Moral Injury and burnout on the rise in healthcare, and tech is totally to blame!

Not really, but everyone enjoys click bait, and if you’re here, it probably worked. Keep reading!

Tech is one of the problems in Healthcare contributing to burnout, but certainly not the only one, nor the biggest, it’s a symptom of a systematic failure.

Widely reported is the ongoing healthcare worker shortage and burnout. Why is everyone so frustrated? Can tech help? What are the implications for companies or people trying to improve healthcare?

In my previous posts I’ve largely blamed EHRs and their disruption to the clinical workflow and patient interaction. I’m certainly not abandoning that, but I also acknowledge that it is part of a larger problem within healthcare about how products are brought in and iterated on in the clinical realm. In any clinical environment when there is an event we do a root cause analysis, take a step back and look at the whole environment of the clinician experience and actions. So, lets take a step back and look at the clinician experience in a corporate healthcare environment.

Depending on sources (Bureau of Labor Statistics is one), around 60%-70% of healthcare workers are employed by, or work for, a health system, this includes physician practices that are contracted with a health system. The work experience of the majority of clinicians is driven by the corporate health environment.

In my writing I operate with several assumptions:

1. No individual working in the healthcare field has the intent to do harm, be it to a patient or another healthcare worker.

2. Every clinician wants to provide the best possible care to their patients and does not try to waste resources.

3. The purpose of a corporation providing healthcare is to maximize patient outcomes.

4. Everyone will try to minimize effort… Everyone. We have policies and procedures to ensure safe practice because even clinicians will take short cuts to save time.

As in any corporation, in healthcare there are ancillary services that support the mission of the organization, finance, HR, IT, and so on. In a for profit corporation outside of healthcare it is understandable to fight for resources to provide an out-sized economic return. In a healthcare corporation the expectation of clinicians is that we fight for resources to provide the best possible patient outcomes and care. The reality of their experience is often very different from that.

For clinicians, everything is a battle.

Since I’m focusing on tech, lets start with a hypothetical, it will likely seem all too familiar to any clinicians out there.

A specialist physician finds a company that developed a software that will comb through medical records and identify essential documentation that will decrease denials and increase reimbursement, it is designed specifically for their specialty practice. The solution is elegant, unobtrusive, it references relevant standards of practice, and the doctors really like the functionality of it.

• The software will be used in the hospital for documentation, so the physician asks the manager to see about purchasing it.

• The manager figures out the savings in physician time, it will exceed the cost of subscription by 10% (well above the hospital’s ROI metric), in addition will ease the administrative burden on other staff, by an amount that’s difficult to quantify, but should be unnecessary.

• With the physician’s support the manager brings the solution to the value analysis committee, submits the VRA form to IT and notifies them of the software integration, sends off the BAA to the company, and meets with finance to add it into the budget. The physicians are enthusiastic about this and staff are happy about the decreased workload.

• One month later the value analysis committee approves.

• One month after that the manager emails IT for an update, and they ask for a meeting about the request. At the meeting is a VP from IT, Informatics VP, the physician, and the VP of the manager’s department. IT states that their current EHR vendor has a solution already built in, it’s a little more expensive, but basically does the same thing and they don’t have to worry about integration or managing another contract, the ROI is not as good, but still above the hospital threshold. They’re going to update the EHR contract and go with that service.

  • Physician states that they’ve seen that solution and it doesn’t work as well, it’s more obtrusive and difficult to use but has trouble articulating why. The manager says it will slightly increase the administrative burden on staff, but is problematic and has trouble articulating exactly why. Neither one has time to devote to provide a side by side comparison or actual numbers to prove it.

• The EHR solution is implemented. Physicians are not happy with it and don’t use it, staff do not like it because its more work.

  • IT feels that the doctors just wanted a new toy and don’t actually want to use technology, finance asks the manager to justify why reimbursements haven’t increased as expected and tell the physicians they have to use the program. Assumption 2 starts to crumble in the eyes of administration. Assumptions 1 & 3 start to crumble in the eyes of staff and physicians.

Why is everyone so frustrated?

The hypothetical situation above is indicative of the experiences of managers and clinicians throughout healthcare. It’s not just a situation with technology, it is pervasive when it comes to staffing, equipment and supplies. Workers are frustrated because, from their view, leadership in the healthcare systems has seemingly lost focus on providing the best working environment for clinicians and focused on providing the easiest solutions.

I do not blame people for seeking to minimize effort or complexity, we all do it without even thinking about it. This, however, is where hospital systems have lost their clinical staff, rather than allowing care to guide operations, it seems that they have allowed operations to guide care. Listen to interviews with CTOs & CIOs, I linked one in my article last month, they don’t want to manage a number of different vendor contracts. I feel this, 100%, I managed around 20 vendor relationships and contracts for cardiology, it’s a headache. But in order to set the clinical staff up for success, you need to provide them the best possible tools. I worked with our physicians and staff every day, if they were happy, they weren’t complaining to me, and they took great care of our patients… I worked hard to keep them happy and productive. In doing so I created headaches for everyone else, but that was OK, we have Tylenol on formulary.

As health systems have grown the administrative layers have been piled on top, growing far faster than clinician employment, they have gotten further removed from the staff carrying out the mission of the health system. The distance can cause a loss of focus on the patient and teams caring for them, and starts to include more and more competing interests. Leadership in health systems needs to return the focus to the caregivers, force others to do what isn’t easy to support the mission of the hospital.

EHRs for example, the problem is the way that the EHRs were chosen, implemented, and continue to be ‘improved’. This process soured everyone on top down tech implementations and the current processes for improvement are not helping, focusing on what is easier, not what is best. Add into the equation how different systems are integrated in hospitals. Who monitors connections when they go down? The vast majority of hospitals rely on the end user reporting a problem. “Nothing works like its supposed to.” Sound familiar? It’s a common complaint among staff.

Consider some experiences from clinicians when interacting with software support:

• “We don’t think you need that” “That tool isn’t built for your environment, you can’t use it.” - Common responses from EHR analysts.

• “How long has the connection been down?” “Which environment does your unit operate in?” “What’s your MAC address?” - Common questions from IT support.

• “This is easier to integrate, we don’t think you need the other product.” - Common response from administration.

Health systems have not demanded better for their staff, they have not demanded that others rise to a challenge, so clinicians just get what’s easier for others. If we think about the supposition that what gets measured, gets managed; the question arises, are health systems measuring the right metrics internally? Likely not if their internal customers are dissatisfied.

Can tech help?

Not at all! They’re to blame, didn’t you read the title?!

Actually, tech plays a huge role in healthcare. While I won’t go into the technological marvel that is the fax machine (see last month’s article), there are many other systems that power clinical advancements and care, making work better and safer.

Tech is responsible countless innovations in healthcare, from new procedures to new discoveries and treatments. If you told me 2007 that we would be able to implant a pacemaker the size of a pencil eraser through a catheter, I would’ve laughed. How long could that battery last?! Of course, I couldn’t google it on my flip phone, so it remained a fairy tale.

In terms of clinical operations, interconnected systems with EHRs enable the safe administration of medicine, instantly connect lab results, monitor vital signs, and so much more. Connections to pharmacy can dramatically improve safety in medication ordering and administration. I won’t get into the actual user experience of these systems, but they are there and have demonstrably contributed to patient safety.

There are a plenty of tech companies out there trying to improve healthcare and the worker experience, but barriers exist. Situations similar to the one above are all too common in healthcare. In my previous article I called for hospitals to have clinical technology coordinator, a role that would seek out and assist in implementing these technologies. A clinician that would have the time and energy to devote to articulating the functionality and bigger picture of user experience to drive adoption, they could even manage the contracts to evaluate the effectiveness. CMIOs are great for physicians, but not as good for the other clinical staff, the focus is on the physician’s tools and technology, not the clinical staff. CTOs should not be focused on clinical effectiveness/usability, their area of expertise is not clinical, nor should it be. Non-physician clinical staff are the largest users of technology in the healthcare system, yet there is rarely a designated person to advocate for their tech needs in the executive offices.

Tools and solutions are out there, more and more appear every day, but breaking down the walls of the health systems is hard. Connecting these technology systems is hard, I don’t know what happens behind the IT curtain, but I understand that it is difficult, although not impossible. In the absence of an engaged health system or hospital, it’s incumbent upon those trying to enter to show their value.

What are the implications for companies or people trying to improve healthcare?

This article by Morgan Cheatham does a really good job highlighting challenges and opportunities. Top down approaches do not work for getting end-user buy in. Clinicians aren’t feeling supported, and if they don’t feel like the vendor cares about their experience, then why would they support the product? End user adoption and engagement is key. How do you get that?

Clinical relevance.

Why is this product clinically relevant. That’s the challenge for any company trying to get end-user buy in, show how it improves the workflow of the clinician or why it’s disruption to the workflow will dramatically improve patient care beyond other efforts of the clinician. It’s where most companies fall flat. If they break into the health system, they fail to show clinical relevance or do not have a willingness to adapt the product to work in a clinical setting. I’ve heard countless pitches from sales and implementation telling me how wonderful it is, but they can’t explain how we will use the product in the clinical setting.

Clinical Credibility.

This is related to clinical relevance, but deals more directly with the user facing interaction. If there is a good understanding of the clinical environment, then the conversation with end-users becomes easier and more meaningful. The experience of clinical end-users is that the people coming in to implement new tools have no meaningful clinical experience or understanding. If a company has someone in with the word “Clinical” in their title, the expectation is they have a deep understanding of patient care, the care environment, and operations. It’s clear when this isn’t the case and credibility is damaged.

If the only person in the company that has direct patient care experience is the CMO, then there is a long uphill battle for clinical credibility. Why? In large complex health organizations the physicians clinical staff work with often don’t know the behind-the-scenes activities of clinical staff and operations. The experience of most healthcare workers is from health systems. Not a knock against physicians, I don’t expect them to be operations experts, I want them to be diagnostic and treatment experts, the organization should be there to support them. The medical science behind the product may be sound, but how it’s integrated is even more important.

“Each setting is unique” is the oft quoted line. It’s not. Once clinical staff has heard that line, you’ve lost. Clinicians have often worked in multiple clinical locations, work doesn’t vary. Within the healthcare environment you will see the same clinical people doing the same things, taking the same steps. Tools may vary, like how each EHR is changed and iterated, but the steps and interactions are all remarkably similar.

Credibility is important, the nursing mafia is a real thing and can destroy a product’s reputation before a rep has left the building. Clinical people talk to each other, we talk about great products, and we talk about bad ones. It’s not confined to a single hospital either, it’s a very efficient network that rarely fails… Be prepared.

Listen and Respond

So much clinical experience is having “solutions” thrown down and the analysts coming in and telling clinical staff we’re doing things wrong and need to adapt. To be different, act different. A product team that comes in and has a genuine interest in learning, listening and responding to feedback with actual steps to improve will provide an outstanding experience for clinical staff, and give them a reason to push for it.

Support

In the situation above, clinical users, managers, and physicians often don’t have time to build a case for using the solution they want. Companies that come ready to support and show why their product is better vs what the health system already has will have an easier time. Show how it saves clinical time, improves outcomes, and/or is cheaper.

You’ve built a product clinicians love and want, now what?

This article by Jack Gomer does a good job explaining some of the challenges for early stage companies trying to get into health systems, it’s also relevant for small companies. I would add a couple of things from my experience working with different vendors.

What’s the structure? Know how the health system is structured and who controls the budget. Which corporation the product is being sold to is important, is it the health system, hospital, practice, clinics? All of these may be separate corporations, and may have more than one IT department even within the same umbrella corporation. Individual units or operating areas may have their own budget that they can play with too.

What’s the approval process? The executive sponsor should be able to list out all the steps for approval. The manager or director for the individual area can likely get it pushed through faster. Many steps can be done in parallel, some need to be done in series. If you have a good relationship with the end-user, their manager or director will act as a guide through the committees and make sure the vendor supplies the information they want the first time.

Who needs to work with integrating a solution? This is where it all comes together, and can fall apart. You have clinical support and a contract, now who is involved in getting it done? The manager or director is the best resource for this, they’ve done it before, they know who needs to get involved. There may be multiple IT departments (even in the same hospital), multiple EHR analysts, and maybe even Biomed, as a start. Managers and directors generally know the ropes and have informal networks to help speed the process, they’ve done it before. I’ve seen implementations drag out for a year or more and turn into a soul crushing process because there was no support from staff. There will be a million reasons to delay implementations, and staff are creative at finding every single one.

Clinicians want helpful technology that just works.

Healthcare workers are desperate for solutions that help them. We adopt helpful technology quickly; texting (until we were told to stop), we love Google (medication look up), we wheel COWs in to patient rooms so they can watch instructions on YouTube, we embrace technology that helps us and/or our patients. And yet we’re constantly frustrated by it, calling IT for systems that are down, interfaces that are not user friendly, and having new solutions pushed down that require more work but offer no help.

We can’t get things that just work. The environment inside healthcare today makes implementing anything new a challenge. Successful sale and launch requires an understanding of not only how the product impacts the care environment, but also the state of mind of and level of engagement of your users. Being active and responsive to end users will show you care about them, do this and they will embrace you and provide some of the best insight you’ll ever get.

In addition to the links in the article, check out the links below for a little more insight. Feel free to connect with me on Linkedin.

Ann Richardson - Shares some of the worst experiences that clinicians have shared with her. Advocate for improving the working environment in healthcare.

Health API Guy - Interesting tech newsletter, good explanations of the tech behind the scenes with understandable explanations.

Health Tech Nerds - Great community of people in healthcare technology.

Jonathan Kendler - Great resource for User Design and Human Factors Engineering.

MDisrupt - Great resource for companies needing clinical and medical expertise and advisory services.

Out-Of-Pocket - Making healthcare funny again. Interesting takes and interviews on the latest in healthcare.

Tido - Provides end to end monitoring of hospital networks. Their blog posts are amazing, whoever is writing them is up there with Charles Dickens or Stephen King, simply a joy to read. **I may be biased.

Zain Syed, PharmD - Great newsletter, hates fax machines, but otherwise a good guy with great ideas for the pharmacy world.