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  • Writer's pictureBruce Cummings

Tackling and Taming the EHR Monster

I read with interest Healthcare Innovations annual list of awardees.  It was the third place finisher, Mercy Health’s remediation of its Electronic HealthRecord (EHR), that I found most compelling.  Mercy Health is a 50-hospital system that spans 4 states with the largest concentration based in Missouri.

As regular readers of blogs posted on this website by my colleague, Paul DeChant MD, MBA or me will recall, we believe that the pathway to alleviating clinician burnout runs through the c-suite.  The more senior leaders are directly connected to the day-to-day concerns and suggestions of front-line clinicians to improve workflow, the greater the prospect for meaningful changes in the often fraught — if not downright toxic — relationship between the c-suite and clinicians.  

Electronic Health Record in Hospitals and Healthcare Systems

One of the most pronounced — and often controversial — features of hospitals and health systems today is a reliance on the Electronic Health Record (EHR).  While there are significant financial benefits to eliminating paper-based charting (think: revenue cycle management, risk management), most clinicians will convincingly argue that paper-based records were actually quicker and easier to navigate in terms of delivering and documenting patient care. Unfortunately, for all their putative benefits, most EHR’s require clinicians to spend an inordinate amount of time trying to retrieve pertinent clinical information and to document care rendered in the record.  Estimates range from 3.5 hours a day to 6 hours a day — over a third of a physician’s time — is spent in the EHR.  (Source:  Richard Payerchin, “Physicians spend 4.5 hours a day on the electronic health record”, Medical Economics, April 21, 2022). 

So, what’s notable about Mercy Health‘s EHR remediation?  It’s not what they did but HOW they did it that I found so impressive. Here’s an except from the March 5 article by Pietje Kobus:

Cheryl Denison, B.S.N., R.N., Mercy's systems clinical integration director, noted in Mercy’s submission [to Healthcare Innovations], “By incorporating human factor principles and actively engaging end users, we were able to decrease time spent documenting, enhance nursing efficiency, and improve overall trust and satisfaction with technology and the EHR. The team updated flowsheet documentation, removed redundancy, and eliminated more than 150 million clicks per year. Over the last 30 days, a decrease in time spent on documentation was maintained from an average of 167 minutes of documentation time to 130 minutes. Additionally, the usage of tools and reports related to clinical decision-making increased. Coordination and communication among the care team were enhanced, and nurses' satisfaction improved.

Part of what kickstarted Project ANEW was realizing that nurses needed help, which became more apparent after the last COVID surge early in 2022. The team was already doing different things to help nurses, including picking up trash. They soon realized that technology wasn’t supporting nurses’ needs. “Nurses were dealing with changes on a daily basis,” Denison explains, “that led to increased burnout.” Furthermore, Denison continues, “The nurses felt they had no voice.” The increase in technology use, the changing patient population, and new nurses coming in who may not be as prepared led to what Denison calls “a crumbling of the foundation of nursing.”

Mercy’s EHR vendor informed the team that Mercy nurses exceeded the national average documenting time. With that, the EHR satisfaction scores dropped post-pandemic. Initially, the team figured they could just give the nurses tips on efficiency. But they soon discovered they needed to go back to baseline. “We know nurses are excited when they can implement evidence-based practice,” Denison says, “We do the clinical inquiry to understand what it should look like and bring that to the table.” Since change happened so rapidly and there was a lack of communication, nurses had many duplicate processes. For example, they were documenting something in five different places. The team was able to introduce quick fixes to address such inconveniences.

Another concern the nurses raised was the time things took. Steps had been added to help solve issues, but documenting things multiple times became an ordeal. There were also misunderstandings around processes. Further education was needed around nursing indicators such as fall risk and skin assessment. Denison indicates that more research and evidence were required to ensure they addressed these gaps. Breece explains that process improvement was needed in different domains. One domain being the hardware in the work environment; for example, infusion pumps and mobile phones. Another was software integration with the EHR. “We uncovered that some nurses, 15 years post initial training, were still using the EHR in the way they were originally trained,” Breece says, “They hadn't taken advantage of the innovation of the evolution around our EHR and our environment.” Together with training teams, the team initiated further education on how to navigate the EHR efficiently.

The team discovered similar trends in Mercy’s various communities and provided each chief nursing officer with an executive summary of their findings. Mercy has over 50 hospitals, and more than 10,000 nurses across its four state system.

Betty Jo Rocchio, D.N.P., C.R.N.A., C.E.N.P., Mercy senior vice president and system chief nursing executive, sponsored the project. The team agrees that this initiative would not have been possible without her support. Denison underscores the importance of senior leader support to replicate this process.

The team has further advice for hospitals that want to replicate what they have accomplished. “The very first thing I would tell them,” Denison says, “is to spend time among nurses.” The team agrees that listening to the nurses made this project successful.

Organizational Wellbeing Solutions - Leadership-Driven Changes

Here are examples of healthcare leadership-driven changes my colleague Paul DeChant, MD, MBA and I often recommend to address clinician burnout and foster achieve organizational wellbeing:

  • expect all leaders, but especially senior executives, to do periodic job shadowing of front-line staff (where observing and deep listening are emphasized)

  • create and require leader standard work (LSW).

  • develop and deploy a sophisticated, deeply ingrained, and rigorous daily management system (DMS) supported by visual display boards or monitors

  • consistently apply one or more of the improvement sciences (Lean, six sigma, operations research, agile, design thinking) in consultation with front-line staff to improve workflow and reduce delays, waste, inefficiency, and job skill mismatches

  • invest in AI/ML solutions -- selected, tested, and endorsed by front-line staff -- that eliminate or at least markedly reduce data entry, administrative requirements, and/or repetitive tasks that are non-value add

  • invest in EHR remediation and optimization

  • regard clinicians as knowledge workers who are given significant latitude to make clinical decisions without unnecessary administrative encumbrances or delays

  • get rid of superfluous or outdated policies, procedures, redundant approvals and other stupid stuff (GROSS)

Ready to transform your hospital or workplace?

Are you frustrated by adversarial relationships between front-line clinicians and senior leadership? Organizational Wellbeing Solutions was formed to enable senior leaders to identify the specific drivers of clinician burnout in their organization; and to support leaders in designing and executing a comprehensive plan to stop clinician burnout, increase retention, and improve operating results. A hallmark of our consultancy is correcting the all-too-frequent distrust and alienation clinicians feel toward the c-suite generally and the CEO in particular. Let us help you help your organization and its clinicians develop a more trusting, aligned, and productive working relationship.


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