Dr. Robert E. Van Demark, President of the South Dakota State Medical Association, penned a recent editorial exploring the growing problem of physician burnout in the U.S. medical system.

From the article:

What is Burnout? 

Burnout is a syndrome characterized by exhaustion, cynicism, and reduced effectiveness. Physician burnout has been shown to influence patient care, patient safety, physician turnover, and patient satisfaction. Burnout also leads to broken relationships, alcohol use and suicidal ideation.

Who is Affected?

In a recent study from the Mayo Clinic and the American Medical Association, approximately 50 percent of physicians in the U.S. are suffering from some degree of burnout. This has increased approximately 10 percent from a previous survey done in 2010. All specialties are affected with the primary care specialties (family practice, internal medicine, pediatrics and emergency medicine) having the highest rates of burnout. In that same study, after adjusting for physician age, sex, specialty, practice setting and hours worked, physicians who used EMRs and computerized physician order entry (CPOE) were less satisfied with the amount of time spent on clerical tasks and were at higher risk for professional burnout. Burnout has also been reported in medical students, residents and residency program directors.

What are the Causes?

The reasons for burnout are variable and complex. Some physicians feel that the widespread use of EHR, electronic prescribing, electronic patient portals, and computerized physician order entry (CPOE) has led to information overload, interruption/distraction, and a dramatic change in the content of professional work. A 2015 study showed that high-stress environments (odds ratio, 13.7) and poor work control (odds ratio, 4.3) correlated with high burnout rates. The factors include chaotic clinical environments, insufficient time for documentation and use of EHR at home, short visits for complex patients, organizational ambivalence toward physician support and a need for work-life balance.

[…]

A recent paper in Clinical Orthopedics and Related Research entitled “Clinical faceoff: physician burnout – fact, fantasy, or the fourth component of the triple aim” discusses physician burnout. One of the phrases used in the article is “the triple aim.” The triple aim suggests a redesign of the health care delivery system to do the following: (1) Improve patient outcomes, (2) increase patient satisfaction, and (3) decrease overall cost. The authors suggest adding a fourth component to the triple aim: provider well-being. The most crucial cog in transforming health care is the practitioner, without whom the delivery of care is impossible. With the dramatic changes in health care today, the effect on health care providers has been largely ignored. If the System is transforming for the better, why are we seeing an epidemic of early physician retirements, career changes, and burnout?

There are many suggestions on what to do but these are not easy for physicians to accomplish. Because of the relationship between distress and the quality of care, we first need to promote physician well-being.(2) We will discuss possible solutions next month’s editorial.

Read the full article on the South Dakota State Medical Association website. 

Robert E. Van Demark is a practicing orthopedic surgeon and President of the South Dakota State Medical Association. He earned a degree in medicine from Tufts University School of Medicine and completed his residency in orthopedic surgery at Mayo Graduate School of Medicine. He is certified by the American Board of Orthopedic Surgery.

It’s no secret that EHRs have had a huge impact on the medical profession.

They impact every individual in the practice, take up a significant amount of the physician’s time, and can negatively effect revenue if claims aren’t completed correctly and submitted in a timely manner. 

Here are just a few recent statistics that demonstrate the need for a solution to the challenges and frustration presented by EHRs. 

According to a study published by the American College of Physicians in 2016 (1), and reinforced by a study published in 2017 by the University of Wisconsin School of Medicine and Public Health, physicians are spending nearly half of each work day entering patient notes into their EHRs. It’s no surprise, then, that 70% of physicians polled in a 2016 Deloitte Study (2) said EHRs actually reduce their productivity. 

As many as 61% of medical reimbursement claims contain errors, and up to 50% of those errors are administrative (according to The Advisory Board (3) and the World Health Organization (4), respectively). 

Samantha by NoteSwift was designed to alleviate the challenges that plague EHR patient note entry.

Samantha simplifies the EHR patient charting process to a single screen, eliminating countless menus and clicks, and automatically assigns all required ICD10, SNOWMED and CPT codes to save physicians time and significantly reduce EHR frustration and physician burnout. Samantha’s proprietary, patent-pending technology parses and dynamically matches typed or dictated narrative text to identify structured, discrete data and automatically place it exactly where it needs to be in the EHR.

Automating the EHR entry process with Samantha by NoteSwift saves physicians 6-8 hours a week on patient charting, eliminates administrative errors, and ensures reimbursement claims are complete and accurate. 

Learn more about Samantha.

Want to see Samantha in action? Schedule a live demonstration for your practice.

Need more information? Please contact us. 

Provider concerns about the time required to enter records into the EHR have driven the widespread use of copying and pasting patient information into electronic health records. Back in 2009, a study published in the Journal of General Internal Medicine reported that 90% of physicians used the copy and paste function in their electronic health records. More recently, the Medscape 2016 EHR Report, which surveyed over 15,000 physicians, cited 66% of physicians use copy and paste at least occasionally today. Despite maintaining popularity among most healthcare providers, this practice has inherent risks. Without careful attention, inaccurate, outdated, inappropriate or otherwise extraneous information can easily be pasted from one patient record into another, or from one EHR screen to another. All these factors jeopardize patient safety, privacy and overall quality of care.

In fact, a 2015 report from The Joint Commission cited “several sentinel events leading to patient harm,” which “reported the copy and paste function as the specific root cause.”

Sentinel events aside, copying and pasting leads to lengthy and complex patient notes, where it’s often difficult to determine the most recent complaint or treatment plan. Lengthy patient histories would be tedious for any provider to retype, but are temptingly simple to copy and paste, making the patient note much more complex (and often confusing) than it needs to be.

Patient privacy can be compromised since it’s inherent in the copy/paste function that information copied onto the system clipboard resides there until either another copy operation is performed or the application is closed. In the meantime, the data is accessible to anyone else who might use that computer.

Accuracy, security and patient safety are all put in peril when copying and pasting from one patient note into another. In addition, an inaccurate record can result in delayed or denied reimbursements for the practice.

It’s not that physicians don’t recognize the risks. In the JGIM study, 61% of physicians said that using copy and paste made it more difficult to find the new information in patient notes; and 71% said that using copy and paste resulted in outdated information in patient notes.

An article by Sara Heath in the March 2, 2016 EHR Intelligence newsletter explains the reasons behind the guidelines for the safe use of copy and paste in patient documentation, published in February 2016 by the ECRI Institute’s Partnership for Health IT Patient Safety. According to the 58-pages of the ECRI Institute’s guidelines, adopting safer copy-and-paste practices would require each practice to implement a series of cumbersome steps, including establishing new levels of staff training and oversight, flagging pasted material for easy identification, distinguishing between appropriate and inappropriate times to copy/paste, and more. It’s clear that putting the new processes into action could undermine any speed improvements derived from copying and pasting. Fortunately, there is a better way to enter patient notes, and it meets the “better technology and workflow practices to quell the problem,” which Heath calls for at the conclusion of her article.

NoteSwift works with Dragon Medical speech recognition to dramatically accelerate the entry of patient documentation in Allscripts Professional EHR™ and Allscripts TouchWorks® EHR. NoteSwift combines the speed and ease of copying and pasting with the much higher standards of accuracy, safety and privacy that come from entering customized data for each patient record. With NoteSwift, completing patient notes is 40% faster because data entry is done via natural voice commands rather than tedious and time-consuming mouse clicks and keystrokes. A typical patient note is entered in less than 3 minutes and with fewer than 5 mouse clicks.

With copy and paste, any increased speed is confined to entering narrative text. With NoteSwift, the increased speed encompasses all aspects of the patient note, including entering narrative text and structured data, navigating from screen to screen, looking up complaints, and completing and sending prescriptions and lab orders. NoteSwift’s use of bookmarks and aliases further streamlines the process. NoteSwift users not only set aside the use of copy-and-paste, but their mouse as well. And, if a provider decides to persist with the use of copy and paste, NoteSwift makes that more secure, too, because NoteSwift automatically clears the clipboard immediately following each transfer of data into the patient note.

Art Nicholas is VP of Sales and Business Development at NoteSwift

You only have to go back a few years to hear proponents of ICD-10 promising that more detailed codes would result in more timely and accurate claims and reimbursements. Was anyone really surprised, though, that adding more codes led to more coding errors?

ICD-10 coding has increased miscodes and lowered office productivity and morale due to the sheer number of codes (an eightfold increase!), their specificity, and the fact that the ultimate responsibility for codes reflecting what actually happened in the exam room resides squarely on the shoulders of the provider, whose time is the most valuable to the practice. Unfortunately, coding isn’t a skill providers are taught in medical school.

A very recent survey by ICD-10 Monitor reports improvements in some areas of coding accuracy between Q1 and Q2 of 2016, but miscodes for ambulatory services are at 17.3% overall, with some categories, such as symptoms, as high as 27.8%.

Missing, incomplete or inaccurate codes result in reimbursements being reduced, delayed or denied. Revising and appealing these claims cost the practice time and money, in some cases up to a third of the value of the claim. In other cases, claims may be approved, but they may be downcoded, bringing lower reimbursement to the practice. On the flip side, sometimes miscodes lead to inflated reimbursements, which if not rectified, can lead to expensive legal action against the practice. All these costs of miscoding affect medical practices by lowering revenue at a time when operating costs are escalating and margins are shrinking. It’s not just monthly cash flow that is at stake, but the financial viability of the practice.

Everyone involved with coding and billing needs to be adept at quickly identifying the correct billing code in every circumstance. This expertise depends on extensive training on ICD-10 codes for both providers and administrative staff—an expense of time and money that may be a hardship for many small practices.

In addition, billing staff needs the training and experience to exercise sound judgment in deciphering which medications and diagnoses are actually current amid an avalanche of data saved in lengthy and complex electronic health records. Otherwise, outdated information can impact submissions to, and decisions made, by the insurance provider.

Identifying the correct ICD-10 codes often involves time-consuming back-and-forth communications between clinical and administrative staff within the practice, staff at insurance carriers and government agencies, and oftentimes the patient, too. This is tedious even on those rare occasions when all the parties are available at the same time. The more typical scenario involves waiting on hold, waiting for information to be found, or waiting for the right individual to be available. This is compounded by the fact that staff members at insurance providers are also still coming up to speed on the new codes.

Spending more time on coding detracts from time spent caring for patients and time spent with family and friends outside the office. But, it’s not only office staff that is affected. Miscodes can be costly to patients, too, resulting in longer wait times, misdiagnoses, higher co-pays, denial of tests and treatments, and in extreme cases, loss of insurance coverage. According to a SERMO poll, 86% of 200 surveyed physicians report that ICD-10 implementation is negatively impacting patient care.

As with any new technology-based initiative, early adopters tend to be more technically proficient. As a result, it’s likely that miscodes will continue to increase as more providers transition to ICD-10. Physicians who are griping today about spending 20+ hours a week completing their patient notes, may soon think of these as the good old days.

One way to simplify the selection of ICD-10 codes is for the provider to be more descriptive when entering diagnoses. This can be a hardship for physicians typing in their notes. It’s much easier to type “pulmonary” than “pulmonary arterial hypertension.” Using voice entry for patient notes makes it much easier to enter a more descriptive diagnosis, which helps to narrow the field of code options. For example, “pulmonary” results in 100+ code choices, while “pulmonary arterial hypertension” results in only 15 choices.

Providers who rely solely on free-text notes for their patient records are at a much higher risk of miscoding because free text doesn’t generate a code and isn’t supported by billing software in the manner that structured data is. It’s likely that someone other than the physician will later use their judgment to decide upon and manually enter a code. In order to minimize the likelihood of billing errors, providers should utilize every possible opportunity to enter structured data into the EHR. With the EHR alone, or just the EHR and speech recognition software, structured data is entered via 100 or more annoying mouse clicks per note. Entering structured data by voice is faster and easier, so providers are more inclined to enter it, resulting in a patient note that supports billing and reporting.

NoteSwift helps providers to document in a manner that supports accurate coding. When NoteSwift is added to the EHR/speech recognition combination, it enables providers to use their voice to navigate through the note, enter more descriptive diagnoses and related treatment plans as structured data, and still enter their narrative text. With NoteSwift, patient notes are completed in fewer than 5 mouse clicks, ICD-10 coding is streamlined through easier entry of descriptive diagnoses, and accurate structured billing information is captured for timely, maximized reimbursements.

Art Nicholas is VP of Sales and Business Development at NoteSwift, Inc.

According to CDC FastStats, in 2013 over 78% of office-based providers had converted from paper to digital, using an EHR system. This means that for the majority of providers, regardless of where they are in the stage of their profession, computer skills will become a necessity. In a 2014 census by the Federation of State Medical Boards, providers with active EHR licenses are split between about 47% age 49 and younger, and about 51% age 50 and older. Why is this important?

Simply put, the most likely computer-savvy users are Millennials and Generation X providers, which make up about 22% and 25% of providers, respectively. The Baby Boomers make up 42%, followed by the Silent Generation at 10%. The two latter groups, which represent slightly more than half of providers, may be less savvy and comfortable with the tools that support EHR systems.

EHRs are complex systems that evolved from supporting single practices to full blown networks, including hospitals. This has been further exacerbated by the need to support Meaningful Use requirements. For most providers the learning curve is very long and time-consuming — and providers have very little time to spare today.

As a patient, I have observed that the EHR detracts from the quality of my care. My PCP, a Generation Xer, sits at the computer with his back to me, pointing and clicking.
In my professional role, I have run tests where I documented an entire patient encounter strictly with the keyboard and mouse. It’s a wonder these providers ever get home for dinner. That’s why Dr. Chris Russell created NoteSwift, a solution that uses speech recognition technology to help eliminate clicking and mousing around.

Having worked with five different EHRs in the development of third party software, I have concluded that there were few providers involved in the design of the EHR user experience. A Medical Economics survey found nearly half of the respondents believe EHRs are making patient care less effective. They claim the EHR causes them to see fewer patients per day due to the documentation requirements and the cumbersome user interfaces.

Although some EHR vendors claim they had provider input in designing these systems, the vendors had to take that input and make it compatible across various specialty areas. This took away from the so-called “provider input.” Additionally, a quick search on the web returns numerous articles discussing the fact that EHRs were essentially designed to maximize billing. Supporting new requirements, like Meaningful Use, means more structured data must be entered from the patient encounter. Rather than designing a new user interface to support these requirements more efficiently, more and busier screens, requiring more clicking, typing, and scrolling, have been added to the EHR, and onto the provider’s shoulders.

On the optimistic side, there is some pretty cool technology available that can be applied to streamline the provider’s process of documenting a patient encounter. Speech recognition is one. While pretty much a commodity today, it hasn’t been exploited to the extent it could/should be in medical practices.

Existing speech recognition packages, such as Nuance Dragon Medical or M*Modal, provide a means to enter the narrative for the patient encounter, accommodating all the specific medical terms with a high degree of accuracy. The flip side is that it has to be done a certain way, and it did not overcome all the new menus, click boxes and requirements for structured data input.

Today, NoteSwift goes beyond basic dictation by leveraging speech to drive the EHR and enter structured data virtually hands-free. It was our response to providers’ dreams of returning to the number of patients they could treat before their EHR days. I believe the opportunity exists to go even further. Cloud-based speech engines now make it possible to access speech capabilities without the need for significant hardware systems. Cloud-based speech, such as Nuance’s Speech Anywhere technology, can also free the provider from the desktop to mobile devices, which are far more convenient and portable. Furthermore, advances in areas like Natural Language Processing can free the physician from the EHR user interface altogether, allowing the provider to do what s/he is most comfortable with, which is to dictate a SOAP note.

Our vision is to enable providers to work the way they used to by dictating a patient encounter according to their own workflow, while the NoteSwift software automatically navigates them through the EHR’s sea of menus and screens — all without them being tied to their desks. And, instead of putting all the technology in their faces, keep it behind the curtain where it belongs. Let’s leave the EHR to the billing office, and help providers get back to more quality face-to-face time with their patients.

Stan Swiniarski is Vice President, Product Development at NoteSwift