Background: Physician burnout is a real problem. A study conducted by the Medscape Physician Compensation Report [http://www.medscape.com/viewarticle/838437] found that almost half of all physicians say they’re experiencing burnout, and the rates have been rising substantially over the past few years, up 15% between 2013 and 2015. Dr. Blake McKinney should know; his specialty, emergency medicine, is among the specialties reporting the most burnout in an editorial published in the Journal of Internal Medicine. I talked to him about how this looks on a day-to-day basis, and what, exactly, should be done to reverse this trend.
Leonard Kish: You work in a busy community trauma center emergency room in Northern California. What does your patient mix look like?
Blake McKinney: We see the entire spectrum, from the wealthy who pay their own health bills without insurance, all the way down to people with absolutely no benefits and no intentions of paying for their healthcare, including many homeless or the mentally ill; along with everyone in between. On the payment side, we work with payers across the board, including HMOs and of course the traditional fee-for-service billing that has been the hallmark of medical reimbursement for the last 70+ years. The complexities of the payment system have dramatic effects on the way physicians are able to help patients, and on the overall (in)efficiency of the system.
LK: What have you observed over the 10 years you’ve been in emergency rooms in terms of a doctor’s time getting absorbed, and how much of that would you say is wasted, as in, not doing what’s important?
Blake McKinney: Based on what I know of the market and what my colleagues and I discuss, no less than 30% and usually around 40% or 50% of the physician’s work output in a day goes into overly complex documentation and the rest of the electronic workflow that has been imputed to us by a complex regulatory environment: There’s a need for hospitals to meet certain core measures, med-legal documentation must be sufficient, electronic physician order entry ensures every action is ascribed to a doctor and ultimately the record of care is used to generate billable codes from the encounter … the pressure to see more patients per hour puts the physician onto a boiler plate as the “price per unit sold” goes down in clinical medicine, based on Fee for Service payment.
It’s common for physicians to interface with three or four electronic platforms to complete one patient encounter. And that may include an Exit Writer feature for discharge papers and prescriptions; it may include a different electronic system to look at images taken in the hospital and yet another one for documentation and payment.
In order to get paid for each encounter in the emergency room, I have to create a billable note; a note which is overly complex, not because that’s what’s good for patient care, or that that’s what’s needed for medical legal protection, or to help the follow on members of the care team in any way. The notes I make in the emergency room are complex because that’s what’s become required in order for my group to be reimbursed by the third party payers, and that’s where 30-50% of my time is going.
Leonard Kish: Some of this, certainly, is usability as well. Of course, we might argue all the billing requirements are the wrong use case to define the usability requirements for EHRs. Can you talk about that, and why it matters?
Blake McKinney: Yes, a good portion of this is usability, and in a perfect world I would like to see the machines working for us. The reality is that most clinicians these days feel like they’re working for the machine; that they’ve been reduced to data entry clerks.
In any system, the trick is to follow the money. The problem in this system is that clinicians and patients are not the customers of the large Electronic Health Records companies. Hospital systems are the customers of the large EHRs. We know that any business aims to please their customer, and EHR vendors have become such a predominant and unwelcome part of a physician’s day because they’re designed to work for the needs of their customers… often at the neglect of the end user.
The systems are not so much designed to address what the physician needs to do for care, but what they need to do to get the right usage codes and measures. These are vital to keeping hospitals profitable – to keep the payments flowing in – and it is the reason electronic health records are constructed as they are.
Leonard Kish: How is this impacting physicians? It seems as if you’re describing a workplace in which much of the day’s work is spent, not in caring for patients, but in figuring out how your employer is going to get paid for the work you do.
Blake McKinney: I’d say figuring out how to get paid is 20-30% of the problem; and by that I mean doing the work you know it takes to get paid, the creation of cumbersome documentation. In this point in clinical medicine, this flawed workflow is woven into the fabric of clinical medicine.
We need to step back and look at the triple aim: enhancing the patient experience, improving the population health and reducing costs, and add a fourth leg of the stool. I think it’s imperative, and that aim would be to improve the work life of providers. It’s been called the “quadruple aim”. The nation is already relying on a strained and globally depressed physician workforce, so physician satisfaction is also going to be critical to keep the best and brightest coming into the field.
Leonard Kish: What can we do to achieve the quadruple aim and pull physician satisfaction into the mix?
Blake McKinney: One study cited by the Rand Corporation left a memorable quote for me: “The principal driver for physician satisfaction is to provide quality care.” And ultimately, in this doctor’s opinion, the ability for physicians to provide quality care rests on the patient’s ability to access care, including specialty services, ancillaries, the ability to be seen by and operated on by a surgeon if needed, to receive chemotherapy if needed, etc.
The access problem rests upon doctors’ ability to see patients through a brick and mortar clinical establishment, but in my experience, 85% of what doctors need to make their assessment and plan is based upon simply listening to the patient. Ignoring the checklist constructed by the EMR system, and just listening to the patient’s description of her symptoms.
So instituting pathways for care that are all about communication first could decompress the brick and mortar apparatus, improving access and flow for others, and as a downstream effect improving physician satisfaction with their careers. Very simply, if physicians are able to get the patients the services they need, they’ll be far happier. Burnout is caused by the frustration of watching your patients languish because they are on a government health insurance program that fundamentally doesn’t pay hospitals or doctors enough for those patients to be prioritized.
To watch a woman with a newly discovered breast lump wait two months for a follow-up imaging study while that cancer grows is extremely disheartening for a physician. Rather than the system embracing and taking care of that woman, the physician has to stand on desk after desk after desk to try and push that patient through every loophole; because the system fundamentally wasn’t designed to provide her access.
This happens every single day in primary clinical practice for those who are caring for populations being managed on private and public prepaid service, and it’s beyond disheartening.
Leonard Kish: How could we turn this fourth aim from theory to practice?
Blake McKinney: When I ask myself how medical care can best be dispensed, and physician job satisfaction can be improved, I think about the way doctors care for their friends and family. And when my friends and family have a medical problem, nine times out of ten, they text me. This was the inspiration for Cirrus MD: text messaging and similar asynchronous communications are a wonderful platform for ongoing patient care, that by definition documents itself for perpetuity.
If the type of communication thread with which I engage my family and friend could be captured into the medical record such that it could be secure, transmissible and something that remained on the record; owned by the house but fully transparent to the patient; that would be a wonderful thing and could help interrupt the current status quo. Today, the problem for physicians and patients alike is the widespread fee for service model of health care that forces this billing system into the middle of the sacred and very much more efficient physician-patient interaction.
Of course that’s just a start, but beginning to find low-cost ways to achieve access will be a critical part of solving both access and physician burnout, by letting them do what they want to do: provide the best care. At CirrusMD we create closed-loop virtual care solutions, systems that are designed for value-based rather than fee-for-service basis.
We need to change the incentive structure so physicians could be paid to “own the life,” so to speak, rather than owning just the single encounter with a patient. With value-based telemedicine, and it’s a unique approach to an industry designed around serving the needs of the hospital. Serve the needs of the physician instead, and we can change the system’s infrastructure entirely, making it far less expensive for the payors, more convenient and less stressful for the patient, and provide a currently unavailable immediacy and transparency for all of the parties in the system.
For more on Blake McKinney and Cirrus MD, see the video interview from #HIMSS16.