Physician Burnout

CHIME Interview Series: Brian D. Patty, VP, CMIO, Clinical Information Systems, Rush University Medical Center

Brian D. Patty MD, CHCIO Eligible, VP & CMIO, Rush University Medical Center

Brian D. Patty MD, CHCIO Eligible, VP & CMIO, Rush University Medical Center

Physician burnout is a significant issue, one that not only affects provider well-being but patient care as well. Brian Patty, CMIO at Rush University Medical Center, is determined to do something about it. He’s working to implement a task force aimed at increasing physician efficiency and satisfaction. In addition to this task force, he sits on a committee whose sole mission is physician well-being at Rush and determining what sort of support they can provide. In this interview, Patty discusses how benchmarking surveys have allowed pinpointing where physician efficiency issues reside, what the seven domains are to address physician burnout, and how an NLP engine is changing the game for sepsis prevention. Additionally, he touches on telemedicine and how Rush has found success in the areas of Movement Disorder and Psychiatry. In his words: the EHR was just the beginning.

Key Insights

We are using Physician Efficiency Profiles, which are reports from our EHR, to identify the physicians that we’re specifically focusing on to help them spend less time in the EHR, be more efficient in the EHR, spend more time with patients, and get home on time, not doing work late at night and on weekends when they’re not scheduled to be working. Those are big factors in physician burnout.

In the areas where we have our associate CMIOs/physician builders, we’ve seen that physicians are reporting that they feel more efficient, so it’s been a very successful program that we’re planning on expanding, in addition to expanding our support team for providers.

The issue with sepsis is it’s a sensitivity and specificity challenge. You can set up an alert that measures blood pressure, heart rate, temperature, and things like that, but the sensitivity is very poor so alerts are firing way too often. We are working with Wolters Kluwer to help develop and deploy a sepsis “engine” with sensitivities and specificities in the 90s to improve the identification of sepsis and decrease alert fatigue for our providers.

We’re helping physicians with their efficiency by using the NLP engine in the background, querying their notes, and assisting them in adding items to the problem or medication list and teeing up orders.

I’ve been doing this for almost 20 years and when I started my job description was basically get physicians to use CPOE and then it was, get the full EHR up and running, and getting physicians to use the other features of the EHR. Now, it’s improving the quality of care, improving efficiency, and really making sure the EHR is working for our providers, for our nurses, for the organization, rather than being an added burden to them.

Campbell: As we start preparing for 2018, from your perspective as a CMIO, what are the top things you’re focused on?

Patty: I am working in strong partnership with our new CIO, Dr. Shafiq Rab, and we’re working on getting our base infrastructure and base Epic build optimized. Then, this coming year, we’re looking at what we can do around innovation, and specifically, around provider efficiency and decreasing provider burnout. That’s a big focus for the coming year.

Campbell: If we can delve into that topic, a little bit more, what components of provider efficiency are you exploring? I noticed that you recently adopted Wolters Kluwer’s POC Advisor, but are there additional clinical documentation improvement initiatives that you’re pursuing? You’ve mentioned in past interviews that to reduce the burden on providers they should explore whether other caregivers upstream can take on some of that administrative burden. Can you elaborate on that topic? Is it around clinical documentation improvement? Is it more around restructuring workflows? Is it retraining?

Patty: Its all of the above. We’ve got a big effort on the ambulatory side right now, of going back out and retraining physicians, specifically focusing on efficiency tips and customizing their Epic profile, and working with them to show them how they can do certain tasks faster and more efficiently. One of the nice things that Epic does is provide us with is what are called provider efficiency profiles. It’s a snapshot of the physician’s use of the EHR over the last six to eight weeks, and it gives us a good sense of, what are the tasks that they’re doing that they spend a lot more time in than other providers, and when are they using Epic. How much of their time in Epic is outside of their typical clinic hours or hospital hours? So, we’re able to see who’s struggling with what and how much extra time they’re spending. Those are the physicians that we’re specifically focusing on to really help them spend less time in the EHR, be more efficient in the EHR, spend more time with patients, and get home on time, not doing work late at night and on weekends when they’re not scheduled to be working. Those are big factors in physician burnout.

That’s one of the big things we’re doing right now as far as training initiatives. We’re also looking at increasing our training staff. At my previous organization, I had a dedicated physician experience team of about eight experienced nurses who were deeply trained in Epic, Dragon, physician workflows, and all the other applications that physicians use. They did all the initial physician training, follow-up training, and rounding on physicians. They then became our physician help desk. When a physician called the help desk, calls were routed directly to this team 24/7, so physicians we’re getting someone who knows all the physician tools, knows the physician workflows, and can help them immediately. So, we basically said, in the hospital from 6am – 6pm, we’d have someone at your elbow within five minutes, if they can’t resolve your issue over the phone. They also had the ability to log into a physician’s computer remotely to see what they were struggling with. We were resolving physician issues very quickly and issues that we couldn’t resolve, rather than having the physician take the time to put in a help desk ticket, that group would put in the tickets for them, track the tickets, then circle back with the provider when the ticket was resolved. Because of this, our provider satisfaction was very high, and we were markedly improving our physician efficiency and use of Epic. I’m the process of building a similar team here at Rush, based on those same principles.

Campbell: That is fantastic approach yielding demonstrable results. Speaking to this point of addressing burnout and provider satisfaction, I love that you’re taking a data driven approach. What was especially profound to me, attending CHIME this year, was the new clinical informatics track, and the presentation that Bryan Bliven and Dr. Tom Silva of Missouri Healthcare gave. Can you touch on surveying and how frequently you may survey end users to understand their satisfaction?

Patty: We’re surveying our providers about twice a year right now, and going forward. One of the surveys that we use is the new KLAS EMR Collaborative Survey, which KLAS has renamed the Arch Collaborative. Basically, it’s an externally benchmarked survey that examines physician engagement, physician efficiency, and a physician’s perceptions of the EHR that they’re using. So, we get a lot of internal data about what our providers think of our instance of Epic, but we can also benchmark our providers efficiency, engagement, and use of various tools to other organizations who have taken the same survey, and its highly valuable information. The other thing that we’re doing, and we’re in the process of rolling this out as part of an annual survey, is to use Stanford’s Provider Wellness Survey, looking at multiple domains, which will give us information on the level of burnout in our providers, and what are the specific areas that we need to work on. Combining that with our EHR survey gives us a good indication of what we organizationally need to work on from a burnout perspective.

We look at about seven domains as we review physician burnout. One is simply assessing burnout, which we’re doing with both of those tools. Another is optimizing the care model, making sure the right people are doing the right things in our EHR and not putting it all on the provider. Starting from the patient, we send out pre-visit surveys so they can start filling in some information, anything that might be new, corrections to their medication list, corrections to their problem list, and any other issues they have directed at the visit and that can actually become, once it’s validated, some of the initial documentation on that patient’s visit. In this way, it alleviated the need to have it be entered by the provider. Then our medical assistants, nurses and admitting staff also contribute to the chart. Once the chart gets to the physician, they’re doing their physical exam, assessment and plan, and a lot of the documentation necessary to comply with regulatory and reporting requirements for various contracts and things like that have already been documented by the rest of the care team so that extra administrative burden isn’t landing on the physicians. So, we assess burnout; we’re optimizing our care model; we’re doing enhanced workforce management, which is around that training piece; we’re decreasing their administrative burden, which falls in line with optimizing the care model and making sure the right people are designing the right things, and also designing Epic in such a way that it’s doing the billing, coding, authorization, and things like that in the background and not requiring physicians to do a lot of that work. The fifth domain that we look at is around clinical efficiency, and some of the work we’re doing with the physician efficiency profile. We’re looking at who, specifically, isn’t efficient and we can go out and retrain them and give them some efficiency tips, but if there’s a global area where we’re seeing that, compared to other organizations, our physicians in general are spending too much time in documentation or more time than other organizations, then we know we have a global issue, a systemic issue, that we need to address by evaluating our documentation tools, or whatever the area is. Other areas are more on the organizational side around engaging physicians both in communication and aligning incentives, making sure they’re really engaged in organizational strategy development; and finally, looking at comprehensive well-being support. We have a physician group, we initially called it Physician Burnout Committee, but we’re now calling it Provider Wellness Committee, looking at what we can do to enhance physician spiritual, emotional, & mental well-being, looking at all those areas to see what kind of support we can provide.

I have some good partners here at Rush on the medical staff and in leadership that are all very supportive of this work. My part of it is focused on primarily what we can do with improvement of our EHR training and support, and others are working on some of those other domains. It’s a very comprehensive program we’re looking to develop here and put into place to improve provider well-being and provider retention. We know that a good portion of our turnover, probably 30%, is just due to burnout. People are either leaving practice, or leaving to another practice site where they have decreased responsibilities so they’re feeling more engaged in their medical practice. We want Rush to be that place that people come to, so we’re looking at what we can do to improve our overall well-being of our providers.

Campbell: Absolutely, a couple things I want to comment on: you came from an environment at HealthEast Care System where it probably wasn’t as competitive so you didn’t have to worry about providers moving to other facilities, so there’s increased competition now. The other thing is, as a self-identified data geek, I love the fact that you’re harvesting operational data from Epic to identify those areas that may be inefficient but also validating via external benchmarking. I think KLAS Arch Collaborative is phenomenal in that it allows you to understand where you fit in comparison to similarly sized groups and organizations.

Patty: The work that Taylor Davis is doing with that Arch Collaborative over at KLAS is just amazing and it really validated some of the early work that we were doing. I brought six associate CMIOs into IS from various areas, internal medicine, general surgery, pediatrics, emergency medicine, and primary care, and when we did our Arch Collaborative survey, the results showed that those were the exact areas where we were significantly differentiating ourselves from the median in physician self-reported efficiency.  When we brought in those associate CMIOs, they were all trained in the Epic physician builder course, so they had a deep knowledge of Epic and could work with the analysts closely to change things. In the areas where we have our associate CMIOs/physician builders, we’ve seen that physicians are reporting that they feel more efficient, so it’s been a very successful program that we’re planning on expanding, in addition to expanding our support team for providers.

Campbell: That is fantastic. If I could switch gears, I want to touch on some more specific topics around telehealth. Is there anything you’re doing in terms of e-visits right now using Epic? As you try and differentiate yourself from competitors in the region, patients may prefer a different type of appointment, not necessarily at the first appointment but perhaps a virtual appointment later on down the road. Could you comment on any telemedicine initiatives within Rush?

Patty: There are a number of things we’re doing around patient engagement and improving our patient experience, and one of them is e-visits. We have two different e-visit platforms that we’re considering, both the Epic e-visit platform and then a commercially available e-visit platform. We’re kicking the tires on both of them to see which one our patients and providers prefer. We’re currently offering e-visits to our patients in two different markets here at Rush. We also have a telemedicine program up and running. The best site for that right now is our movements disorders clinic. As you can imagine, we have a large catchment area for that clinic and since these patients have a movement disorder, they typically aren’t able to drive, so when they need to come to a clinic visit it takes two people out for the day in travel time, since their spouse, relative, significant other, or caretaker has to drive them as well. With our movements disorder clinic, our neurologists have found that a good portion of the visits can be done via telemedicine because they can observe tremors and things like that remotely and not require patients to come in every time for a visit. They’ll have to come in on occasion, but this markedly decreases the amount of times patients have to travel to Rush for their follow up appointments to see how things are progressing.

We are also using a fair amount of telepsychiatry. We’ve found rather than just doing phone psychiatry, which a lot of organizations have done for years, our psychiatrists really like video capabilities because there are a lot of nonverbal cues that they can pick up with a video conversation that they’re not picking up on a phone conversation, and as such, we’re rapidly expanding our telepsych capabilities.

As I previously mentioned, we do a fair amount of patient pre-visit questionnaires, so patients are filling out information prior to coming in for a visit, or in-between visits just to follow up and see how they’re doing. We also offer the ability to schedule and communicate with providers via secure email through our portal.

Campbell: Thank you for elaborating on that topic. Another topic that I wanted to discuss with you is sepsis surveillance. After reading the 2017 KLAS report on sepsis, what was staggering to me is that you would think there is ubiquitous adoption but certainly there’s a lot of opportunity left on the table, that can be attributed to the inherent functionality and technical step function that you have to get past within the native EHR.  Can you comment on the approach you took in deploying a sepsis surveillance solution?

Patty: We’re still in the process of pre-deployment with Wolters Kluwer POC Advisor. The issue with sepsis is it’s a sensitivity and specificity challenge. You can set up an alert that monitors blood pressure, heart rate, temperature, and things like that, but the sensitivity can be very poor, so alerts are firing way too often. As much as we tried to refine alerts on our own, we were still only having a sensitivity and specificity with our sepsis alerts in Epic in the upper 60s. So, as you can imagine, a little over 30% of the time, when the alert fires, it’s not sepsis, and a little over 30% of the time, when there is sepsis, the alerts not picking it up. What we really liked is some of the early published data around the Wolters Kluwer POC Advisor where they’re in the low 90s, both sensitivity and specificity, so alert fatigue is reduced and you’re picking up more sepsis cases earlier. We’re combing that with a technology from a company called Hiteks that has a NLP engine where they can pull non-structured data out of the EHR to also feed the POC Advisor engine, so we fully expect it will be much more accurate.

We’re also using that same NLP engine in a number of other areas. Epic has a functionality called Note Reader, where at the end of a note a physician can have a computer read the note with an NLP engine. In the background, the solution will query documentation, retrieve diagnoses, medications, problems, and things like that and then compares that to the problem, medication, and allergy list to say, ‘hey I noticed that you mentioned that the patient is on azithromycin. We don’t see that in the medication list, do you want us to add that?’ or similarly, ‘we noticed you mentioned the patient has diabetes, do you want to add some more specificity to that and add it to the problem list because we don’t see it there.’ We’re helping physicians with their efficiency by using the NLP engine in the background, querying their notes, and assisting them in adding items to the problem or medication list and teeing up orders. We have that in our production environment now with a limited group of physicians testing it and we are refining the algorithms, but plan on rolling that out early next year when we roll out Dragon and some other efficiency tools.

Campbell: Extremely compelling innovation through leveraging cutting-edge health IT solutions. Before we wrap up, I wanted to touch on a topic that I heard echoed over and over again while at the CHIME Fall Forum and other conferences: the transition away from the CMIO being the implementation lead and convincing providers to use the EMR. I think you articulated this best when you said, that was just the beginning, using the EMR was step one; there’s a whole slew of other things to focus on once the EMR has been implemented. There would seem to be a large amount of responsibility for the CMIO to be the ‘glue person,’ as you have to liaison between leadership, administration, with clinicians, with IT. As such, I’d imagine there’s a lot of negotiation and communication that takes place. I realize that that role has evolved, but if you could comment on that and how you’ve learned to adjust in your approach as a result of that evolution.

Patty: I’ve been doing this for almost 20 years and when I started, my job description was basically get physicians to use CPOE and then it was, get the full EHR up and running, and getting physicians to use the other features of the EHR. Now, it’s improving the quality of care, improving efficiency, and making sure the EHR is working for our providers, for our nurses, and for the organization, rather than being an added burden to them. We want to get to the point where we’re improving their efficiency, letting them spend more time with their patients, and letting them spend more time with their family at home. That’s the goal right now, improving the quality of care, improving the efficiency of care, and improving our provider/nurse satisfaction with their overall job and specifically with the EHR.

About Brian D. Patty

With over 20 years of experience in healthcare informatics, Patty is currently VP of Clinical Information Systems and Chief Medical Informatics Officer (CMIO) at Rush University Medical Center where he oversees the optimization of Epic and related clinical and revenue cycle applications. He is charged with setting the strategic vision for clinical care and population heath from an IT perspective. He chairs the Clinical Communication Steering Committee, the Telemedicine and Patient Technologies Steering Committee and the Clinical Informatics Committee. Patty also oversees a team of six associate CMIOs responsible for innovation and optimization across the continuum of care. He was named as one of 30 leading CMIO Experts by Health Data Management magazine in June of 2016.

Prior to coming to Rush in March of 2015 he served for 10 years as VP and CMIO at the HealthEast Care System in St. Paul, Minn. As the CMIO at HealthEast he was responsible for championing clinical applications and the use of technology to serve patients and improve the quality of care, leading computerized provider order entry (CPOE) and electronic health record (EHR) implementations system wide. His final project at HealthEast was as the executive lead for the “Big Bang” implementation of Epic’s entire suite of clinical and revenue cycle applications across the four hospitals and 31 clinics of the HealthEast Care System.

Patty’s long-standing quest to promote quality improvement through evidence-based medicine led to an Association of Medical Directors of Information Systems (AMDIS) Award in 2005 for his success in a CPOE implementation at a community hospital and ultimately to his role as the CMIO for HealthEast. In 2011 Patty received another AMDIS award for his championing the EHR’s role in the quality improvement efforts at HealthEast. He was also named to Modern Healthcare’s Top 25 Clinical Informaticists in that same year. And most recently was the winner of the 2012 Healthcare Informatics/AMDIS IT Innovation Advocate Award.