Measuring Physician Morale and Workload

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Emil Bertram Goodman
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1 Measuring Physician Morale and Workload The Impact of the EMR and PCMH Transformation Bruce Soloway, MD, Vice-Chair M. Diane McKee, MD, Director, Division of Research Department of Family and Social Medicine Montefiore Medical Center and Albert Einstein College of Medicine May 2014

2 Disclosures No conflicts to disclose

3 Faculty burnout Many primary care residency faculty report feeling burned out by the burden of clinical and teaching responsibilities. Maslach Burnout Inventory Exhaustion feeling emotionally overextended and exhausted Cynicism unfeeling and impersonal response to recipients of service Professional Efficacy feelings of competence and successful achievement

4 Setting Montefiore Medical Group 22 primary care sites in the Bronx Teaching vs. non-teaching FM vs. multi-specialty Insured vs. FQHC EMR introduced in First attempts to launch PCMH in Maslach Burnout Inventory administered to attending MDs at multiple sites in 2012 and 2013

5 * * * p<0.05

6 Sources of exhaustion: Visit vs. Non-visit Work The primary care session continues to be fully scheduled with relatively brief patient visits But increasing amounts of care are delivered before, after, and between patient visits ( non-visit work ) Lab review, phone calls, , e-prescribing Other modes of electronic intra- and interoffice communication

7 Sources of exhaustion: Inadequate staffing FHC actual and expected core staff Actual Expected FHC actual and expected core staff per clinician Core/MD Expected

8 Sources of exhaustion: Effects of the EMR Improvements in content and legibility of records access to information interprofessional communication But increased expectations on providers to provide and document more services at each visit document in greater detail

9 Where does the time for added clinical effort come from? Non-visit work and completion of documentation spill over into time nominally allotted for non-clinical (academic, administrative) work restorative personal and family activities Evidence??

10 Purpose of study To measure the time spent by primary care providers on EMR documentation outside of scheduled patient care and precepting hours

11 EMR time = primary care time At Montefiore, the time spent by physicians logged on to the EMR is a fairly accurate surrogate marker for the total time spent delivering and supervising primary care services Most primary care tasks require use of the EMR Most non-primary care clinical tasks are performed with other tools measurable

12 Study sites Teaching FQHCs 2 FM, 1 Med/Peds Data for April and May 2013 Non-teaching FQHCs 1 FM, 1 FM/Med/Peds Data for May 2013

13 Methods (1) Obtain raw data from hospital databases For all residents, fellows, and attendings All login and logout events from EMR database Start and end times for all clinical sessions and precepting sessions

14 Methods (2) Arrange all events (login, logout, session start and end) in a single database, sorted First, by provider Then, within each provider, in chronological order For each provider, calculate the interval (in minutes) between each pair of consecutive events

15 Methods (3) Interpretation of time intervals Provider is considered in session from each clinical or precepting start session event until the following end session event. Intervals between consecutive events are counted as EMR time if any of the following conditions are met: Provider is in session during that interval, OR First event is a login event, OR Second event is a logout event 5 minutes deducted for every timed logout event

16 Sample Chronological Event Log for One Provider

17 Methods (4) Analysis EMR time = time in session or on EMR or both Session time = time scheduled for direct clinical care or precepting Primary outcome = ratio of total EMR time to scheduled session time

18 Results

26 Conclusions (1) Physician burnout is measurable May be higher in teaching than in comparable non-teaching environments Staffing ratios are measurable Important to assure adequate support staff for effective teamwork Collaboration as part of a robust team may help prevent physician burnout

27 Conclusions (2) EMR log-on time is a measurable marker of physician clinical workload May be far in excess of scheduled clinical hours Documentation and other non-visit clinical work invade time allocated for academic and personal pursuits

28 Potential remedies Measure burnout, staffing ratios, and physician EMR hours as PCMH outcomes Build enhanced teams with collaborative workflows Maximize delegation of non-physician tasks Schedule adequate desktop time for MDs May impact FFS revenue Capitation to support teams and MD nonvisit work

29 Questions?

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