MedStar’s Human Factors Center: An Interview with Dr. Raj Ratwani

Background: Recently, I had a wide ranging interview with Dr. Raj Ratwani, Acting Center Director and Scientific Director of MedStar Health’s National Center for Human Factors in Healthcare.

The center is MedStar’s patient safety, and usability applied research arm. MedStar is the Mid Atlantic area’s largest medical facility non profit operating 10 major hospitals as well as dozens of urgent care, rehab and medical groups.

MedStar set up the center, as part of its Institute for Innovation five years ago. The Institute is an in house service of several centers that conduct research, analysis, development and education. In addition to human factors, the Institute turns MedStar staff’s ideas into commercial products, conducts professional education, encourages healthy lifestyles and develops in house software products.

The Human Factors Center’s work concentrates on medical devices, as well as creating new processes and procedures. The center’s 30 person staff features physicians, nurses, engineers, product designers, patient safety, usability and human factors specialists. The Center’s focus is on both MedStar and on improving the nation’s healthcare system with grants and contracts from AHRQ, ONC, CMS, etc., as well as many device manufacturers.

Dr. Raj Ratwani

Dr. Ratwani: Dr. Ratwani’s publications are extensive and were one reason prompting my interview. I met with him in his office in the old Intelsat building along with Rachel Wynn the center’s post doctoral fellow. We covered several topics from the center’s purpose to ONC’s Meaningful Use (MU) program to the center’s examination of adverse event reporting systems.

Center’s Purpose: I started by asking him what he considered the center’s main focus? He sees the center’s mission as helping those who deliver services by reducing their distractions and errors and working more productively. He said that while the center examines software systems, devices take up the lion’s share of its time from a usability perspective.

The center works on these issues in several ways. Sometimes they just observe how users carry out a task. Other times, they may use specialized equipment such as eye tracking systems. Regardless, their aim is to aid users to reduce errors and increase accuracy. He noted how distractions can cause errors even when a user is doing something familiar. If a distraction occurs in the middle of a task, the user can forget they’ve already done a step and will needlessly repeat it. This not only takes time, but can also lead to cascading errors.

Impact: I asked him how they work with the various medical centers and asked about their track record. Being in house, he said, they have the advantage of formal ties to MedStar’s clinicians. However, he said their successes were a mixed bag. Even when there is no doubt about a change’s efficacy, its acceptance can depend on a variety of budget, logistic and personal factors.

EHR Certification. I then turned to the center’s studies of ONC’s MU vendor product certification. Under his direction, the center sent a team to eleven major EHR vendors to examine how they did their testing. Though they interviewed vendor staffs, they were unable to see testing. Within that constraint, they still found great variability in vendor’s approach. That is, even though ONC allowed vendors to choose their own definition of user centered design, vendors often strayed even from these self defined standards.

MU Program: I then asked his opinion of the MU program. He said he thought that the $40 billion spent drove EHR adoption for financial not clinical reasons. He would have preferred a more careful approach. The MU1 and MU2 programs weren’t evidence based. The program’s criteria needed more pilot and clinical studies and that interoperability and usability should have been more prominent.

Adverse Events: Our conversation then turned to the center’s approach to adverse events, that is instances involving patient safety. Ratwani is proud of a change he helped implement in Medstar’s process. Many institutions take a blame game approach to them berating and shaming those involved. MedStar treats them as teaching moments. The object is to determine root causes and how to implement change. Taking a no fault approach promotes open, candid discussions without staff fearing repercussions.

I finally asked him about his studies applying natural language processing to adverse patient safety reports. His publications in this area analyze the free text sections of adverse reporting systems. He told me they often found major themes in the report texts that the systems didn’t note. As a follow on, he described their project to manage and present the text from these systems. He explained that even though these systems capture free text, the text is so voluminous that users have a difficult time putting them to use.

My thanks to Dr. Ratwani and his staff for arranging the interview and their patience in explaining their work.

____________________________________

A word about DC’s old Intelsat building that houses the Institute. Normally, I wouldn’t comment on an office building. If you’ve seen one, etc., etc. Not so here. Built in the 1980s, it’s an example of futurist or as I prefer to call it Sci-Fi architecture and then some. The building has 14 interconnected “pods” with a façade meant to look like, well, a gargantuan satellite.

Intelsat Building

To reach an office, you go down long, open walkways suspended above an atrium. It’s all other unworldly. You wouldn’t be terribly surprised if Princess Leia rounded a corner. It’s not on the usual tourist routes and you can’t just walk in, but if you can wangle it, it’s worth a visit.

Intelsat Building Interior

 

Burnout’s Overused and Underdefined

Recently, John hosted a #HITsm chat on using technology to fight physician burnout. The topic’s certainly timely, and it got me to wondering just what is physician burnout. Now, the simple answer is fatigue. However, when I started to look around for studies and insights, I realized that burnout is neither easily defined nor understood.

The Mayo Clinic, among others, defines it this way:

Job burnout is a special type of job stress — a state of physical, emotional or mental exhaustion combined with doubts about your competence and the value of your work. 

So, it is fatigue plus self doubt. Well, that’s for starters. Burnout has its own literature niche and psychologists have taken several different cracks at a more definitive definition without any consensus other than it’s a form of depression, which doesn’t have to be work related.

Unsurprisingly, burnout is not in the DSM-5. It’s this lack of a clinical definition, which makes it easy to use burnout like catsup to cover a host of issues. I think this is exactly why we have so many references to physician or EHR burnout. You can use burnout to cover whatever you want.

It’s easy to find articles citing EHRs and  burnout. For example, a year ago April, The Hospitalist headlined, “Research Shows Link Between EHR and Physician Burnout.” The article then flatly says, “The EHR has been identified as a major contributor to physician burnout.” However, it never cites a study to back this up.

If you track back through its references, you’ll wind up at a 2013 AMA study, “Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy.” Developed by the Rand Corporation, it’s an extensive study of physician job satisfaction. Unfortunately, for those who cite it for EHR and burnout, it never links the two. In fact, the article never discusses the two together.

Not surprisingly, burnout has found its way into marketing. For example, DataMatrix says:

Physician burnout can be described as a public health crisis especially with the substantial increase over the last couple of years. The consequences are significant and affect the healthcare system by affecting the quality of care, health care costs and patient safety.

Their solution, of course, is to buy their transcription services.  What’s happened here is that physician work life dissatisfaction has been smushed together with burnout, which does a disservice to both. For example, Medscape recently published a study on burnout, which asked physicians about their experience. Interestingly, the choices it gave, such as low income, too many difficult patients – difficult being undefined — are all over the place.

That’s not to say that all physician burnout studies are useless. A recent study, Electronic Health Record Effects on Work-Life Balance and Burnout Within the I3 Population Collaborative, used a simple, five item scale to ask physicians how they viewed their work life. See Figure 1.

Figure 1 Single-Item Burnout Scale.

Their findings were far more nuanced than many others. EHRs played a role, but so did long hours. They found:

EHR proficiency training has been associated with improved job satisfaction and work-life balance.14 While increasing EHR proficiency may help, there are many potential reasons for physicians to spend after-hours on the EHR, including time management issues, inadequate clinic staffing, patient complexity, lack of scribes, challenges in mastering automatic dictation systems, cosigning resident notes, messaging, and preparing records for the next day. All of these issues and their impact on burnout and work-life balance are potential areas for future research.

There’s a need to back off the burnout rhetoric. Burnout’s overused and under defined. It’s a label for what may be any number of underlying issues. Subsuming these into one general, glitzy term, which lacks clinical definition trivializes serious problems. The next time you see something defined as physician or EHR burnout, you might just ask yourself, what is that again?

EHRs and Keyboarding: Is There an Answer?

One of the givens of EHR life is that users, especially physicians, spend excessive time keying into EHRs. The implication is that much keyboarding is due to excessive data demands, poor usability or general app cussedness. There’s no end of studies that support this. For example, a recent study at the University of Wisconsin-Madison’s Department of Family Medicine and Community Health in the Annals of Family Medicine found that:

Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. The study broke out times spent on various tasks and found, unsurprisingly, that documentation and chart review took up almost half the time.

Figure 1. Percent Physician’s Time on EHR

This study is unique among those looking at practitioners and EHRs. They note:

Although others have suggested work task categories for primary care,13 ours is the first taxonomy proposed to capture routine clinical work in EHR systems. 

They also make the point that they captured physician EHR use not total time spent with patients. Other studies have reached similar EHR use conclusions. The consensus is there too much time keyboarding and not enough time spent one to one with the patient. So, what can be done? Here, I think, are the choices:

  1. Do Nothing. Assume that this is a new world and tough it out.
  2. Use Scribes. Hire scribes to do the keyboarding for physicians.
  3. Make EHRs Easier. Improve EHRs’ usability.
  4. Make EHRs Smarter. Adapt EHRs to physician’s needs through artificial intelligence (AI) solutions.
  5. Offload to Patients. Use patient apps to input data, rather than physician keyboarding.

Examining the Alternatives

 1. Do Nothing. Making no change in either the systems or practioners’ approach means accepting the current state as the new normal. It doesn’t mean that no changes will occur. Rather, that they will continue at an incremental, perhaps glacial, pace. What this says more broadly is that the focus on keyboard, per se, is wrong. The question is not what’s going in so much as what is coming out compared to old, manual systems. For example, when PCs first became office standards, the amount of keyboarding vs. pen and paper notations went viral. PCs produced great increases in both the volume and quality of office work. This quickly became the new norm. That hasn’t happened with EHRs. There’s an assumption that the old days were better. Doing nothing acknowledges that you can’t go back. Instead, it takes a stoic approach, and assumes things will get better eventually, so just hang in there.

2. Scribes. The idea of using a scribe is simple. As a doctor examines a patient, the scribe enters the details. Scribes allow the physician to off load the keyboarding to someone with medical knowledge who understands their documentation style. There is no question that scribes can decrease physician keyboarding. This approach is gaining in popularity and is marketed by various medical societies and scribe services companies.

However, using scribes brings a host of questions. How are the implemented? I think the most important question is how a scribe fits into a system’s workflow. For example, how does an attending review a scribe’s notes to determine they convey the attending’s clinical findings, etc. The attending is the responsible party and anything that degrades or muddies that oversight is a danger to patient safety. Then, there are questions of patient privacy and just how passive an actor is a scribe?

If you’re looking for dispositive answers, you’ll have to wait. There are many studies showing scribes improve physician productivity, but few about the quality of the product.

3. Make EHRs Easier. Improving EHR usability is the holy grail of health IT and about as hard to find. ONC’s usability failings are well known and on going, but it isn’t alone. Vendors know that usability is something they can claim without having to prove. That doesn’t mean that usability and its good friend productivity aren’t important and are grossly overdue. As AHRQ recently found:

In a review of EHR safety and usability, investigators found that the switch from paper records to EHRs led to decreases in medication errors, improved guideline adherence, and (after initial implementation) enhanced safety attitudes and job satisfaction among physicians. However, the investigators found a number of problems as well.

These included usability issues, such as poor information display, complicated screen sequences and navigation, and mismatch between user workflow in the EHR and clinical workflow. The latter problems resulted in interruptions and distraction, which can contribute to medical error.

Additional safety hazards included data entry errors created by the use of copy-forward, copy-and-paste, and electronic signatures, lack of clarity in sources and date of information presented, alert fatigue, and other usability problems that can contribute to error. Similar findings were reported in a review of nurses’ experiences with EHR use, which highlighted the altered workflow and communication patterns created by the implementation of EHRs.

Improving EHR usability is not a metaphysical undertaking. What’s wrong and what works have been known for years. What’s lacking is both the regulatory and corporate will to do so. If all EHRs had to show their practical usability users would rejoice. Your best bet here may be to become active in your EHR vendor’s user group. You may not get direct relief, but you’ll have a place, albeit small, at the table. Otherwise, given vendor and regulatory resistance to usability improvements, you’re better off pushing for a new EHR or writing your own front EHR front end.

4. Make EHRs Smarter. If Watson can outsmart Kent Jennings, can’t artificial Intelligence make EHRs smarter? As one of my old friends used to tell our city council, “The answer is a qualified yes and a qualified no.”

AI takes on many, many forms and EHRs can and do use it. Primarily, these are dictation – transcription assistant systems. They’re known as Natural Language Processing (NLP). Sort of scribes without bodies. NLP takes a text stream, either live or from a recording, parses it and puts it in the EHR in its proper place. These systems combine the freedom of dictation with AI’s ability to create clinical notes. That allows, the theory maintains, a user to maintain patient contact while creating the note, thus solving the keyboarding dilemma.

 The best-known NLP system Nuance’s Dragon Medical One, etc. Several EHR vendors have integrated Dragon or similar systems into their offerings. As with most complex, technical systems, though, NLP implementation requires a full scale tech effort. Potential barriers are implementation or training shortcuts, workflow integration and staff commitment. NLP’s ability to quickly gather information and place it is a given. What’s not so certain is its cost effectiveness or its product quality. In those respects, its quality and efficacy is similar to scribes and subject to much the same scrutiny.

One interesting and wholly unexpected NLP system result occurred in a study by the University of Washington Researchers. The study group used an Android app NLP dictation system, VGEENS, that captured notes at bedside. Here’s what startled the researchers:

….Intern and resident physicians were averse to creating notes using VGEENS. When asked why this is, their answers were that they have not had experience with dictation and are reluctant to learn a new skill during their busy clinical rotations. They also commented that they are very familiar with creating notes using typing, templates, and copy paste.

The researchers forgot that medical dictation skills are just that, a skill and don’t come without training and practice. It’s a skill of older generations and that keyboarding is today’s given. 

5. Offload to Patients. I hadn’t thought of this one until I saw an article in the Harvard Business Review. In a wide ranging review, the authors saw physicians as victims of medical overconsumption and information overload:

In our recent studies of how patients responded to the introduction of a portal allowing them to e-mail health concerns to their care team, we found that the e-mail system that was expected to substitute for face-to-face visits actually increased them. Once patients began using the portal, many started sharing health updates and personal news with their care teams.

One of their solutions is to off load data collection and monitoring to patient apps:

Mightn’t we delegate some of the screening work to patients themselves? Empowering customers with easy-to-use tools transformed the tax reporting and travel industries. While we don’t expect patients to select what blood-pressure medications to be on, we probably can offload considerable amounts of the monitoring and perhaps even some of the treatment adjustment to them. Diabetes has long been managed this way, using forms of self-care that have advanced as self-monitoring technology has improved.

This may be where we are going; however, it ignores the already crowded app field. Moreover, every app seems to have its own data protocol. Health apps are a good way to capture and incorporate health data. They may be a good way to offload physicians’ keyboarding, but health apps are a tower of protocol Babel right now. This solution is as practical as saying that the way to curb double entering data in EHRs is to just make them interoperable.

What’s an EHR User to Do?

If each current approach to reducing keyboarding has problems, they are not fatal. I think that physician keyboarding is a problem and that it is subject to amelioration, if not solution.

For example, here’s Nordic’s Joel Martin on EHR usability:

… In reality, much of this extra work is a result of expanded documentation and quality measure requirements, security needs, and staffing changes. As the healthcare industry shifts its focus to value-based reimbursement and doing more with less, physician work is increasing. That work often takes place in the EHR, but it isn’t caused by the EHR’s existence.

Blaming the EHR without optimizing its use won’t solve the problem. Instead, we should take a holistic view of the issues causing provider burnout and use the system to create efficiencies, as it’s designed to do.  

The good news is that optimizing the EHR is very doable. There are many things that can be done to make it easier for providers to complete tasks in the EHR, and thereby lower the time spent in the system.

Broadly speaking, these opportunities fall into two categories.

First, many organizations have not implemented all the time-saving features that EHR vendors have created. There are features that dramatically lower the time required to complete EHR tasks for common, simple visits (for instance, upper respiratory infections). We rarely see organizations that have implemented these features at the time of our assessments, and we’re now working with many to implement them.

In addition, individual providers are often not taking advantage of features that could save them time. When we look at provider-level data, we typically see fewer than half of providers using speed and personalization features, such as features that let them rapidly reply to messages. These features could save 20 to 30 minutes a day on their own, but we see fewer than 50 percent of providers using them.

Optimization helps physicians use the EHR the way it was intended – in real-time, alongside patient care, to drive better care, fewer mistakes, and higher engagement. Ultimately, we envision a care environment where the EHR isn’t separate from patient care, but rather another tool to provide it. 

What does that mean for scribes or NLP? Recognize they are not panaceas, but tools. The field is constantly changing. Any effort to address keyboarding should look at a range of independent studies to identify their strengths and pitfalls. Note not only the major findings, but also what skills, apps, etc., they required. Then, recognize the level of effort a good implementation always requires. Finally, as UW’s researchers found,surprises are always lurking in major shake ups.

 

Usability, Interoperability are Political Questions: We Need an EHR Users Group

Over the years, writers on blogs such as EHRandHIPAA have vented their frustration with lousy EHR usability and interoperability problems. Usability has shown no real progress unless you count all the studies showing that its shortcomings cost both time and money, drives users nuts and endangers patient lives.

The last administration’s usability approach confused motion with progress with a slew of roadmaps, meetings and committees. It’s policies kowtowed to vendors. The current regime has gone them one better with a sort of faith based approach. They believe they can improve usability as long it doesn’t involve screens or workflow. Interoperability has seen progress, mostly bottom up, but there is still no national solution. Patient matching requires equal parts data, technique and clairvoyance.I think the solution to these chronic problems isn’t technical, but political. That is, vendors and ONC need to have their feet put to the fire. Otherwise, in another year or five or ten we’ll be going over the same ground again and again with the same results. That is, interop will move ever so slowly and usability will fade even more from sight – if that’s possible.

So, who could bring about this change? The one group that has no organized voice: users. Administrators, hospitals, docs, nurses and vendors have their lobbyists and associations. Not to mention telemed, app and device makers. EHR users, however, cut across each of these groups without being particularly influential in any. Some groups raise these issues; however, it’s in their context, not for users in general. This means no one speaks for common, day in day out, EHR users. They’re never at the table. They have no voice. That’s not to say there aren’t any EHR user groups. There are scads, but vendors run almost all of them.

What’s needed is a national association that represents EHR users’ interests. Until they organize and earn a place along vendors, etc., these issues won’t move. Creating a group won’t be easy. Users are widely dispersed and play many different roles. Then there is money. Users can’t afford to pony up the way vendors can. An EHR user group or association could take many forms and I don’t pretend to know which will work best. All I can do is say this:

EHR Users Unite! You Have Nothing to Lose, But Your Frustrations!

There’s a New Medicare ID Coming in April – CMS Dumps SSN

Following a 2015 Congressional directive, CMS is abandoning its Social Security based Medicare ID for a new randomly generated one. The new card will be hitting beneficiary’s mailboxes in April with everyone covered by a year later.

The old ID is a SSN plus one letter. The letter says if you are a beneficiary, child, widow, etc. The new will have both letters and numbers. It is wholly random and drops the coding for beneficiary, etc. Fortunately, it will exclude S, L, O, I, B and Z, which can look like numbers. You can see the new ID’s details here.

                           New Medicare ID Card

Claimants will have until 2020 to adopt the new IDs, but that’s not the half of it. For the HIT world, this means many difficult, expensive and time consuming changes. CMS sees this as a change in how it tracks claims. However, its impact may make HIT managers wish for the calm and quiet days of Y2K. That’s because adopting the new number for claims is just the start. Their systems use the Medicare ID as a key field for just about everything they do involving Medicare. This means they’ll not only have to cross walk to the new number, but also their systems will have to look back at what was done under the old.

Ideally, beneficiaries will only have to know their new number. Realistically, every practice they see over the next several years will want both IDs. This will add one more iteration to patient matching, which is daunting enough.

With MACRA Congress made a strong case for Medicare no longer relying on SSNs for both privacy and security reasons. Where it failed was seeing it only as a CMS problem and not as an HIT problem with many twists and turns.