For the last 18 years, I have been a physician at the forefront of digital health transformation. I celebrate the disappearance of illegible handwriting, especially my own, and rejoice in new opportunities to improve care through comprehensive data and analytics. Our healthcare system has changed immensely during that time. But sometimes, we need to be shaken out of our routine to notice the extent of the change and perhaps the wisdom of it. That is exactly what happened to me last year.
Last year I became a frequent client of my doctor’s office. Diagnosis: I needed to do a better job of taking care of myself. Treatment: I splurged and acquired a scribe for a vaccine clinic commitment. For those shifts, I turned my back on the computer and paperwork and focused purely on the patients. Lo and behold, I found a joy that has been long absent: I loved being a doctor again! So, what have I been doing for the last 18 years? Like the proverbial boiled frog, I have been sitting in the water and failing to take notice of the profound change in temperature that took place between when I got in and the present moment. What resulted was the kind of creeping malaise that can contribute to fatigue and burnout.
Just like my own health, the incremental changes and pressures from all sides of the healthcare system have been stealthily building. Gradual change can be a good way to nudge closer to an improved future, but if the temperature is not taken periodically along the journey, it can lead to a crisis. Here are the major contributors to healthcare’s hot pot:
- Administrative burden. The number of forms needing completion for various purposes has grown without regulation. Insurance forms, work excuses, ministry of transportation forms, public health lab questionnaires, special drug authorization forms, qualification forms for bariatrics … the list seems to go on and on. The cost savings of these exercises actually creates a cost burden to the care provider that is not considered in the equation.
- There is too much information. Scrolling and reading through narrative notes is like trying to read a novel in 10 minutes. A colleague once told me that she was terrified to click on links to provincial systems because the deluge of information would overwhelm her, yet we are expected to know and act on every piece of information available.
- There is a lack of integration. We log into the EMR for our clinic, HIS for our hospital, vaccine management system for our vaccines, pharmacy systems for meds, etc. If I administer a vaccine and record it in the vaccine registry, it does not instantly transfer to the EMR where I manage my patient population. Rarely are any of these systems interconnected. This means less time for clinicians to spend with patients and more opportunities for missed information.
- Managing the broken system is expensive. Individual clinics are spending money on systems, security, and management of said systems and security that could instead be spent on the quality and safety of care. Efforts to fix the broken system tend not to address root causes, leading to mental and financial burnout.
Verdict: Healthcare practitioners are burning out because the health system has heated up to the point of catching fire. Yet, I promise: Joy can return! We can and should turn down the temperature. Let me be very clear, I am not advocating that the solution to all our woes is to run out and hire scribes. Nor is it to head back to paper. The solution is to realize that the world has changed too much to nudge ourselves into the next day. It is time for systematic change in healthcare. Here are three areas of focus that might cool things down:
- Getting Rid of Stupid Stuff (GRoSS).[1] We should consider following in the footsteps of Dr. Melinda Ashton and her organization that launched a program examining their environment for things that might have been a good idea at the time of their initiation but no longer served a purpose. In the true spirit of a LEAN exercise, they slimmed down their work to much success. For a more fulsome exercise, we will need to appeal to external authorities or the regulatory bodies that create clinicians’ administrative tasks to perform the same exercise to protect clinicians from administrative burden.
- Redefine the effective team. We can and should still experience joy in our work. The key is ensuring the right person is doing the job, allowing them to work at the top of their license. We need to let clinicians focus on clinical work while leaving care management to those who excel at organization. For example, in Canada, we would benefit from the assistance of Health Ministries to financially incentivize innovation in healthcare team development. In return, individual health services need to take responsibility for establishing good workflow and division of labor, which means being willing to change.
- Get the big picture. Creating a concise narrative of a patient’s journey can be time-consuming. When patient histories become too complex, it is beneficial to have a care summary created and accessible in the chart. Additionally, graphic summaries can further decrease the cognitive load of reading through mountains of information. This centralized big picture (which in turn relies on centralized or interoperable data infrastructure; see below) could facilitate communication and coordination around the patient’s care plan.
- Centralize effective tools. Managing information systems becomes increasingly complex as they mature. Our model needs to centralize the tools while decentralizing the teams and mode of care delivery. Centralizing tools also cuts down on integration needs, cost redundancy, security risks, and reporting complexities. Instrumental to the success of centralized tools is end-user involvement in their development and respect for the clinician and patient flow.
What is the temperature in your healthcare system? Is it time for you to focus on incremental change or to hop out of the pot into a new model?
[1] Ashton, Melinda. Getting Rid of Stupid Stuff. N Engl J Med 2019;379;19:1789-1791.