This is a shared responsibility. Physicians have a responsibility for self-care and recognition that their well-being impacts their patients. However, given the prevalence of distress in medicine, it is clear that the majority of the problems are system-based -- purely individual-focused assignment of responsibility is blaming the victim.

This means organizations and health systems have a responsibility to maintain environments within which physicians can thrive. Failing to meet this obligation is to fail the patients we collectively serve.

The recent improvements with interoperability have significantly reduced administrative tasks. I frequently see patients for a second opinion and often they do not bring all of their tests results to our first visit. Previously, this would require one of my office staff to call the hospital where the test was done, have a consent signed by the patient, fax the consent, and then get a copy of the results. This would often take over an hour in the best of circumstances. Now, I can click a button and have the results as if I had ordered the test.

I think there may be a limit to how effective interoperability can be if you are interoperating with an EHR system that has inherent flaws that do not get addressed first. Also, perhaps there is a need to build an EHR that has been designed with interoperability at it's heart, vs being an afterthought to please customers.

Nonetheless, there are so many great 3rd party innovations out there that can immediately help with physician burden that allowing them to be interoperable with existing EHRs would mean significant progress in the short term I think.

I completely agree with Dr. Virani about EHR system design. While interoperability has improved administrative burden, the poor design and subsequent inefficient work flow of many of the current EHRs is far from ideal.

EHR vendors can better align EHR system design with real-world clinical workflow and testing; improve clinical decision support usability; improve clinical documentation functionality; improve presentation of clinical data within EHRs; promote user interface optimization in EHRs that will improve efficiency, experience, and end user satisfaction; and much more.

Adherence to proper human factor engineering principles can help developers better support the clinical workflow and reduce cognitive load on the end user. This process must include considerations around both product design and product testing. Just as testing a product’s performance in real-world settings is critical, individuals involved in testing must accurately represent the end-user customer base.

Health IT testing should use rigorous testing requirements and use cases. This is necessary for both pre- and post-implementation of health IT. Research has shown that there is an absence of requirements and guidance on how to test clinician interactions with EHRs—specifically around safety issues. Clinical test cases, which are scenarios that reflect realistic patient conditions and how health care providers treat individuals, can help detect hazards.

There also needs to be a concerted effort across EHR developers to harmonize clinical content in their products. Health IT industry-wide standardized use and transmission of discrete data would allow for better end user functionality by potentially creating care and documentation efficiencies and preventing life-threatening transcription errors and patient adverse events.

For more information, check out AMA’s response to the Office of National Coordinator for Health Information Technology’s strategy on reducing regulatory and administrative burden: tinyurl.com/y653wwtq

What Paul said! The end-user seems very poorly involved in product development, which would support the hypothesis that the user experience is not important to the developers or the institutions implementing these systems. If it doesn't serve the user in supporting better care for patients, it should be scrapped and the team needs to go back to the drawing board. Instead, this typically leads to retraining of the end-users to adapt to flawed systems!

Organizations that are focusing on this have made amazing strides. i use EPIC as a practicing internist. I have peer-to-peer support at my request. A physician shadows me after he has looked at my 'signal'data. He sees where i am spending the most time and shares opps for efficiencies.

Also my Division Chair turned off the requirement to reenter password and user name when I (already signed in and in a chart) prescribed a medicine. this saved me and my colleagues hours each week! he did this one phone call!!! Thank you Dr Dunham !
There are so many opportunities to decrease what comes to our inbox : copied charts, notifications of admissions, discharges and transfers etc. I turned off notifications of lab tests and xrays other MDs ordered. I trust my colleagues will attend to the results of the tests they ordered. this cut down what entered my inbox by 50
%! It can be done!

The AMA STEPS Forward modules provide numerous examples of clinics that have implemented approaches to decrease administrative burden -- edhub.ama-assn.org/steps-forwa....

Scribes! Scribe support can reduce documentation burden and improve efficiency. Physicians who have scribes report higher satisfaction and patients do not seem to mind. See: bit.ly/2mQGbR0 and bit.ly/2nqlsn7 among others

Scribes seem a sensible short-term solution, though are they really just papering over the cracks, or truly addressing the underlying issues?

Caveat to the below is that I have not personally used any of the platforms, but have heard some good things so I am sharing.

1. I attended a DrChrono (drchrono.com) presentation at the Rock Health Summit yesterday, and their EHR seems to be designed with the clinician in mind, very flexible and open to all manner of APIs. One example of their end-user focus given yesterday was that they had a PCP that runs a clinic asking them if they can include support for stylus-based text on an iPad. They said they would update their system to include this input.

2. There are many AI-powered voice assistants out there now that help with transcribing conversations into the EHR. One such example is Suki (suki.ai). They have partnered with Sutter Health amongst others. I got a (marketing) email from them yesterday highlighting feedback they had received from doctors around how Suki has helped them free up time to get to the cinema for the first time in years etc. Seems of value. There are others are like Notable Health and Saykara.

All health care stakeholders are impacted by administrative burden especially patients. The increasing amount of administrative responsibility placed upon physicians adds unnecessary costs not only to practices and the Medicare program but also negatively impacts patient care. Unnecessary administrative tasks undercut the patient-physician relationship. For example, studies have documented lower patient satisfaction when physicians spend more time looking at the computer and performing clerical tasks. Moreover, for every hour of face-to-face time with patients, physicians spend nearly two additional hours on administrative tasks throughout the day. The increase in administrative tasks is unsustainable, diverts time and focus away from patient care, and leads to additional stress and burnout among physicians.

Specifically, prior authorization (PA) requirements--which can be quite burdensome--must be carefully and thoughtfully applied to prevent care delays that can lead to negative clinical
outcomes. According to a recent AMA survey of 1,000 practicing physicians, 91 percent of physicians said that PA can delay a patient’s access to necessary care. These delays may have serious implications for patients and their health, as 75 percent of physicians reported that PA can lead to treatment abandonment, and 28 percent of physicians reported that PA has led to a serious adverse event (e.g., hospitalization, disability, death) for a patient in their care.

Thank you for sharing Paul! It's important for our community to note that administrative burden does pose immediate and potentially long term-effects for the patient.

I have been practicing medicine for 16 years and the administrative burden has impacted my colleagues and me significantly, with very little of it positive. When our group was in private practice, we utilized a small EHR with an electronic tablet and were able to stay fairly productive without much frustration. This was mainly a function of the fact the the tablet style EHR was very similar to a paper chart.

When our group was acquired by a larger healthcare system, we adopted their EHR and found that most of us were about 30% less productive. We now need rooming MA's and complicated transcription services to meet all the required meaningful use action items. Ordering a simple X-ray is now a 17 click process. Along with most of my colleagues, I have accepted the "new normal" but often discuss how much easier it was to connect with patients before the increased administrative burden of the EHR. That said, some workflows, such as calling patients with results, are more efficient, so that is a plus.

Other administrative tasks such as performing peer-to-peer discussions to get procedures approved have also had a negative impact, both personally and professionally. It seems both odd and unfair to call an organization, be put on hold for 5-10 minutes, give patient information, and then schedule a meeting for a later day with a physician who is not even seeing patients. Meanwhile, my patients are waiting in rooms wondering why I am not on time. To avoid this, I typically perform peer-to-peer tasks over my lunch hour. However, skipping meals and not having time to recharge ourselves both contribute to physician burnout, which is something else I am trying to avoid.

In summary, what I have shared is not new to anyone on this panel. I look forward to reading about and sharing some innovative approaches to decreasing administrative burden, as there are thousands of physicians who desperately need it. Thanks

Thanks for sharing, Adam! Looking forward to hearing from all of you out there!

I think one major reason (among many, including how limited physician input into EHR design is typically) behind these burdensome "hassle factors" in practice is the fact that most of this time is not directly valued. It is expected work but is not paid for. More importantly, it is not clear that most of this is beneficial to patients. Therefore, it provides no meaning, value, or purpose, the "MVP" of physician well-being.

I am not suggesting that we double down on the business-ification of medicine, but we have allowed ourselves to become helpless and voiceless victims. As Danielle Ofri wrote recently in the NYT, our own professionalism and dedication to our patients has been weaponized against us. If it doesn't serve the patient, we shouldn't do it, and we should use the time recovered in that revolution to serve our patients. Period.

These are incredible answers to start our dialog on such a broadly reaching topic.

As we move ahead in our discussion, consider how administrative burden affects us personally. Understanding this aspect of the problem gives context and provides the 'space' for deep understanding and change at the most visceral level.

The current burden has impacted me and my patients directly during each and every visit. Now there is a '3rd' person in the room that demands attention. In order to view any part of the patient's record I need to log on which may take 20 clicks and then if I don't interface in some way with the computer (while I attempt to have a conversation with the patient) I am automatically signed off after just a few minutes for security purposes. This is so unnecessary as I am in an exam room alone with the patient. This auto 'timeout' is set internally by our IT team not the EHR vendor! By design I am interrupted several times during a 20 min visit just so that I don't get logged off automatically. This does not serve our patients well.

Administrative burden pulls me away from the bedside, and distracts me when I'm home with my family. It is never ending, and draining my passion for medicine. I live the 2 hours of clerical tasks for every 1 hour of patient care. See: bit.ly/2lYqd7a. If the engineers at Toyota were spending 2/3rds of their time filling out forms rather than advancing technology the CEOs would be spending their work effort implementing meaningful change.