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EHR stress linked to burnout
Physicians who experience stress related to the use of health information technology are twice as likely to experience burnout.
Rebekah Gardner, MD, of Brown University in Providence, R.I., and her colleagues surveyed all 4,197 Rhode Island physicians in 2017 to learn how the use of electronic health records affected their practices and their job satisfaction.
Just over a quarter (25.0%) of 1,792 respondents reported burnout. Among electronic health record users (91% of respondents), 70% reported health IT-related stress (J Am Med Inform Assoc. doi: 10.1093/jamia/ocy145).
“After adjustment, physicians reporting poor/marginal time for documentation had 2.8 times the odds of burnout (95% confidence interval, 2.0-4.1; P less than .0001) compared to those reporting sufficient time,” according to the researchers.
The team looked at three stress-related variables: whether the EHR adds to the frustration of one’s day; whether physicians felt they had sufficient time for documentation; and the amount of time spent on the EHR at home. Variables were measured on a four- or five-point scale depending on the question related to the specific stress variable.
Almost two-thirds (64.2%) of respondents “agreed” or “strongly agreed” that EHRs add to the frustration of their day.
“It was the most commonly cited HIT-related stress measure in almost every specialty, with the highest prevalence among emergency physicians (77.6%),” the investigators wrote.
More than a third of physicians (37.7%) reported “moderately high” or “excessive” time spent on EHRs at home; this metric was the most commonly cited stress measure among pediatricians (63.6%).
Nearly half (46.4%) of physicians reported “poor” or “marginal” sufficiency of time for documentation.
“Presence of any 1 of the HIT-related stress measures was associated with approximately twice the odds of burnout among physician respondents,” Dr. Gardner and her colleagues noted, adding that “measuring and addressing HIT-related stress is an important step in reducing workforce burden and improving the care of our patients.”
To alleviate burnout, the authors recommended increased use of scribes, use of medical assistants to help create a more team-based documentation function, improved EHR training, providing more time during the day for documentation, and streamlining documentation expectations, with certain culture shifts needed in some cases (i.e., banning work-related email and clinical tasks for vacationing physicians).
SOURCE: Gardner R et al. J Am Med Inform Assoc. doi: 10.1093/jamia/ocy145.
Physicians who experience stress related to the use of health information technology are twice as likely to experience burnout.
Rebekah Gardner, MD, of Brown University in Providence, R.I., and her colleagues surveyed all 4,197 Rhode Island physicians in 2017 to learn how the use of electronic health records affected their practices and their job satisfaction.
Just over a quarter (25.0%) of 1,792 respondents reported burnout. Among electronic health record users (91% of respondents), 70% reported health IT-related stress (J Am Med Inform Assoc. doi: 10.1093/jamia/ocy145).
“After adjustment, physicians reporting poor/marginal time for documentation had 2.8 times the odds of burnout (95% confidence interval, 2.0-4.1; P less than .0001) compared to those reporting sufficient time,” according to the researchers.
The team looked at three stress-related variables: whether the EHR adds to the frustration of one’s day; whether physicians felt they had sufficient time for documentation; and the amount of time spent on the EHR at home. Variables were measured on a four- or five-point scale depending on the question related to the specific stress variable.
Almost two-thirds (64.2%) of respondents “agreed” or “strongly agreed” that EHRs add to the frustration of their day.
“It was the most commonly cited HIT-related stress measure in almost every specialty, with the highest prevalence among emergency physicians (77.6%),” the investigators wrote.
More than a third of physicians (37.7%) reported “moderately high” or “excessive” time spent on EHRs at home; this metric was the most commonly cited stress measure among pediatricians (63.6%).
Nearly half (46.4%) of physicians reported “poor” or “marginal” sufficiency of time for documentation.
“Presence of any 1 of the HIT-related stress measures was associated with approximately twice the odds of burnout among physician respondents,” Dr. Gardner and her colleagues noted, adding that “measuring and addressing HIT-related stress is an important step in reducing workforce burden and improving the care of our patients.”
To alleviate burnout, the authors recommended increased use of scribes, use of medical assistants to help create a more team-based documentation function, improved EHR training, providing more time during the day for documentation, and streamlining documentation expectations, with certain culture shifts needed in some cases (i.e., banning work-related email and clinical tasks for vacationing physicians).
SOURCE: Gardner R et al. J Am Med Inform Assoc. doi: 10.1093/jamia/ocy145.
Physicians who experience stress related to the use of health information technology are twice as likely to experience burnout.
Rebekah Gardner, MD, of Brown University in Providence, R.I., and her colleagues surveyed all 4,197 Rhode Island physicians in 2017 to learn how the use of electronic health records affected their practices and their job satisfaction.
Just over a quarter (25.0%) of 1,792 respondents reported burnout. Among electronic health record users (91% of respondents), 70% reported health IT-related stress (J Am Med Inform Assoc. doi: 10.1093/jamia/ocy145).
“After adjustment, physicians reporting poor/marginal time for documentation had 2.8 times the odds of burnout (95% confidence interval, 2.0-4.1; P less than .0001) compared to those reporting sufficient time,” according to the researchers.
The team looked at three stress-related variables: whether the EHR adds to the frustration of one’s day; whether physicians felt they had sufficient time for documentation; and the amount of time spent on the EHR at home. Variables were measured on a four- or five-point scale depending on the question related to the specific stress variable.
Almost two-thirds (64.2%) of respondents “agreed” or “strongly agreed” that EHRs add to the frustration of their day.
“It was the most commonly cited HIT-related stress measure in almost every specialty, with the highest prevalence among emergency physicians (77.6%),” the investigators wrote.
More than a third of physicians (37.7%) reported “moderately high” or “excessive” time spent on EHRs at home; this metric was the most commonly cited stress measure among pediatricians (63.6%).
Nearly half (46.4%) of physicians reported “poor” or “marginal” sufficiency of time for documentation.
“Presence of any 1 of the HIT-related stress measures was associated with approximately twice the odds of burnout among physician respondents,” Dr. Gardner and her colleagues noted, adding that “measuring and addressing HIT-related stress is an important step in reducing workforce burden and improving the care of our patients.”
To alleviate burnout, the authors recommended increased use of scribes, use of medical assistants to help create a more team-based documentation function, improved EHR training, providing more time during the day for documentation, and streamlining documentation expectations, with certain culture shifts needed in some cases (i.e., banning work-related email and clinical tasks for vacationing physicians).
SOURCE: Gardner R et al. J Am Med Inform Assoc. doi: 10.1093/jamia/ocy145.
FROM JAMIA
Key clinical point: EHR-related stress is a measurable predictor of physician burnout.
Major finding: Seventy percent of EHR users who responded to a survey reported stress related to the use of health information technology.
Study details: Survey of all 4,197 physicians in Rhode Island; 1,792 (43%) responded.
Disclosures: The Rhode Island Department of Health funded the study. The authors reported no conflicts of interest.
Source: Gardner R et al. J Am Med Inform Assoc. doi: 10.1093/jamia/ocy145.
Class-action suit filed against ABIM over MOC
A group of internists is suing the American Board of Internal Medicine over its maintenance of certification (MOC) process, alleging that the board is monopolizing the MOC market.
The lawsuit, filed Dec. 6 in Pennsylvania district court, claims that ABIM is charging inflated monopoly prices for maintaining certification, that the organization is forcing physicians to purchase MOC, and that ABIM is inducing employers and others to require ABIM certification. The four plaintiff-physicians are asking a judge to find ABIM in violation of federal antitrust law and to bar the board from continuing its MOC process. The suit is filed as a class action on behalf of all internists and subspecialists required by ABIM to purchase MOC to maintain their ABIM certifications. The plaintiffs seek damages and injunctive relief, plus lawsuit and attorney costs arising from ABIM’s alleged antitrust violations.
In a statement, ABIM expressed disappointment at the lawsuit and said the organization will vigorously defend itself, adding that doing so will “consume resources far better dedicated to continuous improvement of its programs.”
ABIM declined to answer questions addressing specific accusations from the lawsuit. However, in an interview, ABIM President Richard Baron, MD, said that “ABIM board-certified physicians have taken the initiative to distinguish themselves. This is a credential that physicians earn. We offer certified physicians the opportunity to demonstrate to the medical community, their peers, and the public that they are current and have special expertise.”
ABIM has not yet filed a formal response to the lawsuit, which was due by Jan. 6. Court documents show that in January, ABIM entered the appearances of four attorneys that will represent the board in the case. From there, discovery and evidence gathering in the case will begin.
Katherine Murray Leisure, MD, an infectious disease specialist based in Plymouth, Mass., is one of the plaintiffs. While she said that she could not comment specifically on the lawsuit, she has written publicly about her ABIM concerns in the past.
In a 2015 letter to Dr. Baron and posted on an anti-MOC website, Dr. Murray outlined a litany of complaints against ABIM’s MOC process and called on the U.S. Congress to investigate ABIM’s financial, legal, and ethical conduct.
“[The American Board of Medical Specialties] and ABIM collected more than $10,000 in fees and lost practice hours every decade from each [diplomate] doing MOC,” Dr. Murray Leisure wrote. “MOC took weeks away from our offices, clinics, patients, families, specialty societies, and individual research. ABMS MOC removed hundreds, perhaps thousands … of America’s best, once board-certified physicians from full hospital careers and earnings whenever [diplomates] did not complete these high-stakes MOC programs. … The righteous and fast solution to such moral, ethical, scientific, and constitutional problems is to end MOC now.”
Plaintiffs Glen Dela Cruz Manalo, MD; Alexa Joshua, MD; and Gerard Kenney, MD, did not return messages seeking comment. When contacted, attorneys for the plaintiffs declined to comment.
The doctors’ 32-page lawsuit characterizes ABIM as an organization motivated by money that has made its MOC process increasingly more burdensome for physicians over the years without evidence that MOC has any beneficial impact on doctors, patients, or the public. Complying with ABIM’s MOC costs internists an average of $23,607 in financial cost and time lost over 10 years, and costs up to $40,495 for some specialists, according to the suit.
The physicians allege that ABIM controls in excess of 95% of the market for MOC of internists, in violation of federal antitrust laws, and that the organization has unlawfully obtained and maintained monopoly power for MOC services.
The board’s illegal tying of its initial certification to its MOC results in burdensome conditions, including “raising the cost of the practice of medicine, constraining the supply of internists thereby harming competition, decreasing the supply of certified internists, and increasing the cost of medical services to patients and consumers,” the suit claims.
The legal challenge details how MOC has personally and professionally impacted each of the four plaintiffs. Dr. Manalo, a gastroenterologist, lost his privileges at St. Vincent Healthcare in Billings, Mont., and was subsequently terminated after he declined to maintain his ABIM certification as a gastroenterologist. In a letter to ABIM, Dr. Manalo wrote that it was “unfair and outright discriminatory that practitioners certified on or after 1990 are the only ones required to certify,” according to the lawsuit. Dr. Manalo later took a position as staff gastroenterologist at Jonathan M. Wainwright Memorial Veterans Affairs Medical Center in Walla Walla, Wash., at a substantially reduced salary. He became unemployed in 2017.
Dr. Murray Leisure obtained an initial and lifelong board certification in internal medicine from ABIM in 1984 and an infectious disease certification in 1990. ABlM terminated Dr. Murray’s infectious diseases certification after she failed her MOC examination in 2009, which led to lost privileges at Jordan Hospital in Plymouth, Mass. The loss caused significant damage to Dr. Murray, including lost income, a tarnished reputation, and the lost opportunity to help patients, according to the lawsuit. Jordan Hospital restored her privileges after Dr. Murray passed her MOC examination in 2012.
Dr. Kenney lost a job opportunity with Mount Nittany Physicians Group in State College, Pa., after he declined to renew his ABIM certification in gastroenterology. He is currently a physician with the University of Pittsburgh Medical Center in Seneca, Pa.
That the ABIM website lists him as “not certified,” is misleading, and makes it appear that his initial certifications were revoked due to failure to pass a MOC examination or misconduct, rather than because the certifications lapsed, according to the suit. The description makes Dr. Kenney appear less qualified to patients, hospitals, insurance companies, medical corporations, other employers, and others, he claims.
Dr. Joshua could not renew her consulting and admitting privileges at Detroit Medical Center after she failed an MOC examination in 2014 and became uncertified in internal medicine, according to the suit. In addition, Blue Cross Blue Shield informed Dr. Joshua it would no longer cover her because it required ABIM certification for coverage. She unsuccessfully appealed based on her certification with the National Board of Physicians and Surgeons. As a result of her certification termination, Dr. Joshua can only practice outpatient medicine at Detroit Medical Center.
In an interview, Dr. Baron emphasized the number of modifications made to its MOC process in recent years after responding to physician concerns. This includes an overhaul of the organization’s governance structure to include more than 200 practicing physicians and opening new avenues for physicians to engage in the creation of assessment content that more closely reflects what they see in practice, he said. In addition, ABIM now surveys all specialists to contribute to the exam blueprint review and the creation of the new Item Writing Task Force.
“We take all suggestions from physicians seriously, and have used it to launch many new initiatives including: the Knowledge Check-In, a new Physician Portal, partnerships to give physicians dual credit for CME and MOC, and exploration of alternative assessment models with medical societies,” he said.
Dr. Baron acknowledged past criticism of the MOC process, but said he is proud of the work ABIM has done to address physician concerns about the choice, relevance, and convenience of its MOC program.
*This story was updated on Feb. 6, 2019.
A group of internists is suing the American Board of Internal Medicine over its maintenance of certification (MOC) process, alleging that the board is monopolizing the MOC market.
The lawsuit, filed Dec. 6 in Pennsylvania district court, claims that ABIM is charging inflated monopoly prices for maintaining certification, that the organization is forcing physicians to purchase MOC, and that ABIM is inducing employers and others to require ABIM certification. The four plaintiff-physicians are asking a judge to find ABIM in violation of federal antitrust law and to bar the board from continuing its MOC process. The suit is filed as a class action on behalf of all internists and subspecialists required by ABIM to purchase MOC to maintain their ABIM certifications. The plaintiffs seek damages and injunctive relief, plus lawsuit and attorney costs arising from ABIM’s alleged antitrust violations.
In a statement, ABIM expressed disappointment at the lawsuit and said the organization will vigorously defend itself, adding that doing so will “consume resources far better dedicated to continuous improvement of its programs.”
ABIM declined to answer questions addressing specific accusations from the lawsuit. However, in an interview, ABIM President Richard Baron, MD, said that “ABIM board-certified physicians have taken the initiative to distinguish themselves. This is a credential that physicians earn. We offer certified physicians the opportunity to demonstrate to the medical community, their peers, and the public that they are current and have special expertise.”
ABIM has not yet filed a formal response to the lawsuit, which was due by Jan. 6. Court documents show that in January, ABIM entered the appearances of four attorneys that will represent the board in the case. From there, discovery and evidence gathering in the case will begin.
Katherine Murray Leisure, MD, an infectious disease specialist based in Plymouth, Mass., is one of the plaintiffs. While she said that she could not comment specifically on the lawsuit, she has written publicly about her ABIM concerns in the past.
In a 2015 letter to Dr. Baron and posted on an anti-MOC website, Dr. Murray outlined a litany of complaints against ABIM’s MOC process and called on the U.S. Congress to investigate ABIM’s financial, legal, and ethical conduct.
“[The American Board of Medical Specialties] and ABIM collected more than $10,000 in fees and lost practice hours every decade from each [diplomate] doing MOC,” Dr. Murray Leisure wrote. “MOC took weeks away from our offices, clinics, patients, families, specialty societies, and individual research. ABMS MOC removed hundreds, perhaps thousands … of America’s best, once board-certified physicians from full hospital careers and earnings whenever [diplomates] did not complete these high-stakes MOC programs. … The righteous and fast solution to such moral, ethical, scientific, and constitutional problems is to end MOC now.”
Plaintiffs Glen Dela Cruz Manalo, MD; Alexa Joshua, MD; and Gerard Kenney, MD, did not return messages seeking comment. When contacted, attorneys for the plaintiffs declined to comment.
The doctors’ 32-page lawsuit characterizes ABIM as an organization motivated by money that has made its MOC process increasingly more burdensome for physicians over the years without evidence that MOC has any beneficial impact on doctors, patients, or the public. Complying with ABIM’s MOC costs internists an average of $23,607 in financial cost and time lost over 10 years, and costs up to $40,495 for some specialists, according to the suit.
The physicians allege that ABIM controls in excess of 95% of the market for MOC of internists, in violation of federal antitrust laws, and that the organization has unlawfully obtained and maintained monopoly power for MOC services.
The board’s illegal tying of its initial certification to its MOC results in burdensome conditions, including “raising the cost of the practice of medicine, constraining the supply of internists thereby harming competition, decreasing the supply of certified internists, and increasing the cost of medical services to patients and consumers,” the suit claims.
The legal challenge details how MOC has personally and professionally impacted each of the four plaintiffs. Dr. Manalo, a gastroenterologist, lost his privileges at St. Vincent Healthcare in Billings, Mont., and was subsequently terminated after he declined to maintain his ABIM certification as a gastroenterologist. In a letter to ABIM, Dr. Manalo wrote that it was “unfair and outright discriminatory that practitioners certified on or after 1990 are the only ones required to certify,” according to the lawsuit. Dr. Manalo later took a position as staff gastroenterologist at Jonathan M. Wainwright Memorial Veterans Affairs Medical Center in Walla Walla, Wash., at a substantially reduced salary. He became unemployed in 2017.
Dr. Murray Leisure obtained an initial and lifelong board certification in internal medicine from ABIM in 1984 and an infectious disease certification in 1990. ABlM terminated Dr. Murray’s infectious diseases certification after she failed her MOC examination in 2009, which led to lost privileges at Jordan Hospital in Plymouth, Mass. The loss caused significant damage to Dr. Murray, including lost income, a tarnished reputation, and the lost opportunity to help patients, according to the lawsuit. Jordan Hospital restored her privileges after Dr. Murray passed her MOC examination in 2012.
Dr. Kenney lost a job opportunity with Mount Nittany Physicians Group in State College, Pa., after he declined to renew his ABIM certification in gastroenterology. He is currently a physician with the University of Pittsburgh Medical Center in Seneca, Pa.
That the ABIM website lists him as “not certified,” is misleading, and makes it appear that his initial certifications were revoked due to failure to pass a MOC examination or misconduct, rather than because the certifications lapsed, according to the suit. The description makes Dr. Kenney appear less qualified to patients, hospitals, insurance companies, medical corporations, other employers, and others, he claims.
Dr. Joshua could not renew her consulting and admitting privileges at Detroit Medical Center after she failed an MOC examination in 2014 and became uncertified in internal medicine, according to the suit. In addition, Blue Cross Blue Shield informed Dr. Joshua it would no longer cover her because it required ABIM certification for coverage. She unsuccessfully appealed based on her certification with the National Board of Physicians and Surgeons. As a result of her certification termination, Dr. Joshua can only practice outpatient medicine at Detroit Medical Center.
In an interview, Dr. Baron emphasized the number of modifications made to its MOC process in recent years after responding to physician concerns. This includes an overhaul of the organization’s governance structure to include more than 200 practicing physicians and opening new avenues for physicians to engage in the creation of assessment content that more closely reflects what they see in practice, he said. In addition, ABIM now surveys all specialists to contribute to the exam blueprint review and the creation of the new Item Writing Task Force.
“We take all suggestions from physicians seriously, and have used it to launch many new initiatives including: the Knowledge Check-In, a new Physician Portal, partnerships to give physicians dual credit for CME and MOC, and exploration of alternative assessment models with medical societies,” he said.
Dr. Baron acknowledged past criticism of the MOC process, but said he is proud of the work ABIM has done to address physician concerns about the choice, relevance, and convenience of its MOC program.
*This story was updated on Feb. 6, 2019.
A group of internists is suing the American Board of Internal Medicine over its maintenance of certification (MOC) process, alleging that the board is monopolizing the MOC market.
The lawsuit, filed Dec. 6 in Pennsylvania district court, claims that ABIM is charging inflated monopoly prices for maintaining certification, that the organization is forcing physicians to purchase MOC, and that ABIM is inducing employers and others to require ABIM certification. The four plaintiff-physicians are asking a judge to find ABIM in violation of federal antitrust law and to bar the board from continuing its MOC process. The suit is filed as a class action on behalf of all internists and subspecialists required by ABIM to purchase MOC to maintain their ABIM certifications. The plaintiffs seek damages and injunctive relief, plus lawsuit and attorney costs arising from ABIM’s alleged antitrust violations.
In a statement, ABIM expressed disappointment at the lawsuit and said the organization will vigorously defend itself, adding that doing so will “consume resources far better dedicated to continuous improvement of its programs.”
ABIM declined to answer questions addressing specific accusations from the lawsuit. However, in an interview, ABIM President Richard Baron, MD, said that “ABIM board-certified physicians have taken the initiative to distinguish themselves. This is a credential that physicians earn. We offer certified physicians the opportunity to demonstrate to the medical community, their peers, and the public that they are current and have special expertise.”
ABIM has not yet filed a formal response to the lawsuit, which was due by Jan. 6. Court documents show that in January, ABIM entered the appearances of four attorneys that will represent the board in the case. From there, discovery and evidence gathering in the case will begin.
Katherine Murray Leisure, MD, an infectious disease specialist based in Plymouth, Mass., is one of the plaintiffs. While she said that she could not comment specifically on the lawsuit, she has written publicly about her ABIM concerns in the past.
In a 2015 letter to Dr. Baron and posted on an anti-MOC website, Dr. Murray outlined a litany of complaints against ABIM’s MOC process and called on the U.S. Congress to investigate ABIM’s financial, legal, and ethical conduct.
“[The American Board of Medical Specialties] and ABIM collected more than $10,000 in fees and lost practice hours every decade from each [diplomate] doing MOC,” Dr. Murray Leisure wrote. “MOC took weeks away from our offices, clinics, patients, families, specialty societies, and individual research. ABMS MOC removed hundreds, perhaps thousands … of America’s best, once board-certified physicians from full hospital careers and earnings whenever [diplomates] did not complete these high-stakes MOC programs. … The righteous and fast solution to such moral, ethical, scientific, and constitutional problems is to end MOC now.”
Plaintiffs Glen Dela Cruz Manalo, MD; Alexa Joshua, MD; and Gerard Kenney, MD, did not return messages seeking comment. When contacted, attorneys for the plaintiffs declined to comment.
The doctors’ 32-page lawsuit characterizes ABIM as an organization motivated by money that has made its MOC process increasingly more burdensome for physicians over the years without evidence that MOC has any beneficial impact on doctors, patients, or the public. Complying with ABIM’s MOC costs internists an average of $23,607 in financial cost and time lost over 10 years, and costs up to $40,495 for some specialists, according to the suit.
The physicians allege that ABIM controls in excess of 95% of the market for MOC of internists, in violation of federal antitrust laws, and that the organization has unlawfully obtained and maintained monopoly power for MOC services.
The board’s illegal tying of its initial certification to its MOC results in burdensome conditions, including “raising the cost of the practice of medicine, constraining the supply of internists thereby harming competition, decreasing the supply of certified internists, and increasing the cost of medical services to patients and consumers,” the suit claims.
The legal challenge details how MOC has personally and professionally impacted each of the four plaintiffs. Dr. Manalo, a gastroenterologist, lost his privileges at St. Vincent Healthcare in Billings, Mont., and was subsequently terminated after he declined to maintain his ABIM certification as a gastroenterologist. In a letter to ABIM, Dr. Manalo wrote that it was “unfair and outright discriminatory that practitioners certified on or after 1990 are the only ones required to certify,” according to the lawsuit. Dr. Manalo later took a position as staff gastroenterologist at Jonathan M. Wainwright Memorial Veterans Affairs Medical Center in Walla Walla, Wash., at a substantially reduced salary. He became unemployed in 2017.
Dr. Murray Leisure obtained an initial and lifelong board certification in internal medicine from ABIM in 1984 and an infectious disease certification in 1990. ABlM terminated Dr. Murray’s infectious diseases certification after she failed her MOC examination in 2009, which led to lost privileges at Jordan Hospital in Plymouth, Mass. The loss caused significant damage to Dr. Murray, including lost income, a tarnished reputation, and the lost opportunity to help patients, according to the lawsuit. Jordan Hospital restored her privileges after Dr. Murray passed her MOC examination in 2012.
Dr. Kenney lost a job opportunity with Mount Nittany Physicians Group in State College, Pa., after he declined to renew his ABIM certification in gastroenterology. He is currently a physician with the University of Pittsburgh Medical Center in Seneca, Pa.
That the ABIM website lists him as “not certified,” is misleading, and makes it appear that his initial certifications were revoked due to failure to pass a MOC examination or misconduct, rather than because the certifications lapsed, according to the suit. The description makes Dr. Kenney appear less qualified to patients, hospitals, insurance companies, medical corporations, other employers, and others, he claims.
Dr. Joshua could not renew her consulting and admitting privileges at Detroit Medical Center after she failed an MOC examination in 2014 and became uncertified in internal medicine, according to the suit. In addition, Blue Cross Blue Shield informed Dr. Joshua it would no longer cover her because it required ABIM certification for coverage. She unsuccessfully appealed based on her certification with the National Board of Physicians and Surgeons. As a result of her certification termination, Dr. Joshua can only practice outpatient medicine at Detroit Medical Center.
In an interview, Dr. Baron emphasized the number of modifications made to its MOC process in recent years after responding to physician concerns. This includes an overhaul of the organization’s governance structure to include more than 200 practicing physicians and opening new avenues for physicians to engage in the creation of assessment content that more closely reflects what they see in practice, he said. In addition, ABIM now surveys all specialists to contribute to the exam blueprint review and the creation of the new Item Writing Task Force.
“We take all suggestions from physicians seriously, and have used it to launch many new initiatives including: the Knowledge Check-In, a new Physician Portal, partnerships to give physicians dual credit for CME and MOC, and exploration of alternative assessment models with medical societies,” he said.
Dr. Baron acknowledged past criticism of the MOC process, but said he is proud of the work ABIM has done to address physician concerns about the choice, relevance, and convenience of its MOC program.
*This story was updated on Feb. 6, 2019.
Designing a better EHR
Hospitals can create a more effective system
It’s well known that overuse is an enormous problem in medicine, and when it comes to antibiotics, the problem is even more striking.
“Half of all inpatient antibiotic use is inappropriate,” says Valerie Vaughn, MD, MSc, a hospitalist at the University of Michigan, Ann Arbor, and coauthor of a BMJ editorial about EHRs and antibiotic overuse.
“This has led to an increase in antibiotic-related adverse events (~20% of all hospitalized patients on antibiotics), Clostridium difficile infections (half a million infections and 29,000 deaths in U.S. annually), and resistant bacteria (which now account for nearly 12% of all bacterial infections, costing $2.2 billion annually).”
EHRs can be a tool to combat that trend – if they are well designed. Clinicians are influenced by the design of their electronic health record, Dr. Vaughn said. “Rather than leave its influence to chance, we should capitalize on what is known about design to promote appropriate testing and treatment through the EHR.” Hospitalists – integral to quality improvement – can have a role in making these changes.
“These improvements will be the most effective if behavioral economics and nudging are considered while designing,” Dr. Vaughn said. “For example, when creating order sets, list recommended options first and when possible make them the default,” she said. “This little change will greatly improve appropriate use.”
For every hour physicians spend on direct patient care, they spend another two with the EHR, Dr. Vaughn wrote. “Given this degree of attention, it is not surprising that the EHR influences physician behavior, especially the overuse of low-value medical care. … Displaying brand-name instead of generic options leads to more expensive prescribing. Allowing labs to be ordered recurrently increases unnecessary phlebotomy. Even individually listing inappropriate antibiotics (rather than grouping them) can make them more noticeable, resulting in more broad-spectrum use.”
“All hospitalists – and humans – are affected by knee-jerk responses. One of the most common in medicine is the urge to treat a positive culture or any positive test. Recognize this urge and resist!” she said. “Antibiotics may be the correct response, but clinicians should first think about whether treatment is necessary based on that patient’s symptoms and comorbidities. Resist the knee-jerk urge to give antibiotics for every positive culture.”
Reference
Vaughn VM et al. Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. BMJ Qual Saf. 24 Mar 2018. doi: 10.1136/bmjqs-2017-007578.
Hospitals can create a more effective system
Hospitals can create a more effective system
It’s well known that overuse is an enormous problem in medicine, and when it comes to antibiotics, the problem is even more striking.
“Half of all inpatient antibiotic use is inappropriate,” says Valerie Vaughn, MD, MSc, a hospitalist at the University of Michigan, Ann Arbor, and coauthor of a BMJ editorial about EHRs and antibiotic overuse.
“This has led to an increase in antibiotic-related adverse events (~20% of all hospitalized patients on antibiotics), Clostridium difficile infections (half a million infections and 29,000 deaths in U.S. annually), and resistant bacteria (which now account for nearly 12% of all bacterial infections, costing $2.2 billion annually).”
EHRs can be a tool to combat that trend – if they are well designed. Clinicians are influenced by the design of their electronic health record, Dr. Vaughn said. “Rather than leave its influence to chance, we should capitalize on what is known about design to promote appropriate testing and treatment through the EHR.” Hospitalists – integral to quality improvement – can have a role in making these changes.
“These improvements will be the most effective if behavioral economics and nudging are considered while designing,” Dr. Vaughn said. “For example, when creating order sets, list recommended options first and when possible make them the default,” she said. “This little change will greatly improve appropriate use.”
For every hour physicians spend on direct patient care, they spend another two with the EHR, Dr. Vaughn wrote. “Given this degree of attention, it is not surprising that the EHR influences physician behavior, especially the overuse of low-value medical care. … Displaying brand-name instead of generic options leads to more expensive prescribing. Allowing labs to be ordered recurrently increases unnecessary phlebotomy. Even individually listing inappropriate antibiotics (rather than grouping them) can make them more noticeable, resulting in more broad-spectrum use.”
“All hospitalists – and humans – are affected by knee-jerk responses. One of the most common in medicine is the urge to treat a positive culture or any positive test. Recognize this urge and resist!” she said. “Antibiotics may be the correct response, but clinicians should first think about whether treatment is necessary based on that patient’s symptoms and comorbidities. Resist the knee-jerk urge to give antibiotics for every positive culture.”
Reference
Vaughn VM et al. Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. BMJ Qual Saf. 24 Mar 2018. doi: 10.1136/bmjqs-2017-007578.
It’s well known that overuse is an enormous problem in medicine, and when it comes to antibiotics, the problem is even more striking.
“Half of all inpatient antibiotic use is inappropriate,” says Valerie Vaughn, MD, MSc, a hospitalist at the University of Michigan, Ann Arbor, and coauthor of a BMJ editorial about EHRs and antibiotic overuse.
“This has led to an increase in antibiotic-related adverse events (~20% of all hospitalized patients on antibiotics), Clostridium difficile infections (half a million infections and 29,000 deaths in U.S. annually), and resistant bacteria (which now account for nearly 12% of all bacterial infections, costing $2.2 billion annually).”
EHRs can be a tool to combat that trend – if they are well designed. Clinicians are influenced by the design of their electronic health record, Dr. Vaughn said. “Rather than leave its influence to chance, we should capitalize on what is known about design to promote appropriate testing and treatment through the EHR.” Hospitalists – integral to quality improvement – can have a role in making these changes.
“These improvements will be the most effective if behavioral economics and nudging are considered while designing,” Dr. Vaughn said. “For example, when creating order sets, list recommended options first and when possible make them the default,” she said. “This little change will greatly improve appropriate use.”
For every hour physicians spend on direct patient care, they spend another two with the EHR, Dr. Vaughn wrote. “Given this degree of attention, it is not surprising that the EHR influences physician behavior, especially the overuse of low-value medical care. … Displaying brand-name instead of generic options leads to more expensive prescribing. Allowing labs to be ordered recurrently increases unnecessary phlebotomy. Even individually listing inappropriate antibiotics (rather than grouping them) can make them more noticeable, resulting in more broad-spectrum use.”
“All hospitalists – and humans – are affected by knee-jerk responses. One of the most common in medicine is the urge to treat a positive culture or any positive test. Recognize this urge and resist!” she said. “Antibiotics may be the correct response, but clinicians should first think about whether treatment is necessary based on that patient’s symptoms and comorbidities. Resist the knee-jerk urge to give antibiotics for every positive culture.”
Reference
Vaughn VM et al. Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. BMJ Qual Saf. 24 Mar 2018. doi: 10.1136/bmjqs-2017-007578.
Decreasing burnout for hospitalists
How one hospital benefited from applying LEAN principles
The symptoms of burnout include emotional exhaustion, depersonalization, and reduced personal efficacy, and burnout is a widespread problem among hospitalists; recent data suggest that half of physicians are experiencing at least one such symptom.
Health care leaders are increasingly concerned that these levels of physician burnout pose a threat to patient quality and safety. “As a result, some health care systems are shifting emphasis from the Triple Aim – population health, reduced costs, and patient satisfaction – to the Quadruple Aim, which incorporates health care provider wellness,” according to a recent abstract.
The authors began their own attempt to address the problem when Penn State Health in Dauphin County, Pa., built a stand-alone children’s hospital and experienced bed demands that exceeded bed availability, creating decreased organizational efficiency, high stress, and elevated physician burnout.
The LEAN principles offer a process-focused, customer-centered methodology that improves efficiency and quality. “We redesigned our service line using LEAN principles, such as ‘staff to demand’ and ‘standardize work,’ ” the authors wrote. “To ‘staff to demand,’ we hired three additional FTE [full-time equivalent employees]. This allowed creation of two rounding teams ([up] from one) and reduced our patient-to-attending ratio from 15:1 to 8:1. Workflow was resequenced and standardized, which enabled teams to see discharges at the start of rounds. We also provided in-house evening and overnight resident supervision. Our model permitted flexibility in physicians’ schedules, deemphasized reliance on RVUs, and heightened purpose and efficiency in work as determinants of providers’ value-adding capacity.”
As a result, both service line and hospital efficiency improved and faculty stress decreased in their hospital. “Mean stress scores decreased from 23 (preintervention) to 15 over the first 2 years, and has remained steady for a period of 3 years. Our divisional work-life balance measurement 2 years after the intervention was 85%, well above the reported average of 41%. We have maintained a low physician turnover rate at 3.5% over the last 3 years.”
Reference
Keefer L et al. LEAN in: Our secrets to decreasing provider stress, maximizing efficiency on a pediatric hospitalist service [abstract]. Accessed April 6, 2018.
How one hospital benefited from applying LEAN principles
How one hospital benefited from applying LEAN principles
The symptoms of burnout include emotional exhaustion, depersonalization, and reduced personal efficacy, and burnout is a widespread problem among hospitalists; recent data suggest that half of physicians are experiencing at least one such symptom.
Health care leaders are increasingly concerned that these levels of physician burnout pose a threat to patient quality and safety. “As a result, some health care systems are shifting emphasis from the Triple Aim – population health, reduced costs, and patient satisfaction – to the Quadruple Aim, which incorporates health care provider wellness,” according to a recent abstract.
The authors began their own attempt to address the problem when Penn State Health in Dauphin County, Pa., built a stand-alone children’s hospital and experienced bed demands that exceeded bed availability, creating decreased organizational efficiency, high stress, and elevated physician burnout.
The LEAN principles offer a process-focused, customer-centered methodology that improves efficiency and quality. “We redesigned our service line using LEAN principles, such as ‘staff to demand’ and ‘standardize work,’ ” the authors wrote. “To ‘staff to demand,’ we hired three additional FTE [full-time equivalent employees]. This allowed creation of two rounding teams ([up] from one) and reduced our patient-to-attending ratio from 15:1 to 8:1. Workflow was resequenced and standardized, which enabled teams to see discharges at the start of rounds. We also provided in-house evening and overnight resident supervision. Our model permitted flexibility in physicians’ schedules, deemphasized reliance on RVUs, and heightened purpose and efficiency in work as determinants of providers’ value-adding capacity.”
As a result, both service line and hospital efficiency improved and faculty stress decreased in their hospital. “Mean stress scores decreased from 23 (preintervention) to 15 over the first 2 years, and has remained steady for a period of 3 years. Our divisional work-life balance measurement 2 years after the intervention was 85%, well above the reported average of 41%. We have maintained a low physician turnover rate at 3.5% over the last 3 years.”
Reference
Keefer L et al. LEAN in: Our secrets to decreasing provider stress, maximizing efficiency on a pediatric hospitalist service [abstract]. Accessed April 6, 2018.
The symptoms of burnout include emotional exhaustion, depersonalization, and reduced personal efficacy, and burnout is a widespread problem among hospitalists; recent data suggest that half of physicians are experiencing at least one such symptom.
Health care leaders are increasingly concerned that these levels of physician burnout pose a threat to patient quality and safety. “As a result, some health care systems are shifting emphasis from the Triple Aim – population health, reduced costs, and patient satisfaction – to the Quadruple Aim, which incorporates health care provider wellness,” according to a recent abstract.
The authors began their own attempt to address the problem when Penn State Health in Dauphin County, Pa., built a stand-alone children’s hospital and experienced bed demands that exceeded bed availability, creating decreased organizational efficiency, high stress, and elevated physician burnout.
The LEAN principles offer a process-focused, customer-centered methodology that improves efficiency and quality. “We redesigned our service line using LEAN principles, such as ‘staff to demand’ and ‘standardize work,’ ” the authors wrote. “To ‘staff to demand,’ we hired three additional FTE [full-time equivalent employees]. This allowed creation of two rounding teams ([up] from one) and reduced our patient-to-attending ratio from 15:1 to 8:1. Workflow was resequenced and standardized, which enabled teams to see discharges at the start of rounds. We also provided in-house evening and overnight resident supervision. Our model permitted flexibility in physicians’ schedules, deemphasized reliance on RVUs, and heightened purpose and efficiency in work as determinants of providers’ value-adding capacity.”
As a result, both service line and hospital efficiency improved and faculty stress decreased in their hospital. “Mean stress scores decreased from 23 (preintervention) to 15 over the first 2 years, and has remained steady for a period of 3 years. Our divisional work-life balance measurement 2 years after the intervention was 85%, well above the reported average of 41%. We have maintained a low physician turnover rate at 3.5% over the last 3 years.”
Reference
Keefer L et al. LEAN in: Our secrets to decreasing provider stress, maximizing efficiency on a pediatric hospitalist service [abstract]. Accessed April 6, 2018.
Parental leave for residents pales in comparison to that of faculty physicians
Leave policies for residents who become new parents are uneven, oft-ignored by training boards, and provide less time off than similar policies for faculty physicians. Those were the findings of a pair of research letters published in JAMA.
Kirti Magudia, MD, of the department of radiology at Brigham and Women’s Hospital in Boston and her colleagues reviewed childbearing and family leave policies for 15 graduate medical education (GME)–sponsoring institutions, all of which were affiliated with the top 12 U.S. medical schools. Though all 12 schools provided paid childbearing or family leave for faculty physicians, only 8 of the 15 did so for residents (JAMA. 2018 Dec 11;320[22)]:2372-4).
In programs that did provide leave, the average of 6.6 weeks of paid total maternity leave for residents was less than the 8.6 weeks faculty receive. Both are considerably less than proscribed by the Family and Medical Leave Act, which requires large employers to provide 12 weeks of unpaid leave, but only after 12 months of employment.
The research focused on only institutional policies for paid leave; unpaid leave and state policies may extend the average, and departments may offer leave that goes beyond specific policies, Dr. Magudia and her colleagues noted.
Changes in the residency population make now the right time for establishing consistent family leave policies, Dr. Magudia said in an interview. “We have people starting training later; we have more female trainees. And with the Match system, you’re not in control of exactly where you’re going. You may not have a support system where you end up, and a lot of the top training institutions are in high cost-of-living areas. All of those things together can make trainees especially vulnerable, and because trainees are temporary employees, changing policies to benefit them is very challenging.
“Wellness is a huge issue in medicine, and at large in society,” she said. “Making sure people have adequate parental leave goes a long way toward reducing stress levels and helping them cope with normal life transitions. We want to take steps that promote success among a diverse community of physicians; we want to retain as many people in the field as possible, and we want them to feel supported.”
Beyond asking all GME-sponsoring institutions to adopt parental leave policies, Dr. Magudia believes trainees must be better informed. “It should be clear to training program applicants what the policies are at those institutions,” she said. “That information is extremely difficult to obtain, as we’ve discovered. You can imagine that, if you are the applicant, it can be difficult to ask about those policies during the interview process because it may affect how things turn out.”
“If we can see changes like these made in the near future,” she added, “we will be in a good place.”
In the second study, Briony K. Varda, MD, of the department of urology at Boston Children’s Hospital, and her colleagues also noted the complications of balancing parental leave with training requirements from specialty boards. They compared leave policies among American Board of Medical Specialty member organizations and found that less than half specifically mentioned parental leave for resident physicians (JAMA. 2018 Dec 11;320[22]:2374-7).
Dr. Varda and her colleagues reviewed the websites of 24 ABMS boards to determine their leave policies; 22 had policies but only 11 cited parental leave as an option for residents. Twenty boards have time-based training requirements and allow for a median of 6 weeks leave for any reason; none of the boards had a specific policy for parental leave. In addition, only eight boards had “explicit and clear clarifying language” that would allow program directors to seek exemptions for their residents.
Though limitations like not detecting all available policies – and a subjective evaluation of the policies that were reviewed – could have impacted their study, the coauthors reiterated that the median of 6 weeks leave is less than the average leave for faculty physicians. They also emphasized the detriments associated with inadequate parental leave, including delayed childbearing, use of assisted reproduction technology, and difficulty breastfeeding.
Dr. Varda underlined the issues that arise for program directors, who “must weigh potentially conflicting factors such as adhering to board and institutional policies, maintaining adequate clinical service coverage, considering precedent within the program, and ensuring that resident physicians are well trained.” To balance the needs of all involved “novel approaches such as use of competency-based rather than time-based training milestones” to determine certification eligibility and, in return, lessen the stresses for new-parent residents, she noted.
The researchers disclosed no relevant conflicts of interest.
SOURCE: Magudia K et al. JAMA. 2018 Dec 11;320[22)]:2372-4; Varda B et al. JAMA. 2018 Dec 11;320[22]:2374-7.
Recent data by Magudia et al. have highlighted the fact that family leave policies supporting parents during medical training are widely inconsistent and in many instances do not exist. Where trainee policies do exist, benefits are routinely less robust than those of permanent faculty who receive on average 30% more paid leave time. Stratifying physician wellness needs by training status seems to be a misplaced approach.
It is not only the medical field which sees inconsistencies in the way family leave is allocated for different types of jobs. Millions of Americans receive no time off after birth or adoption, at a time when corporate America offers elite benefits for child care. In medicine, however, there is an expectation that paid family leave should be the norm, perhaps because of our mission to improve the quality of health care.
Of course, there are valid distinctions between faculty and trainees: faculty are more permanent, are more professionally differentiated and accomplished than trainees, have greater responsibilities, and are recruited for their expertise. Arguably, faculty deserve better compensation than trainees.
But the importance of parental leave transcends the routine benefits arguments. There is something more universal about how we value parenting. Parental leave policies benefit the health of parent and child, increase career satisfaction, and improve retention. The process of birth or adoption, ensuing fatigue, family bonding needs, and life-restructuring will challenge all parents regardless of career status.
Awareness of the inadequacies of parental leave policies is the first step in remedying the disparities in support for our trainees. Establishing an equal and adequate family leave policy for physicians at any stage is consistent with the goal of success and well-being for us all.
Laurel Fisher, MD, AGAF, professor of clinical internal medicine, division of gastroenterology, University of Pennsylvania, Philadelphia. She reports no conflicts of interest.
Recent data by Magudia et al. have highlighted the fact that family leave policies supporting parents during medical training are widely inconsistent and in many instances do not exist. Where trainee policies do exist, benefits are routinely less robust than those of permanent faculty who receive on average 30% more paid leave time. Stratifying physician wellness needs by training status seems to be a misplaced approach.
It is not only the medical field which sees inconsistencies in the way family leave is allocated for different types of jobs. Millions of Americans receive no time off after birth or adoption, at a time when corporate America offers elite benefits for child care. In medicine, however, there is an expectation that paid family leave should be the norm, perhaps because of our mission to improve the quality of health care.
Of course, there are valid distinctions between faculty and trainees: faculty are more permanent, are more professionally differentiated and accomplished than trainees, have greater responsibilities, and are recruited for their expertise. Arguably, faculty deserve better compensation than trainees.
But the importance of parental leave transcends the routine benefits arguments. There is something more universal about how we value parenting. Parental leave policies benefit the health of parent and child, increase career satisfaction, and improve retention. The process of birth or adoption, ensuing fatigue, family bonding needs, and life-restructuring will challenge all parents regardless of career status.
Awareness of the inadequacies of parental leave policies is the first step in remedying the disparities in support for our trainees. Establishing an equal and adequate family leave policy for physicians at any stage is consistent with the goal of success and well-being for us all.
Laurel Fisher, MD, AGAF, professor of clinical internal medicine, division of gastroenterology, University of Pennsylvania, Philadelphia. She reports no conflicts of interest.
Recent data by Magudia et al. have highlighted the fact that family leave policies supporting parents during medical training are widely inconsistent and in many instances do not exist. Where trainee policies do exist, benefits are routinely less robust than those of permanent faculty who receive on average 30% more paid leave time. Stratifying physician wellness needs by training status seems to be a misplaced approach.
It is not only the medical field which sees inconsistencies in the way family leave is allocated for different types of jobs. Millions of Americans receive no time off after birth or adoption, at a time when corporate America offers elite benefits for child care. In medicine, however, there is an expectation that paid family leave should be the norm, perhaps because of our mission to improve the quality of health care.
Of course, there are valid distinctions between faculty and trainees: faculty are more permanent, are more professionally differentiated and accomplished than trainees, have greater responsibilities, and are recruited for their expertise. Arguably, faculty deserve better compensation than trainees.
But the importance of parental leave transcends the routine benefits arguments. There is something more universal about how we value parenting. Parental leave policies benefit the health of parent and child, increase career satisfaction, and improve retention. The process of birth or adoption, ensuing fatigue, family bonding needs, and life-restructuring will challenge all parents regardless of career status.
Awareness of the inadequacies of parental leave policies is the first step in remedying the disparities in support for our trainees. Establishing an equal and adequate family leave policy for physicians at any stage is consistent with the goal of success and well-being for us all.
Laurel Fisher, MD, AGAF, professor of clinical internal medicine, division of gastroenterology, University of Pennsylvania, Philadelphia. She reports no conflicts of interest.
Leave policies for residents who become new parents are uneven, oft-ignored by training boards, and provide less time off than similar policies for faculty physicians. Those were the findings of a pair of research letters published in JAMA.
Kirti Magudia, MD, of the department of radiology at Brigham and Women’s Hospital in Boston and her colleagues reviewed childbearing and family leave policies for 15 graduate medical education (GME)–sponsoring institutions, all of which were affiliated with the top 12 U.S. medical schools. Though all 12 schools provided paid childbearing or family leave for faculty physicians, only 8 of the 15 did so for residents (JAMA. 2018 Dec 11;320[22)]:2372-4).
In programs that did provide leave, the average of 6.6 weeks of paid total maternity leave for residents was less than the 8.6 weeks faculty receive. Both are considerably less than proscribed by the Family and Medical Leave Act, which requires large employers to provide 12 weeks of unpaid leave, but only after 12 months of employment.
The research focused on only institutional policies for paid leave; unpaid leave and state policies may extend the average, and departments may offer leave that goes beyond specific policies, Dr. Magudia and her colleagues noted.
Changes in the residency population make now the right time for establishing consistent family leave policies, Dr. Magudia said in an interview. “We have people starting training later; we have more female trainees. And with the Match system, you’re not in control of exactly where you’re going. You may not have a support system where you end up, and a lot of the top training institutions are in high cost-of-living areas. All of those things together can make trainees especially vulnerable, and because trainees are temporary employees, changing policies to benefit them is very challenging.
“Wellness is a huge issue in medicine, and at large in society,” she said. “Making sure people have adequate parental leave goes a long way toward reducing stress levels and helping them cope with normal life transitions. We want to take steps that promote success among a diverse community of physicians; we want to retain as many people in the field as possible, and we want them to feel supported.”
Beyond asking all GME-sponsoring institutions to adopt parental leave policies, Dr. Magudia believes trainees must be better informed. “It should be clear to training program applicants what the policies are at those institutions,” she said. “That information is extremely difficult to obtain, as we’ve discovered. You can imagine that, if you are the applicant, it can be difficult to ask about those policies during the interview process because it may affect how things turn out.”
“If we can see changes like these made in the near future,” she added, “we will be in a good place.”
In the second study, Briony K. Varda, MD, of the department of urology at Boston Children’s Hospital, and her colleagues also noted the complications of balancing parental leave with training requirements from specialty boards. They compared leave policies among American Board of Medical Specialty member organizations and found that less than half specifically mentioned parental leave for resident physicians (JAMA. 2018 Dec 11;320[22]:2374-7).
Dr. Varda and her colleagues reviewed the websites of 24 ABMS boards to determine their leave policies; 22 had policies but only 11 cited parental leave as an option for residents. Twenty boards have time-based training requirements and allow for a median of 6 weeks leave for any reason; none of the boards had a specific policy for parental leave. In addition, only eight boards had “explicit and clear clarifying language” that would allow program directors to seek exemptions for their residents.
Though limitations like not detecting all available policies – and a subjective evaluation of the policies that were reviewed – could have impacted their study, the coauthors reiterated that the median of 6 weeks leave is less than the average leave for faculty physicians. They also emphasized the detriments associated with inadequate parental leave, including delayed childbearing, use of assisted reproduction technology, and difficulty breastfeeding.
Dr. Varda underlined the issues that arise for program directors, who “must weigh potentially conflicting factors such as adhering to board and institutional policies, maintaining adequate clinical service coverage, considering precedent within the program, and ensuring that resident physicians are well trained.” To balance the needs of all involved “novel approaches such as use of competency-based rather than time-based training milestones” to determine certification eligibility and, in return, lessen the stresses for new-parent residents, she noted.
The researchers disclosed no relevant conflicts of interest.
SOURCE: Magudia K et al. JAMA. 2018 Dec 11;320[22)]:2372-4; Varda B et al. JAMA. 2018 Dec 11;320[22]:2374-7.
Leave policies for residents who become new parents are uneven, oft-ignored by training boards, and provide less time off than similar policies for faculty physicians. Those were the findings of a pair of research letters published in JAMA.
Kirti Magudia, MD, of the department of radiology at Brigham and Women’s Hospital in Boston and her colleagues reviewed childbearing and family leave policies for 15 graduate medical education (GME)–sponsoring institutions, all of which were affiliated with the top 12 U.S. medical schools. Though all 12 schools provided paid childbearing or family leave for faculty physicians, only 8 of the 15 did so for residents (JAMA. 2018 Dec 11;320[22)]:2372-4).
In programs that did provide leave, the average of 6.6 weeks of paid total maternity leave for residents was less than the 8.6 weeks faculty receive. Both are considerably less than proscribed by the Family and Medical Leave Act, which requires large employers to provide 12 weeks of unpaid leave, but only after 12 months of employment.
The research focused on only institutional policies for paid leave; unpaid leave and state policies may extend the average, and departments may offer leave that goes beyond specific policies, Dr. Magudia and her colleagues noted.
Changes in the residency population make now the right time for establishing consistent family leave policies, Dr. Magudia said in an interview. “We have people starting training later; we have more female trainees. And with the Match system, you’re not in control of exactly where you’re going. You may not have a support system where you end up, and a lot of the top training institutions are in high cost-of-living areas. All of those things together can make trainees especially vulnerable, and because trainees are temporary employees, changing policies to benefit them is very challenging.
“Wellness is a huge issue in medicine, and at large in society,” she said. “Making sure people have adequate parental leave goes a long way toward reducing stress levels and helping them cope with normal life transitions. We want to take steps that promote success among a diverse community of physicians; we want to retain as many people in the field as possible, and we want them to feel supported.”
Beyond asking all GME-sponsoring institutions to adopt parental leave policies, Dr. Magudia believes trainees must be better informed. “It should be clear to training program applicants what the policies are at those institutions,” she said. “That information is extremely difficult to obtain, as we’ve discovered. You can imagine that, if you are the applicant, it can be difficult to ask about those policies during the interview process because it may affect how things turn out.”
“If we can see changes like these made in the near future,” she added, “we will be in a good place.”
In the second study, Briony K. Varda, MD, of the department of urology at Boston Children’s Hospital, and her colleagues also noted the complications of balancing parental leave with training requirements from specialty boards. They compared leave policies among American Board of Medical Specialty member organizations and found that less than half specifically mentioned parental leave for resident physicians (JAMA. 2018 Dec 11;320[22]:2374-7).
Dr. Varda and her colleagues reviewed the websites of 24 ABMS boards to determine their leave policies; 22 had policies but only 11 cited parental leave as an option for residents. Twenty boards have time-based training requirements and allow for a median of 6 weeks leave for any reason; none of the boards had a specific policy for parental leave. In addition, only eight boards had “explicit and clear clarifying language” that would allow program directors to seek exemptions for their residents.
Though limitations like not detecting all available policies – and a subjective evaluation of the policies that were reviewed – could have impacted their study, the coauthors reiterated that the median of 6 weeks leave is less than the average leave for faculty physicians. They also emphasized the detriments associated with inadequate parental leave, including delayed childbearing, use of assisted reproduction technology, and difficulty breastfeeding.
Dr. Varda underlined the issues that arise for program directors, who “must weigh potentially conflicting factors such as adhering to board and institutional policies, maintaining adequate clinical service coverage, considering precedent within the program, and ensuring that resident physicians are well trained.” To balance the needs of all involved “novel approaches such as use of competency-based rather than time-based training milestones” to determine certification eligibility and, in return, lessen the stresses for new-parent residents, she noted.
The researchers disclosed no relevant conflicts of interest.
SOURCE: Magudia K et al. JAMA. 2018 Dec 11;320[22)]:2372-4; Varda B et al. JAMA. 2018 Dec 11;320[22]:2374-7.
FROM JAMA
Social media can help doctors stay up to date
SAN DIEGO –
“People want to see that you’re a person and not strictly a physician,” said Dr. Yates, a pediatric hematologist at Texas Children’s Hospital in Houston, who has had an active Twitter presence for the last few years.
Dr. Yates – whose Twitter handle is @sicklecelldoc – said she dipped a toe in the social media waters because she wanted to bring accurate medical information to patients in the arena where they are seeking information.
“I want families to understand their condition as well as they can on whatever level they can, and so I just found this to be another way to do that ... outside of my clinic,” she said during an interview at the annual meeting of the American Society of Hematology.
But beyond correcting misinformation and serving as an advocate for patients, Dr. Yates said she gets professional benefits from being on Twitter. For instance, she uses the platform to find relevant articles as soon as they publish, without wading through all the journals.
“It’s allowed me to kind of streamline what I read,” she said.
Dr. Yates said Twitter is her social media platform of choice because it provides a simple, succinct way to communicate and provide links to more in-depth resources.
While social media can be fun and rewarding for physicians, Dr. Yates said think before you post. Ask yourself, “would you tell your chairperson this?”
Dr. Yates reported having no relevant financial disclosures.
SAN DIEGO –
“People want to see that you’re a person and not strictly a physician,” said Dr. Yates, a pediatric hematologist at Texas Children’s Hospital in Houston, who has had an active Twitter presence for the last few years.
Dr. Yates – whose Twitter handle is @sicklecelldoc – said she dipped a toe in the social media waters because she wanted to bring accurate medical information to patients in the arena where they are seeking information.
“I want families to understand their condition as well as they can on whatever level they can, and so I just found this to be another way to do that ... outside of my clinic,” she said during an interview at the annual meeting of the American Society of Hematology.
But beyond correcting misinformation and serving as an advocate for patients, Dr. Yates said she gets professional benefits from being on Twitter. For instance, she uses the platform to find relevant articles as soon as they publish, without wading through all the journals.
“It’s allowed me to kind of streamline what I read,” she said.
Dr. Yates said Twitter is her social media platform of choice because it provides a simple, succinct way to communicate and provide links to more in-depth resources.
While social media can be fun and rewarding for physicians, Dr. Yates said think before you post. Ask yourself, “would you tell your chairperson this?”
Dr. Yates reported having no relevant financial disclosures.
SAN DIEGO –
“People want to see that you’re a person and not strictly a physician,” said Dr. Yates, a pediatric hematologist at Texas Children’s Hospital in Houston, who has had an active Twitter presence for the last few years.
Dr. Yates – whose Twitter handle is @sicklecelldoc – said she dipped a toe in the social media waters because she wanted to bring accurate medical information to patients in the arena where they are seeking information.
“I want families to understand their condition as well as they can on whatever level they can, and so I just found this to be another way to do that ... outside of my clinic,” she said during an interview at the annual meeting of the American Society of Hematology.
But beyond correcting misinformation and serving as an advocate for patients, Dr. Yates said she gets professional benefits from being on Twitter. For instance, she uses the platform to find relevant articles as soon as they publish, without wading through all the journals.
“It’s allowed me to kind of streamline what I read,” she said.
Dr. Yates said Twitter is her social media platform of choice because it provides a simple, succinct way to communicate and provide links to more in-depth resources.
While social media can be fun and rewarding for physicians, Dr. Yates said think before you post. Ask yourself, “would you tell your chairperson this?”
Dr. Yates reported having no relevant financial disclosures.
REPORTING FROM ASH 2018
Unit-based assignments: Pros and cons
Geographic cohorting shows ‘varying success’
A relatively recent practice catching on in many different hospitalist groups is geographic cohorting, or unit-based assignments. Traditionally, most hospitalists have had patients assigned on multiple different units. Unit-based assignments have been touted as a way of improving interdisciplinary communication and provider and patient satisfaction.1
How frequently are hospital medicine groups using unit-based assignments? SHM sought to quantify this trend in the recently published 2018 State of Hospital Medicine Report. Overall, among hospital medicine groups serving adults only, a little over one-third (36.4%) of groups reported utilizing unit-based assignments. However, there was significant variation, particularly dependent on group size. Geographic cohorting was used only in 7.6% of groups with 4 or fewer full-time equivalents, and in 68.8% of groups with 30 or more FTE. These data seem logical, as the potential gains from cohorting likely increase with group/hospital size, where physicians would otherwise round on an increasingly large number of units.
As has been shared in the hospital medicine literature, groups have experienced variable success with geographic cohorting. Improvements have been achieved in interprofessional collaboration, efficiency, nursing satisfaction,2 and, in some instances, length of stay. Unit-based assignments have allowed some groups to pilot other interventions, such as interdisciplinary rounds.
But geographic cohorting comes with its implementation challenges, too. For example, in many hospitals, some units have differing telemetry or nursing capabilities. And, in other institutions, there are units providing specialized care, such as care for neurology or oncology patients. The workload for hospitalists caring for particular types of patients may vary, and with specialty units, it may be more difficult to keep a similar census assigned to each hospitalist.
While some groups have noted increased professional satisfaction, others have noted decreases in satisfaction. One reason is that, while the frequency of paging may decrease, this is replaced by an increase in face-to-face interruptions. Also, unit-based assignments in some groups have resulted in hospitalists perceiving they are working in silos because of a decrease in interactions and camaraderie among providers in the same hospital medicine group.
At my home institution, University of California, San Diego, geographic cohorting has largely been a successful and positively perceived change. Our efforts have been particularly successful at one of our two campuses where most units have telemetry capabilities and where we have a dedicated daytime admitter (there are data on this in the Report as well, and a dedicated daytime admitter is the topic of a future Survey Insights column). Unit-based assignments have allowed the implementation of what we’ve termed focused interdisciplinary rounds.
Our unit-based assignments are not perfect – we re-cohort each week when new hospitalists come on service, and some hospitalists are assigned a small number of patients off their home unit. Our internal data have shown a significant increase in patient satisfaction scores, but we have not realized a decrease in length of stay. Despite an overall positive perception, hospitalists have sometimes noted an imbalanced workload – we have a particularly challenging oncology/palliative unit and a daytime admitter that is at times very busy. Our system also requires the use of physician time to assign patients each morning and each week.
In contrast, while we’ve aimed to achieve the same success with unit-based assignments at our other campus, we’ve faced more challenges there. Our other facility is older, and fewer units have telemetry capabilities. A more traditional teaching structure also means that teams take turns with on-call admitting days, as opposed to a daytime admitter structure, and there may not be beds available in the unit assigned to the admitting team of the day.
Overall, geographic cohorting is likely to be considered or implemented in many hospital medicine groups, and efforts have met with varying success. There are certainly pros and cons to every model, and if your group is looking at redesigning services to include unit-based assignments, it’s worth examining the intended outcomes. While unit-based assignments are not for every group, there’s no doubt that this trend has been driven by our specialty’s commitment to outcome-driven process improvement.
Addendum added Feb. 15, 2019: The impact of UC San Diego's efforts discussed in this article are the author's own opinions through limited participation in focused interdisciplinary rounds, and have not been validated with formal data analysis. More study is in progress on the impact of focused interdiscplinary rounds on communication, utilization, and quality metrics. Sarah Horman, MD ([email protected]), Daniel Bouland, MD ([email protected]), and William Frederick, MD ([email protected]), have led efforts at UC San Diego to develop and implement focused interdisciplinary rounds, and may be contacted for further information.
Dr. Huang is physician advisor for care management and associate clinical professor in the division of hospital medicine at the University of California, San Diego. He is a member of SHM’s practice analysis subcommittee.
References
1. O’Leary KJ et al. Interdisciplinary teamwork in hospitals: A review and practical recommendations for improvement. J Hosp Med. 2012 Jan;7(1):48-54.
2. Kara A et al. Hospital-based clinicians’ perceptions of geographic cohorting: Identifying opportunities for improvement. Am J Med Qual. 2018 May/Jun;33(3):303-12.
Geographic cohorting shows ‘varying success’
Geographic cohorting shows ‘varying success’
A relatively recent practice catching on in many different hospitalist groups is geographic cohorting, or unit-based assignments. Traditionally, most hospitalists have had patients assigned on multiple different units. Unit-based assignments have been touted as a way of improving interdisciplinary communication and provider and patient satisfaction.1
How frequently are hospital medicine groups using unit-based assignments? SHM sought to quantify this trend in the recently published 2018 State of Hospital Medicine Report. Overall, among hospital medicine groups serving adults only, a little over one-third (36.4%) of groups reported utilizing unit-based assignments. However, there was significant variation, particularly dependent on group size. Geographic cohorting was used only in 7.6% of groups with 4 or fewer full-time equivalents, and in 68.8% of groups with 30 or more FTE. These data seem logical, as the potential gains from cohorting likely increase with group/hospital size, where physicians would otherwise round on an increasingly large number of units.
As has been shared in the hospital medicine literature, groups have experienced variable success with geographic cohorting. Improvements have been achieved in interprofessional collaboration, efficiency, nursing satisfaction,2 and, in some instances, length of stay. Unit-based assignments have allowed some groups to pilot other interventions, such as interdisciplinary rounds.
But geographic cohorting comes with its implementation challenges, too. For example, in many hospitals, some units have differing telemetry or nursing capabilities. And, in other institutions, there are units providing specialized care, such as care for neurology or oncology patients. The workload for hospitalists caring for particular types of patients may vary, and with specialty units, it may be more difficult to keep a similar census assigned to each hospitalist.
While some groups have noted increased professional satisfaction, others have noted decreases in satisfaction. One reason is that, while the frequency of paging may decrease, this is replaced by an increase in face-to-face interruptions. Also, unit-based assignments in some groups have resulted in hospitalists perceiving they are working in silos because of a decrease in interactions and camaraderie among providers in the same hospital medicine group.
At my home institution, University of California, San Diego, geographic cohorting has largely been a successful and positively perceived change. Our efforts have been particularly successful at one of our two campuses where most units have telemetry capabilities and where we have a dedicated daytime admitter (there are data on this in the Report as well, and a dedicated daytime admitter is the topic of a future Survey Insights column). Unit-based assignments have allowed the implementation of what we’ve termed focused interdisciplinary rounds.
Our unit-based assignments are not perfect – we re-cohort each week when new hospitalists come on service, and some hospitalists are assigned a small number of patients off their home unit. Our internal data have shown a significant increase in patient satisfaction scores, but we have not realized a decrease in length of stay. Despite an overall positive perception, hospitalists have sometimes noted an imbalanced workload – we have a particularly challenging oncology/palliative unit and a daytime admitter that is at times very busy. Our system also requires the use of physician time to assign patients each morning and each week.
In contrast, while we’ve aimed to achieve the same success with unit-based assignments at our other campus, we’ve faced more challenges there. Our other facility is older, and fewer units have telemetry capabilities. A more traditional teaching structure also means that teams take turns with on-call admitting days, as opposed to a daytime admitter structure, and there may not be beds available in the unit assigned to the admitting team of the day.
Overall, geographic cohorting is likely to be considered or implemented in many hospital medicine groups, and efforts have met with varying success. There are certainly pros and cons to every model, and if your group is looking at redesigning services to include unit-based assignments, it’s worth examining the intended outcomes. While unit-based assignments are not for every group, there’s no doubt that this trend has been driven by our specialty’s commitment to outcome-driven process improvement.
Addendum added Feb. 15, 2019: The impact of UC San Diego's efforts discussed in this article are the author's own opinions through limited participation in focused interdisciplinary rounds, and have not been validated with formal data analysis. More study is in progress on the impact of focused interdiscplinary rounds on communication, utilization, and quality metrics. Sarah Horman, MD ([email protected]), Daniel Bouland, MD ([email protected]), and William Frederick, MD ([email protected]), have led efforts at UC San Diego to develop and implement focused interdisciplinary rounds, and may be contacted for further information.
Dr. Huang is physician advisor for care management and associate clinical professor in the division of hospital medicine at the University of California, San Diego. He is a member of SHM’s practice analysis subcommittee.
References
1. O’Leary KJ et al. Interdisciplinary teamwork in hospitals: A review and practical recommendations for improvement. J Hosp Med. 2012 Jan;7(1):48-54.
2. Kara A et al. Hospital-based clinicians’ perceptions of geographic cohorting: Identifying opportunities for improvement. Am J Med Qual. 2018 May/Jun;33(3):303-12.
A relatively recent practice catching on in many different hospitalist groups is geographic cohorting, or unit-based assignments. Traditionally, most hospitalists have had patients assigned on multiple different units. Unit-based assignments have been touted as a way of improving interdisciplinary communication and provider and patient satisfaction.1
How frequently are hospital medicine groups using unit-based assignments? SHM sought to quantify this trend in the recently published 2018 State of Hospital Medicine Report. Overall, among hospital medicine groups serving adults only, a little over one-third (36.4%) of groups reported utilizing unit-based assignments. However, there was significant variation, particularly dependent on group size. Geographic cohorting was used only in 7.6% of groups with 4 or fewer full-time equivalents, and in 68.8% of groups with 30 or more FTE. These data seem logical, as the potential gains from cohorting likely increase with group/hospital size, where physicians would otherwise round on an increasingly large number of units.
As has been shared in the hospital medicine literature, groups have experienced variable success with geographic cohorting. Improvements have been achieved in interprofessional collaboration, efficiency, nursing satisfaction,2 and, in some instances, length of stay. Unit-based assignments have allowed some groups to pilot other interventions, such as interdisciplinary rounds.
But geographic cohorting comes with its implementation challenges, too. For example, in many hospitals, some units have differing telemetry or nursing capabilities. And, in other institutions, there are units providing specialized care, such as care for neurology or oncology patients. The workload for hospitalists caring for particular types of patients may vary, and with specialty units, it may be more difficult to keep a similar census assigned to each hospitalist.
While some groups have noted increased professional satisfaction, others have noted decreases in satisfaction. One reason is that, while the frequency of paging may decrease, this is replaced by an increase in face-to-face interruptions. Also, unit-based assignments in some groups have resulted in hospitalists perceiving they are working in silos because of a decrease in interactions and camaraderie among providers in the same hospital medicine group.
At my home institution, University of California, San Diego, geographic cohorting has largely been a successful and positively perceived change. Our efforts have been particularly successful at one of our two campuses where most units have telemetry capabilities and where we have a dedicated daytime admitter (there are data on this in the Report as well, and a dedicated daytime admitter is the topic of a future Survey Insights column). Unit-based assignments have allowed the implementation of what we’ve termed focused interdisciplinary rounds.
Our unit-based assignments are not perfect – we re-cohort each week when new hospitalists come on service, and some hospitalists are assigned a small number of patients off their home unit. Our internal data have shown a significant increase in patient satisfaction scores, but we have not realized a decrease in length of stay. Despite an overall positive perception, hospitalists have sometimes noted an imbalanced workload – we have a particularly challenging oncology/palliative unit and a daytime admitter that is at times very busy. Our system also requires the use of physician time to assign patients each morning and each week.
In contrast, while we’ve aimed to achieve the same success with unit-based assignments at our other campus, we’ve faced more challenges there. Our other facility is older, and fewer units have telemetry capabilities. A more traditional teaching structure also means that teams take turns with on-call admitting days, as opposed to a daytime admitter structure, and there may not be beds available in the unit assigned to the admitting team of the day.
Overall, geographic cohorting is likely to be considered or implemented in many hospital medicine groups, and efforts have met with varying success. There are certainly pros and cons to every model, and if your group is looking at redesigning services to include unit-based assignments, it’s worth examining the intended outcomes. While unit-based assignments are not for every group, there’s no doubt that this trend has been driven by our specialty’s commitment to outcome-driven process improvement.
Addendum added Feb. 15, 2019: The impact of UC San Diego's efforts discussed in this article are the author's own opinions through limited participation in focused interdisciplinary rounds, and have not been validated with formal data analysis. More study is in progress on the impact of focused interdiscplinary rounds on communication, utilization, and quality metrics. Sarah Horman, MD ([email protected]), Daniel Bouland, MD ([email protected]), and William Frederick, MD ([email protected]), have led efforts at UC San Diego to develop and implement focused interdisciplinary rounds, and may be contacted for further information.
Dr. Huang is physician advisor for care management and associate clinical professor in the division of hospital medicine at the University of California, San Diego. He is a member of SHM’s practice analysis subcommittee.
References
1. O’Leary KJ et al. Interdisciplinary teamwork in hospitals: A review and practical recommendations for improvement. J Hosp Med. 2012 Jan;7(1):48-54.
2. Kara A et al. Hospital-based clinicians’ perceptions of geographic cohorting: Identifying opportunities for improvement. Am J Med Qual. 2018 May/Jun;33(3):303-12.
ONC releases draft strategy on reducing EHR burden
A new federal proposal aims to move you away from the keyboard and back face-to-face with your patients.
The draft strategy from the Office of the National Coordinator for Health IT has three aims: to reduce the time and effort to record information in EHRs; to reduce the time and effort required to meet regulatory requirements; and to improve the functionality and ease of use of EHRs.
“This draft strategy includes recommendations that will allow physicians and other clinicians to provide effective care to their patients with a renewed sense of satisfaction for them and their patients,” Andrew Gettinger, MD, chief clinical officer at ONC, and Kate Goodrich, MD, chief medical officer at the Centers for Medicare & Medicaid Services, wrote in a recent blog post. “We are taking one more step toward improving the interoperability and usability of health information by establishing a goal, strategy, and recommendations to reduce regulatory and administrative burdens relating to the use of EHRs.”
To ease documentation burdens, the proposal seeks to “mitigate the EHR-related burden associated with a variety of administrative processes,” the draft strategy notes. “We are considering how reforming certain administrative requirements or optimizing out-of-date requirements for health IT–enabled health care provider work flows can reduce the burden of clinical documentation.”
Specifically, ONC proposes to reduce the overall regulatory burden, leverage data present in the electronic record to reduce the redocumentation, waive certain documentation requirements for participants in advanced alternative payment models (APMs), and promote standardized documentation for ordering and prior authorization.
To improve health IT usability, the draft strategy aims to “address how improvements in the design and use of health IT systems” can reduce burden and calls on clinicians, software developers, and other vendors to collaborate.
To do so, ONC recommends better alignment between EHR design and clinical work flow and making improvements to clinical decision support, as well as improving the presentation of clinical data within EHRs and clinical documentation functionality.
ONC also recommends standardizing basic clinical operations across all EHRs, designing EHR interfaces that are standard to health care delivery, and better integration of the EHR with the exam room.
The draft strategy also includes recommendations to help doctors better understand the financial requirements for successful implementation and optimize the log-in procedures to help reduce burden.
EHR reporting strategies “are designed to address many of the programmatic, technical, and operational challenges raised by stakeholders to reduce EHR-related burden associated with program reporting.”
ONC wants to simplify scoring for the “promoting interoperability” performance category in the Merit-based Incentive Payment System (MIPS) track of the Quality Payment Program and improving other measures of health IT usage; applying additional data standards to make data access, extraction, and integration across multiple systems easier and less costly; and exploring alternate, less burdensome approaches to electronic quality measurement through pilot programs and reporting program incentives.
Finally, public health reporting strategies “look at a set of topics linked to federal, state, local, territorial, and tribal government policies and public health programs, with a specific focus on EPCS [electronic prescribing for controlled substances] and PDMPs [prescription drug monitoring programs]. Where EHR-related burden remains a key barrier to progress in these areas, there are several recommendations for how stakeholders can advance these burden reduction goals related to public health.”
In this area, ONC is recommending increasing adoption of e-prescribing of controlled substances with access to medication history to better inform prescribing of controlled substances, harmonizing reporting requirements across federally funded programs to streamline reporting requirements, and providing better guidance about HIPPA and federal confidentially requirements governing substance abuse disorder to better facilitate the electronic exchange of health information for patient care.
Comments on the report may be submitted electronically through Jan. 28, 2019.
A new federal proposal aims to move you away from the keyboard and back face-to-face with your patients.
The draft strategy from the Office of the National Coordinator for Health IT has three aims: to reduce the time and effort to record information in EHRs; to reduce the time and effort required to meet regulatory requirements; and to improve the functionality and ease of use of EHRs.
“This draft strategy includes recommendations that will allow physicians and other clinicians to provide effective care to their patients with a renewed sense of satisfaction for them and their patients,” Andrew Gettinger, MD, chief clinical officer at ONC, and Kate Goodrich, MD, chief medical officer at the Centers for Medicare & Medicaid Services, wrote in a recent blog post. “We are taking one more step toward improving the interoperability and usability of health information by establishing a goal, strategy, and recommendations to reduce regulatory and administrative burdens relating to the use of EHRs.”
To ease documentation burdens, the proposal seeks to “mitigate the EHR-related burden associated with a variety of administrative processes,” the draft strategy notes. “We are considering how reforming certain administrative requirements or optimizing out-of-date requirements for health IT–enabled health care provider work flows can reduce the burden of clinical documentation.”
Specifically, ONC proposes to reduce the overall regulatory burden, leverage data present in the electronic record to reduce the redocumentation, waive certain documentation requirements for participants in advanced alternative payment models (APMs), and promote standardized documentation for ordering and prior authorization.
To improve health IT usability, the draft strategy aims to “address how improvements in the design and use of health IT systems” can reduce burden and calls on clinicians, software developers, and other vendors to collaborate.
To do so, ONC recommends better alignment between EHR design and clinical work flow and making improvements to clinical decision support, as well as improving the presentation of clinical data within EHRs and clinical documentation functionality.
ONC also recommends standardizing basic clinical operations across all EHRs, designing EHR interfaces that are standard to health care delivery, and better integration of the EHR with the exam room.
The draft strategy also includes recommendations to help doctors better understand the financial requirements for successful implementation and optimize the log-in procedures to help reduce burden.
EHR reporting strategies “are designed to address many of the programmatic, technical, and operational challenges raised by stakeholders to reduce EHR-related burden associated with program reporting.”
ONC wants to simplify scoring for the “promoting interoperability” performance category in the Merit-based Incentive Payment System (MIPS) track of the Quality Payment Program and improving other measures of health IT usage; applying additional data standards to make data access, extraction, and integration across multiple systems easier and less costly; and exploring alternate, less burdensome approaches to electronic quality measurement through pilot programs and reporting program incentives.
Finally, public health reporting strategies “look at a set of topics linked to federal, state, local, territorial, and tribal government policies and public health programs, with a specific focus on EPCS [electronic prescribing for controlled substances] and PDMPs [prescription drug monitoring programs]. Where EHR-related burden remains a key barrier to progress in these areas, there are several recommendations for how stakeholders can advance these burden reduction goals related to public health.”
In this area, ONC is recommending increasing adoption of e-prescribing of controlled substances with access to medication history to better inform prescribing of controlled substances, harmonizing reporting requirements across federally funded programs to streamline reporting requirements, and providing better guidance about HIPPA and federal confidentially requirements governing substance abuse disorder to better facilitate the electronic exchange of health information for patient care.
Comments on the report may be submitted electronically through Jan. 28, 2019.
A new federal proposal aims to move you away from the keyboard and back face-to-face with your patients.
The draft strategy from the Office of the National Coordinator for Health IT has three aims: to reduce the time and effort to record information in EHRs; to reduce the time and effort required to meet regulatory requirements; and to improve the functionality and ease of use of EHRs.
“This draft strategy includes recommendations that will allow physicians and other clinicians to provide effective care to their patients with a renewed sense of satisfaction for them and their patients,” Andrew Gettinger, MD, chief clinical officer at ONC, and Kate Goodrich, MD, chief medical officer at the Centers for Medicare & Medicaid Services, wrote in a recent blog post. “We are taking one more step toward improving the interoperability and usability of health information by establishing a goal, strategy, and recommendations to reduce regulatory and administrative burdens relating to the use of EHRs.”
To ease documentation burdens, the proposal seeks to “mitigate the EHR-related burden associated with a variety of administrative processes,” the draft strategy notes. “We are considering how reforming certain administrative requirements or optimizing out-of-date requirements for health IT–enabled health care provider work flows can reduce the burden of clinical documentation.”
Specifically, ONC proposes to reduce the overall regulatory burden, leverage data present in the electronic record to reduce the redocumentation, waive certain documentation requirements for participants in advanced alternative payment models (APMs), and promote standardized documentation for ordering and prior authorization.
To improve health IT usability, the draft strategy aims to “address how improvements in the design and use of health IT systems” can reduce burden and calls on clinicians, software developers, and other vendors to collaborate.
To do so, ONC recommends better alignment between EHR design and clinical work flow and making improvements to clinical decision support, as well as improving the presentation of clinical data within EHRs and clinical documentation functionality.
ONC also recommends standardizing basic clinical operations across all EHRs, designing EHR interfaces that are standard to health care delivery, and better integration of the EHR with the exam room.
The draft strategy also includes recommendations to help doctors better understand the financial requirements for successful implementation and optimize the log-in procedures to help reduce burden.
EHR reporting strategies “are designed to address many of the programmatic, technical, and operational challenges raised by stakeholders to reduce EHR-related burden associated with program reporting.”
ONC wants to simplify scoring for the “promoting interoperability” performance category in the Merit-based Incentive Payment System (MIPS) track of the Quality Payment Program and improving other measures of health IT usage; applying additional data standards to make data access, extraction, and integration across multiple systems easier and less costly; and exploring alternate, less burdensome approaches to electronic quality measurement through pilot programs and reporting program incentives.
Finally, public health reporting strategies “look at a set of topics linked to federal, state, local, territorial, and tribal government policies and public health programs, with a specific focus on EPCS [electronic prescribing for controlled substances] and PDMPs [prescription drug monitoring programs]. Where EHR-related burden remains a key barrier to progress in these areas, there are several recommendations for how stakeholders can advance these burden reduction goals related to public health.”
In this area, ONC is recommending increasing adoption of e-prescribing of controlled substances with access to medication history to better inform prescribing of controlled substances, harmonizing reporting requirements across federally funded programs to streamline reporting requirements, and providing better guidance about HIPPA and federal confidentially requirements governing substance abuse disorder to better facilitate the electronic exchange of health information for patient care.
Comments on the report may be submitted electronically through Jan. 28, 2019.
Feds call for EHR interoperability. Again.
WASHINGTON – In what feels like a tradition, the need to solve interoperability issues was front and center once again as the key goal presented by Health and Human Services officials at the annual meeting of the Office of the National Coordinator.
“It is actually impossible to move to a future health system, the one that we need ... without a truly interoperable system,” HHS Deputy Secretary Eric Hargan said Nov. 29 during a keynote address.
“Patients need to be able to access their own records. Period,” he added.
Mr. Hargan emphasized that the HHS will define what it wants to see regarding interoperability, but leave it up to vendors and developers to come up with solutions on how this will be accomplished.
One example that he mentioned is Blue Button 2.0, a part of the MyHealthEData initiative, which allows Medicare patients to connect their claims data to apps to help them make informed decisions about their care.
“The use of apps here reflects to potential, we believe, for patient-centered technology to improve health,” Mr. Hargan said.
He also noted that the agency is looking at how existing law and regulation – such as the antikickback statute, the Stark law, HIPAA, and federal privacy regulations – might be hindering the transition to value-based care.
This analysis is “specifically focused on understanding as quickly as we can ... how current interpretations of these laws may be impeding value-based transformation and coordinated care,” Mr. Hargan said.
ONC is also taking a look at reducing provider burden, issuing a draft strategy for comment that specifically targets provider burden related to the use of EHRs and offer up a series of recommendations to help address it.
WASHINGTON – In what feels like a tradition, the need to solve interoperability issues was front and center once again as the key goal presented by Health and Human Services officials at the annual meeting of the Office of the National Coordinator.
“It is actually impossible to move to a future health system, the one that we need ... without a truly interoperable system,” HHS Deputy Secretary Eric Hargan said Nov. 29 during a keynote address.
“Patients need to be able to access their own records. Period,” he added.
Mr. Hargan emphasized that the HHS will define what it wants to see regarding interoperability, but leave it up to vendors and developers to come up with solutions on how this will be accomplished.
One example that he mentioned is Blue Button 2.0, a part of the MyHealthEData initiative, which allows Medicare patients to connect their claims data to apps to help them make informed decisions about their care.
“The use of apps here reflects to potential, we believe, for patient-centered technology to improve health,” Mr. Hargan said.
He also noted that the agency is looking at how existing law and regulation – such as the antikickback statute, the Stark law, HIPAA, and federal privacy regulations – might be hindering the transition to value-based care.
This analysis is “specifically focused on understanding as quickly as we can ... how current interpretations of these laws may be impeding value-based transformation and coordinated care,” Mr. Hargan said.
ONC is also taking a look at reducing provider burden, issuing a draft strategy for comment that specifically targets provider burden related to the use of EHRs and offer up a series of recommendations to help address it.
WASHINGTON – In what feels like a tradition, the need to solve interoperability issues was front and center once again as the key goal presented by Health and Human Services officials at the annual meeting of the Office of the National Coordinator.
“It is actually impossible to move to a future health system, the one that we need ... without a truly interoperable system,” HHS Deputy Secretary Eric Hargan said Nov. 29 during a keynote address.
“Patients need to be able to access their own records. Period,” he added.
Mr. Hargan emphasized that the HHS will define what it wants to see regarding interoperability, but leave it up to vendors and developers to come up with solutions on how this will be accomplished.
One example that he mentioned is Blue Button 2.0, a part of the MyHealthEData initiative, which allows Medicare patients to connect their claims data to apps to help them make informed decisions about their care.
“The use of apps here reflects to potential, we believe, for patient-centered technology to improve health,” Mr. Hargan said.
He also noted that the agency is looking at how existing law and regulation – such as the antikickback statute, the Stark law, HIPAA, and federal privacy regulations – might be hindering the transition to value-based care.
This analysis is “specifically focused on understanding as quickly as we can ... how current interpretations of these laws may be impeding value-based transformation and coordinated care,” Mr. Hargan said.
ONC is also taking a look at reducing provider burden, issuing a draft strategy for comment that specifically targets provider burden related to the use of EHRs and offer up a series of recommendations to help address it.
REPORTING FROM ONC 2018
How do hospital medicine groups deal with staffing shortages?
Persistent demand for hospitalists nationally
During the last two decades, the United States health care labor market had an almost insatiable appetite for hospitalists, driving the specialty from nothing to over 50,000 members. Evidence of persistent demand for hospitalists abounds in the freshly released 2018 State of Hospital Medicine (SoHM) report: rising salaries, growing responsibility for the overall hospital census, and a diversifying scope of services.
The SoHM offers fascinating and detailed insights into these trends, as well as hundreds of other aspects of the field’s growth. Unfortunately, this expanding and dynamic labor market has a challenging side for hospitals, management companies, and hospitalist group leaders – we are constantly recruiting and dealing with open positions!
As a multisite leader at an academic health system, I’m looking toward the next season of recruitment with excitement. In the fall and winter we’re fortunate to receive applications from the best and brightest graduating residents and hospitalists. I realize this is a blessing, particularly compared with programs in rural areas that may not hear from many applicants. However, even when we succeed at filling the openings, there is an inevitable trickle of talent out of our clinical labor pool during the spring and summer. One person is invited to spend 20% of their time leading a teaching program, another secures a highly coveted grant, and yet another has to move because their spouse is relocated. By then, we don’t have a packed roster of applicants and have to solve the challenge in other ways. What does the typical hospital medicine program do when faced with this circumstance?
The 2018 SoHM survey first asked program leaders whether they had open and unfilled physician positions during the last year because of turnover, growth, or other factors. On average, 66% of groups serving adults and 48% of groups serving children said “yes.” For the job seekers out there, take note of some important regional differences: The regions with the highest percentage of programs dealing with unfilled positions were the East and West Coasts at 79% and 73%, respectively.
Next, the survey asked respondents to describe the percentage of total approved physician staffing that was open or unfilled during the year. On average, 12% of positions went unfilled, with important variation between different types of employers. For a typical HM group with 15 full-time equivalents, that means constantly working short two physicians!
Not only is it hard for group leaders to manage chronic understaffing, it definitely takes a toll on the group. We asked leaders to describe all of the ways their groups address coverage of the open positions. The most common tactics were for existing hospitalists to perform voluntary extra shifts (70%) and the use of moonlighters (57%). Also important were the use of locum tenens physicians (44%) and just leaving some shifts uncovered (31%).
The last option might work in a large group, where everyone can pick up an extra couple of patients, but it nonetheless degrades continuity and care progression. In a small group, leaving shifts uncovered sounds like a recipe for burnout and unsafe care – hopefully subsequent surveys will find that we can avoid that approach! Obviously, the solutions must be tailored to the group, their resources, and the alternative sources of labor available in that locality.
The SoHM report provides insight into how this is commonly handled by different employers and in different regions – we encourage anyone who is interested to purchase the report (www.hospitalmedicine.org/sohm) to dig deeper. For better or worse, the issue of unfilled positions looks likely to persist for the intermediate future. The exciting rise of hospital medicine against the backdrop of an aging population means job security, rising income, and opportunities for many to live where they choose. Until the job market saturates, though, we’ll all find ourselves looking at email inboxes with a request or two to pick up an extra shift!
Dr. White is associate professor of medicine at the University of Washington, Seattle. He is the chair of SHM’s Practice Analysis Committee.
Reference
Society of Hospital Medicine. 2018 State of Hospital Medicine Report. pp. 89, 90, 181, 152.
Persistent demand for hospitalists nationally
Persistent demand for hospitalists nationally
During the last two decades, the United States health care labor market had an almost insatiable appetite for hospitalists, driving the specialty from nothing to over 50,000 members. Evidence of persistent demand for hospitalists abounds in the freshly released 2018 State of Hospital Medicine (SoHM) report: rising salaries, growing responsibility for the overall hospital census, and a diversifying scope of services.
The SoHM offers fascinating and detailed insights into these trends, as well as hundreds of other aspects of the field’s growth. Unfortunately, this expanding and dynamic labor market has a challenging side for hospitals, management companies, and hospitalist group leaders – we are constantly recruiting and dealing with open positions!
As a multisite leader at an academic health system, I’m looking toward the next season of recruitment with excitement. In the fall and winter we’re fortunate to receive applications from the best and brightest graduating residents and hospitalists. I realize this is a blessing, particularly compared with programs in rural areas that may not hear from many applicants. However, even when we succeed at filling the openings, there is an inevitable trickle of talent out of our clinical labor pool during the spring and summer. One person is invited to spend 20% of their time leading a teaching program, another secures a highly coveted grant, and yet another has to move because their spouse is relocated. By then, we don’t have a packed roster of applicants and have to solve the challenge in other ways. What does the typical hospital medicine program do when faced with this circumstance?
The 2018 SoHM survey first asked program leaders whether they had open and unfilled physician positions during the last year because of turnover, growth, or other factors. On average, 66% of groups serving adults and 48% of groups serving children said “yes.” For the job seekers out there, take note of some important regional differences: The regions with the highest percentage of programs dealing with unfilled positions were the East and West Coasts at 79% and 73%, respectively.
Next, the survey asked respondents to describe the percentage of total approved physician staffing that was open or unfilled during the year. On average, 12% of positions went unfilled, with important variation between different types of employers. For a typical HM group with 15 full-time equivalents, that means constantly working short two physicians!
Not only is it hard for group leaders to manage chronic understaffing, it definitely takes a toll on the group. We asked leaders to describe all of the ways their groups address coverage of the open positions. The most common tactics were for existing hospitalists to perform voluntary extra shifts (70%) and the use of moonlighters (57%). Also important were the use of locum tenens physicians (44%) and just leaving some shifts uncovered (31%).
The last option might work in a large group, where everyone can pick up an extra couple of patients, but it nonetheless degrades continuity and care progression. In a small group, leaving shifts uncovered sounds like a recipe for burnout and unsafe care – hopefully subsequent surveys will find that we can avoid that approach! Obviously, the solutions must be tailored to the group, their resources, and the alternative sources of labor available in that locality.
The SoHM report provides insight into how this is commonly handled by different employers and in different regions – we encourage anyone who is interested to purchase the report (www.hospitalmedicine.org/sohm) to dig deeper. For better or worse, the issue of unfilled positions looks likely to persist for the intermediate future. The exciting rise of hospital medicine against the backdrop of an aging population means job security, rising income, and opportunities for many to live where they choose. Until the job market saturates, though, we’ll all find ourselves looking at email inboxes with a request or two to pick up an extra shift!
Dr. White is associate professor of medicine at the University of Washington, Seattle. He is the chair of SHM’s Practice Analysis Committee.
Reference
Society of Hospital Medicine. 2018 State of Hospital Medicine Report. pp. 89, 90, 181, 152.
During the last two decades, the United States health care labor market had an almost insatiable appetite for hospitalists, driving the specialty from nothing to over 50,000 members. Evidence of persistent demand for hospitalists abounds in the freshly released 2018 State of Hospital Medicine (SoHM) report: rising salaries, growing responsibility for the overall hospital census, and a diversifying scope of services.
The SoHM offers fascinating and detailed insights into these trends, as well as hundreds of other aspects of the field’s growth. Unfortunately, this expanding and dynamic labor market has a challenging side for hospitals, management companies, and hospitalist group leaders – we are constantly recruiting and dealing with open positions!
As a multisite leader at an academic health system, I’m looking toward the next season of recruitment with excitement. In the fall and winter we’re fortunate to receive applications from the best and brightest graduating residents and hospitalists. I realize this is a blessing, particularly compared with programs in rural areas that may not hear from many applicants. However, even when we succeed at filling the openings, there is an inevitable trickle of talent out of our clinical labor pool during the spring and summer. One person is invited to spend 20% of their time leading a teaching program, another secures a highly coveted grant, and yet another has to move because their spouse is relocated. By then, we don’t have a packed roster of applicants and have to solve the challenge in other ways. What does the typical hospital medicine program do when faced with this circumstance?
The 2018 SoHM survey first asked program leaders whether they had open and unfilled physician positions during the last year because of turnover, growth, or other factors. On average, 66% of groups serving adults and 48% of groups serving children said “yes.” For the job seekers out there, take note of some important regional differences: The regions with the highest percentage of programs dealing with unfilled positions were the East and West Coasts at 79% and 73%, respectively.
Next, the survey asked respondents to describe the percentage of total approved physician staffing that was open or unfilled during the year. On average, 12% of positions went unfilled, with important variation between different types of employers. For a typical HM group with 15 full-time equivalents, that means constantly working short two physicians!
Not only is it hard for group leaders to manage chronic understaffing, it definitely takes a toll on the group. We asked leaders to describe all of the ways their groups address coverage of the open positions. The most common tactics were for existing hospitalists to perform voluntary extra shifts (70%) and the use of moonlighters (57%). Also important were the use of locum tenens physicians (44%) and just leaving some shifts uncovered (31%).
The last option might work in a large group, where everyone can pick up an extra couple of patients, but it nonetheless degrades continuity and care progression. In a small group, leaving shifts uncovered sounds like a recipe for burnout and unsafe care – hopefully subsequent surveys will find that we can avoid that approach! Obviously, the solutions must be tailored to the group, their resources, and the alternative sources of labor available in that locality.
The SoHM report provides insight into how this is commonly handled by different employers and in different regions – we encourage anyone who is interested to purchase the report (www.hospitalmedicine.org/sohm) to dig deeper. For better or worse, the issue of unfilled positions looks likely to persist for the intermediate future. The exciting rise of hospital medicine against the backdrop of an aging population means job security, rising income, and opportunities for many to live where they choose. Until the job market saturates, though, we’ll all find ourselves looking at email inboxes with a request or two to pick up an extra shift!
Dr. White is associate professor of medicine at the University of Washington, Seattle. He is the chair of SHM’s Practice Analysis Committee.
Reference
Society of Hospital Medicine. 2018 State of Hospital Medicine Report. pp. 89, 90, 181, 152.