
mo
nth
W…>501
8
%1
7
%
1
7
%1
2
%
1
2
%
1
3
%
2
3
%
2
1
%
1
9
%
2
0
%
1
4
%
1
6
%
2
2
%
6
%
3
8
%
47.323.322.519.4
% of Total33.916.515.96.912.92.52.82.31.91.70.50.70.20.10.1
Setting / Participants
130 family physicians (average experience 19.4 years) from 18 clinics (4 residency, 14 community) managed by the University of Wisconsin Department of Family Medicine and Community Health
32 hours
Work after Work
per month 1 full week/mo
“Pajama Time”
Sat nights belong to Epic
Date
night
Week
nights
1-2
hr/nig
ht
• Downing NL, Bates DW, Longhurst CA. Physician Burnout in the
Electronic Health Record Era: Are We Ignoring the Real Cause?. Ann
Intern Med. ;169:50–51. doi: 10.7326/M18-0139
/wEPDwUJ2173C2F0/wEdABVly0J90Annals of I255AIMSearch Thihttp://annalTruetruetruefalse
AnnFamMed study results(taken verbatim)
Clinicians spent 355 minutes (5.9 hours) of an 11.4-hour workday in the EHR
per weekday per 1.0 clinical full-time equivalent: 269 minutes (4.5 hours) during
clinic hours and 86 minutes (1.4 hours) after clinic hours.
Clerical and administrative tasks including documentation, order entry, billing
and coding, and system security accounted for nearly one-half of the total EHR
time (157 minutes, 44.2%).
Inbox management accounted for another 85 minutes (23.7%).
Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: Primary Care
Physician Workload Assessment Using EHR Event Log Data and Time-Motion
Observations. Ann Fam Med. 2017;15(5):419-426.
Scribes: What’s all the fuss?
• The fastest growing medical field
– Nearly 20% of physicians now use scribes
– 10% plan on hiring scribes in the near future
• May enhance physician efficiency,
improve physician satisfaction, and
increase billing.
Gold J, “Scribes are the Fastest Growing Medical Field and Providers are Concerned,” The Doctor Weighs In, June 1, 2017, https:
//thedoctorweighsin.com/scirbes-are-the-fastest-growing-medical-field-and-providers-are-concerned/.
AMA On-line Calculators
https://www.stepsforward.org/modules/team-
documentation#
• Improved patient-physician interaction
• Improved documentation
JGIM 2016
Adjusted MA Role
Before MD
• Rooms
patient
• Collects and
documents
SH,ROS, etc
• Updates
background
info
With MD
• Presents
info to MD
• MD has
direct
conversation
After MD
• Scribes
remainder of
visit
• Enters
orders
• Reviews
plan
Team Documentation
Cleveland Clinic
• Pre-visit (MA)
– Med Rec
– Agenda, HPI
• Visit (MA + MD)
– med,lab, x-ray orders
– followup
• Post-visit (MA)
– Reviews visit summary
– Health coaching
• MD next patient
Team Documentation
Cleveland Clinic
• New Model
– 2 MA: 1 MD
– 2 pt/d cover cost
– 21 → 28 visits/d
– 30% ↑ revenue
– Spread to others
– “We’re having FUN”
• Research
– More F2F time (p <.001) Am J Med 2015 128(9):1025-1028
– Q doc as good or better J Fam Pract 2016
I used to spend an hour or two in the evening
after my family went to bed completing my
charts for the day. I haven’t logged on from
home in so long, I’ve forgotten how to use
the remote access system.
Kevin Hopkins M.D.
The MA’s are more fully engaged in
patient care than they have ever been and
they enjoy their work…They have
increased knowledge about medical care in
general and about their individual patients
in particular.
Kevin Hopkins M.D.
Team Documentation
Bellin Health Green Bay
Pre Post
Very
Dissatisfied/D
issatisfied
42% 0%
Neutral 24% 14%
Satisfied/Very
Satisfied
34% 86%
How satisfied are you in
your role?
Voice recognition software
• Useful, but
technology is still
early
• Most impactful for
those who struggle
with typing
The Medical Group Leader’s EMR Optimization Playbook.
https://www.advisory.com/research/medical-group-strategy-council/white-
papers/2018/the-medical-group-leaders-emr-optimization-
playbook?WT.ac=GrayBoxM_MGSC_ResRep_x_x_x_PN_2018Oct17_Eloqua-
RMKTG+Blog
• Stanford Children’s
Health
– Used by 12 out of 200
• Universal health
Services (King of
Prussia, PA)
– 60% reduction in
transcription costs
– 36% improved
documentation of
severity of illness
Other EMR shortcuts
• Templates
• Auto-text
• Smart phrases
– .risk
– .lastweight
– .lastbp
• Sticky notes
– Remember family
member names,
favorite vacations
• Many EMRs can track
time and performance
variables
Medscape 2018
MedicationRefill
Chronic Disease
Management
PROVIDER
Test Results
AcuteVisits
PreventativeVisits
Patient Orders/Triage
RNCMA/LPN
Referral to Specialist
Referral to Ancillary Services
Managing Messages, Test Results, Calling
Patients
Paper Work
OLD MODEL OF PATIENT CARE
54
Redistribute Work Strategically
• “Instead of sending all the work to the most
highly trained person to distribute…think about
how the work can be distributed before it gets to
the most highly trained person.”
– Bruce Bagley 4/1/16 AMA Wire
Real team-based care
Daily Huddles
South Huntington BWH
Daily Huddles
• 5-10 minutes long
• All team members present
• Set out the plan for the day
– Patients requiring additional attention
– Problems with supplies
– Room set up needs
– Etc.
Pre-visit Planning
• Review last note and ensure testing is
complete
• Use registry or pre-visit checklist to identify
gaps in care
• Remind patients of appointments and what
to bring
Mayo-Red Cedar arranges for pre-visit lab
Rooming Protocols
• Identify the reason for the visit and help the patient set
the visit agenda
• Perform medication reconciliation
• Screen for conditions based on protocols
• Update past medical, family and social history
• Provide immunizations based on standing orders
• Arrange for preventive services based on standing
orders
• Assemble medical equipment, if needed, before the
physician enters the exam room https://www.stepsforward.org/modules/patient-discharge-and-rooming
Discharge Protocols
• Print and review an updated medication
list and visit summary
• Reiterate to patients the medical
instructions prescribed by the physician
• Coordinate the next steps of care
https://www.stepsforward.org/modules/patient-discharge-and-rooming
County Case Study
Neurology clinic
100 inbox messages per day
Information Overload
Daily Inbox Messages
0
10
20
30
40
50
60
70
80
Num
ber
of M
esag
es
Type of Physician
Number of Messages per day
PCPs
Specialists
Murphy, Daniel R. et al. “The Burden of Inbox Notifications
in Commercial Electronic Health Records.”
JAMA internal medicine 176.4 (2016): 559–560. PMC.
Inbox Restructuring
• Engage IT
• Track current messages to determine volume
• Identify messages that can be rerouted
– Daily PN for hospitalized patients
– Routine PT notes
– Lab results ordered by consultants
– Refill request
– Pre-visit labs initial results
• Create a team pool inbox https://www.stepsforward.org/modules/ehr-inbasket-
management#
Fairview: Filtering Inbox
Reduce inbox time 90min/d to few min
County Case Study
General Medicine Clinic
More Time Wasters
• Refill prescriptions outside of visit
• Refill prescriptions q 3 mo rather q15
• Ordering lab between visits
• Processing phone/email request for
referral for eye exam, mammogram
• Calling patients back for results reporting
• Calling other physicians for office notes
Annual Prescription Renewals
• “90 + 4”
• Physician time
– 0.5 hr/d
• Nursing time
– 1 hr/d per physician
Point of Care Testing
0
20
40
60
80
100
Tests ordered perpatient
Re-visits Follow-up phonecalls
Follow-up letters
Metrics before and after implementation of POC(HgA1c, lipids, metabolic panel)
After POC Before POC
Crocker B, Lewandrowski E,
Lewandrowski N, Gregory K,
Lewandrowski K. Patient
Satisfaction With Point-of-Care
Laboratory Testing: Report of a
Quality Improvement Program in
an Ambulatory Practice of an
Academic Medical Center. Clin
Chem Acta 2013; 424:8-12.
Pre-visit Labs
• 89% ↓ phone calls (p<0.001)
• 85% ↓ letters (p<0.0001)
• 61% ↓ additional visits (p<0.001)
• 21% ↓ tests ordered (p<0.0001)
• ↑ patient satisfaction
• Saved $26/visit
• Crocker B, Lewandrowski E, Lewandrowski N, Gregory K, Lewandrowski K. Patient
Satisfaction With Point-of-Care Laboratory Testing: Report of a Quality Improvement
Program in an Ambulatory Practice of an Academic Medical Center. Clin Chem Acta
2013; 424:8-12.; and personal communication/poster 3.4.14
Same day pre-visit lab (15 min)
ThedaCare
www.stepsforward.org
• Teams
– Expanded rooming
– Team documentation
– Prescription management
– Pre-visit planning/lab
– Team meetings
– Daily huddles
• Culture
– Preventing Burnout
– Resiliency
– Wellness in Residency
– Transforming culture
Transformation Toolkits
• Value
– Panel management
– Medication adherence
– Burnout Prevention
– Diabetes prevention
– Hypertension
• Technology
– Telemedicine
– EHR implementation
The Doctor 2016
The Doctor 1891 Fildes
