Hello, and thank you for joining us for the first 

. Today, we’re bringing you a hard-hitting discussion on a grave threat to high-quality healthcare: physician burnout. This panel, titled “Leveraging High-Tech Tools in the Fight Against Physician Burnout,” is not your typical take on this ubiquitous topic. Of course, we know physician burnout is a problem. In a recent report from Geneia, 80 percent of physicians said they are at risk of burnout. Research suggests that the problem not only harms doctors, but it also negatively affects patient care and raises costs for hospitals, all while we’re losing doctors to suicide and dealing with a physician shortage.

So, what can we do? That’s the most important question at hand, and that’s the question we’re going to answer today. We know that EHRs [electronic health records] are linked to health IT [information technology]-related stress in physicians, but we also know that EHRs have a massive potential upside. While it’s easy to blame technology for physician burnout, today we’re taking on a more challenging, more important task: We’re exploring how healthcare leaders can actually use technology to combat physician burnout. Because we cannot afford to let our doctors suffer any longer.

I’m Geeta Nayyar, a health-technology executive who hosts the digital medical news channel “TopLine MD TV,” as well as “Dr. #YOLO,” a podcast series dedicated to helping you live your one and only best life. I’m recognized as one of the most powerful women in health IT, a top 100 health-tech influencer, and one of the top 26 smartest people in health IT, according to Becker’s Report.

Participating today on our distinguished panel is Heather Staples Lavoie, a 30-plus-year healthcare leader and current president of the health-tech company Geneia, which integrates EHR data as well as other sources such as wearables and social determinants and applies analytics to help hospitals, physicians, and health plans succeed in the digital transformation. Geneia also produced the Physician Misery Index, which measures this problem.

Janae Sharp is one of today’s most sought-after health-tech key opinion leaders, with experience in building EHRs, media, and more. She serves on the board of Utah HIMSS [Healthcare Information and Management Systems Society], several startups, and is also the founder of the Sharp Index, a nonprofit organization she created after her husband, a physician, died by suicide.

And finally, we have Rasu Shrestha. Rasu is a respected thought leader and health IT visionary who is known for driving enterprise change. He recently became chief strategy officer and executive vice president at Atrium Health, following 11 years at University of Pittsburgh Medical Center. He is also a HIMSS board member, and he chairs the HIMSS Innovation Committee.

Thank you so much for joining us. Let’s dive right in. After learning that a problem exists, the next step is to really measure its scope. What would you say is critical, aside from technology? Is it the culture? Is it attitudes? What is it, Rasu, that makes this such a difficult topic?

 Geeta, it’s really important. This topic of burnout is so real and so prevalent really across the board. And I think the No. 1 thing that we need to get our arms around is the mindset. We’re not ready, in large part, to admit the fact that the very people who are healing our patients are actually hurting right now. And the mindset around how we might be able to address that notion, that reluctance to really admit to the fact that we have a major problem, is what we need to get our arms around.

Given the fact that there is a God complex that oftentimes exists with physicians — and it’s bidirectional, and I’m not saying this in a bad way &mdash; physicians are expected to heal. And physicians conversely expect their patients to obey and to understand what they’re saying and to listen to the protocols and the prescriptions that they put on the table. And that God complex, this notion that, “Oh my goodness, that physician, the healer, could actually be hurting,” we need to get around that.

Yes, those are some big words, Rasu. Would you agree with that, Heather? Do you think that the mindset is one of the biggest problems in the system today?

 It is. I certainly think that physicians are viewed as invincible, and because they tend to be workhorses, they take on so much. Sometimes I think they have been a bit reluctant to admit that the burden they’ve been bearing is too great. Maybe it feels a little bit like admitting to failure to a certain extent.

And yet I think the burden that we’ve placed upon them is just unnecessary, and it really is too great. We’ve asked them to do so much more than is expected as part of clinical practice. We’ve relegated their role to be data entry clerks, which I think certainly dehumanizes them to a certain extent. It diminishes their importance in the organization, and so I think it’s not only extra burden on them, but also it really undermines all of the training that they have pursued in their entire career.

I totally agree with you. No one really feels bad for physicians, right? They’re held to this pedestal and are supposed to be perfect in many ways. Janae, I know you’ve done a lot of work on measuring burnout and metrics. Can you share with us your thoughts on some of these things?

 Yes. I think it’s important to think about it, too, because we talk a lot about burnout, and some people also call this phenomenon of not really being able to meet your expectations the moral injury. Is this burnout? What exactly is going on? And we know when we’re talking about someone’s mental health, we ask, “How are we really measuring this?” And nobody wants to look at it and say, “Oh, on a scale of 1 to 10, I’m pretty burned out, which means I’m bad at my job.”

And quantifying that is difficult. We know that what gets measured matters in healthcare, and in some cases right now that’s a billing code. And the challenge for everyone is to say, “OK, we know something is wrong. How do we measure this appropriately? How do we look at it? What matters?” And that’s a lot more challenging. I know I’ve said challenge five times, but it is just a giant challenge to ask, “How much of a moral injury do you have?”

Thanking the Physicians Championing Physician Burnout

Leaders Weigh in on Solutions for Physician Burnout

Fixing Physician Burnout Is More Than Just the Decent Thing to Do

Shedding Light on the Culture Behind Physician Burnout

I love that once you measure physician burnout, it matters. So once an organization has measured it, what’s next? Rasu, Heather, what’s next?

 What’s really interesting is there are measurements out there, and what we’ve seen time and again is the magnitude, the depth, the gravity of physician burnout. And it’s not just physician burnout, by the way, it’s clinician burnout across the board. The nurses, the frontline clinicians who are interacting with our patients, who are helping physicians perform better, they’re burning out in droves as well.

But people feel bad for nurses. They don’t feel bad for doctors, right?

 That is true. That’s unfortunate. But it is a prevalent matter, a matter that is prevalent really across the board. I read somewhere that over 60 percent of clinicians have some form of burnout, and out of those, over 10 percent have some form of mental health challenges.

I totally believe that. It’s interesting when I say that no one feels bad for the physician, you’re right that folks seem to understand that the care team can get burned out, but somehow the head of that care team — being the physician &mdash; is supposed to be agnostic from what the rest of the team is feeling. Heather, what are your thoughts on once you’ve measured it, once you’ve looked at it, what do you do then? What is an organization supposed to do after that?

 Certainly I think that it’s not just the organization, but also as we look at what may be some of the contributing factors to getting to this point. So we’ve had physicians for centuries, and yet it seems to be only at an epidemic point currently. So what has changed? I think some of what has changed is the process by which they conduct their work. If we think back even to not that many years ago, but certainly even into the '90s and in the '80s, to do a history and physical exam was a relatively straightforward exercise where you could run through a record of systems, record that fairly simply, verbalize that, have a transcriptionist take all of that down, and code it fairly naturally. And that worked as part of a physician’s workflow. There wasn’t a ton of afterwork associated with that.

But today, certainly now that physicians are using electronic health records [EHRs] and electronic health records are still relatively new in the scheme of things, they’re to a certain extent fumbling their way through. Doing a history and physical is a lot more complicated. They’re actually having to code after the fact. The accuracy of their coding is used in a very different way than it ever was before. I think we should look at — from an organization perspective that employs physicians or has launched an electronic health record &mdash; understanding some of the pressure we’ve placed on physicians, and what might we be able to do to lessen that burden.

I think leading up to an EHR implementation, the go-live point has always seemed like the final point. There’s been some dispensation for physicians in terms of relaxing some of the visits, the production, that they might have had to be focused on leading up to that point. But after go-live, it’s all systems go and not recognizing that the real work happens after go-live. And that’s when physicians are really left struggling with, “How is this my new reality?”

We need to understand that the burden is still great, that physicians are fumbling through the electronic health record. So what can be done? Is it that we really need to look at what we’re expecting in terms of production on physicians on the databases, and relaxing that? Are we looking at how we might be able to help some of the afterwork? So I think really examining what is causing the challenges at an organization level, and then even from a health IT [information technology] level, is important. What can be done to resolve those factors that are causing this burnout?

You bring up a good point, which is that we have so many advanced tools, so many ways to kind of analyze this information. Janae, what are your thoughts on this? There are so many different analytic tools that we’ve got out there as it relates to burnout. Cost, effect, how do you actually analyze all of this information?

 I have a couple of thoughts about that because I’ve been really trying to quantify it more. And some of that is, we’ve been trying to quantify it, even how much it costs, because people in healthcare speak money. So I wanted to be able to say, “This is something that matters because it’s costing you this much.” We’ve looked at tons of tools, and one of the things that we noticed was when we’re measuring things in terms of multiple problems, there’s no one right answer and there’s not actually one tool that really quantifies it perfectly. And that’s part of why this conversation is important, too, because we have multiple issues.

The people who are burned out and have mental health issues, those people are less likely to accept help. They don’t care anymore. There are some people who have burnout and don’t have any mental health issues, and those are an opportunity for a healthcare system to recognize that something’s wrong with their leadership, something’s wrong with their systems. There are also people who are very healthy and burned out with tons of stress. So it’s really difficult to say what the one answer is. There’s never going to be one answer, and that’s why it’s still a problem. If it was easy, they would have fixed it by now.

But the trick is to connect with those people who are in the bottom quadrant, the at-risk people who are burned out and who have mental health distress where they’re probably not going to make it in their job, and we don’t know to what extent that will continue. So healthcare systems need to be able to look at the individual but also at themselves. What is it about our hospital that is so unhealthy? That’s why I say there are so many opportunities to improve. There are so many things you can do that will incrementally improve things. And, on a fundamental level, with our technology, we’re failing. Our technology doesn’t make physicians’ lives more joyful. So, when you have a huge problem and technology isn’t helping, you can change the technology.

Measuring Physician Burnout and Mapping Its Future

Rasu, you’ve got a big role, you’ve got a big title, right? This is something that you, your organization and your doctors are dealing with. From a strategic view and from an innovation view, how much is the measurement of physician burnout important to your bottom line? How much is that tool and that measurement really important to you?

 I think, in so many different ways, that’s what matters the most. Because we’re all concerned in health systems with providing not just care, but optimal care. We want what is in the well-being of the patients that we’re serving. And if we’re not able to measure and really address the specifics of the burnout of those healers who are providing that care, then we’re not doing anyone service.

What’s really interesting, on top of what Janae just said, is that I actually believe that it starts at the top. So, yes, we need to take care of the physicians and the clinicians who are out there on the floors and providing that care. But this is a cultural and a moral imperative. It starts at the top. It’s important for us to: A) recognize that this thing is happening; B) measure it as you rightly said; and C) specifically have programs in place to address this. Not just to check a box to say that we have programs that are measuring and addressing the issues of clinician burnout, but to really specifically have programs that are actually proactively going after this in meaningful ways.

Heather, what are your thoughts on this? Have you seen a particular customer, a particular provider organization, really move the needle on this with some of the tools that your organization deals with?

 Yes. We’ve been advocating for quite some time. Starting in 2015, we launched the Physician Misery Index to assess the degree of physician satisfaction, or the degree of physician misery, that was being experienced out in the field. And, on a scale of 1 to 5, it was nearing 4. It was about 3.7 at the time. And, actually, we redid the survey in 2018 and it was even higher. It was almost exactly 4 points out of a 5-point scale. So it’s actually gotten worse over the past three years, even though we’re obviously in healthcare technology and we thought that things might potentially be improving.

We’ve encouraged our customers, but we have made the survey freely available as well to anyone who wants to use it. It’s just a nine-question survey, and we’ve used it with customers — before they implement our software, but certainly during implementation and then periodically thereafter &mdash; to monitor this on an ongoing basis, just like you might evaluate for employee satisfaction and levels of engagement across the board. But this is specifically to home in on physicians, given the challenges that we know are being experienced, to see how things are faring and to course-correct.

We’ve had customers who then have been using that as a monitoring tool, to be able to course-correct and to have a dialogue with physicians. It’s really to be able to check in with physicians about what’s going on and how we can make things better — what are some of the challenges &mdash; and to have open discourse. Because that’s what it’s going to take in terms of coming to some strong solutions. And it varies by organization. Certainly, there are common root causes, but it does vary by organization in terms of what some of the expectations are and what the culture is that’s been set by that organization.

So much of what we talk about for our patients is prevention, right? It’s about value, it’s about prevention. What’s the No. 1 measure for prevention in this? Like Janae said, once someone is already burned out, we’ve pretty much lost them depending on where they are from a mental health perspective. Each of you, what’s the number one thing you think from a preventive standpoint that is just critical?

 What’s interesting is, when you look at the issue of burnout across the board, I think there are scales upon which you’re able to look at the human elements of what it means to make sure that this caregiver continues to not just survive but thrive. Because it’s very different. And we’re human beings, and we have these expectations that we talk about to get the job done because we’re not allowed to complain. We just go in there. You’ve got your medical degree, you’re slapped with a white coat and you’ve got your stethoscope around your neck. Just go there and do your job, don’t complain. But it’s not just about surviving, it really is about thriving.

I think when you look at the scales, there’s the resiliency aspect that you need to measure and you need to look at. How resilient are these human beings, these healers, in the tasks that they have in front of them? The engagement aspect; how engaged are they? Are they actually engaged and motivated in the things that they’re doing? And then there’s, at the other end, the empowerment aspect. Are they empowered to actually do the things that they’re supposed to do? So there are multiple things that we can look at, but I think it’s really important to unearth this one by one and make sure that you go after this in a very calculated way.

I love that. Instead of a Physician Misery Index, maybe a Physician Strive Index. That sounds great.

 One of the things that I think is important is that we have all these measures, but there might not be an ideal measure. Physicians love studies. This is something that I’ve realized working with them: They love data, they love studies.

 They want to publish it. They want to be the best at this. Change, especially in mental health, doesn’t correlate to how many studies you’ve taken. So the stories are important. The measuring tool is a tool to help people heal. And I think that’s part of the underlying bigger problem. You’ve taken people who are super hard working, used to succeeding, and love tools, and suddenly you give them a tool — maybe that’s the electronic health record, maybe that’s our health system &mdash; but these tools don’t actually lead to healing. So we have to say these measures all fail in creating a healing environment because tools aren’t the things that heal us.

Identifying Measures to Fight Physician Burnout at the Enterprise Level

So health technology has gotten a lot of heat for causing physician burnout, right? It’s the EMR [electronic medical record], that’s the reason that all these doctors are burned out. I think doctors have been burned out for a long time, long before the EMR. But what is your take on it? What do you feel about that?

 I think that’s a good thing. So we’ve been tracking, I’ve been tracking, news about burnout and about physician mental health for a while. And recently, there’s this huge surge of blaming your electronic health records. And at first, I was super frustrated. I thought, “Really, it’s not really your records. That’s not the problem.”

Well, it’s easier to blame the record, right?

 Yes, and I think that can be a proxy measure for increased burden, but they’re also not that great. And that’s something that’s relatively modern, just saying that technology is the reason, technology is the failure. I called 2018 the year of hating your electronic health record [EHR]. That’s the theme of the year in the news. This is why we have all these problems. And so I don’t think that is everything. It’s been happening for a while, like you said.

 It’s not everything, but I think it is something. It is something significant. We’ve got to call a spade a spade. And when you look at the specific tasks that physicians have across the board, we’re spending 44 percent of our time, on average, with our backs to the patients, entering notes into the EMR. We’re coders, we’re billers, we’re documenters. We’re not physicians 44 percent of the time, but that was not why I went into medical school.

 No, it wasn’t for data entry. We didn’t go to medical school to enter notes into the EMR. Now, that’s part of how we practice the business of healthcare. That is absolutely all right, and there’s nothing wrong with that. But I do think that technology has become an impediment to care. So we need to call a spade a spade and address the notion that 44 percent of the time, I have my back faced to the patient.

 What we found in our surveying is that a lot of physicians say the business and regulation of healthcare has actually caused a lot of the burden as well. We’re measuring people who are high performers and we’re expecting more and more from them. We’re reimbursing on an individual unit less and less. Primary care contributes so much to the overall health of a population, and yet they bear a disproportionate burden of all the documentation associated with care as well. And reimbursement being as it is and the requirement for documentation to be able to get credit for the service has placed an additional burden. So the EHR is the record keeping center of all of that, but all of that pressure has been placed on the back of the physicians.

I’m going to push back a little bit. So, when we rolled out the EMR at George Washington University, which is when I was in my training, everyone had a different user experience. I actually did not turn my back to the patient, Rasu. I just turned to the side and I would type like this, because I was able to do that. So every user is different. Specifically, from Heather’s point of view, how do you get your technologies to be adopted by physicians? Because to your point, a lot of doctors struggle with it, but if you’ve done it right, the idea was that data entry would be easier.

 Well, there are workarounds, and I think the method that you described is one that’s been adopted by a lot of physicians as well. And that’s, in my opinion, a workaround, it’s a compromise. It is not the ideal state, and it would still contribute to burnout.

 Yes. One specific thing just to build on what Heather mentioned earlier is the notion of where we are as an industry. I think as an industry we’ve gotten to a point where healthcare is so darn complex. The order of the day in healthcare is really around defensive medicine. Defensive medicine is the reality of how healthcare functions today. Because of defensive medicine, what we’re mandated to do is to overdocument — copy/paste and copy/forward &mdash; and we’re putting in all sorts of codes. And everything is to cover my behind, so that I’m not going to get sued for the thing that I’m documenting or that the health system suddenly doesn’t lose all of this money as a result of a big lawsuit and all of that. And I think it’s important for us to diagnose ourselves as a healthcare industry and say, “All right, how did we get to this point? How do we really address the notion of this defensive medicine reality that is propagating the notion for us to document and for us to focus inordinately on these regulations that have become the reality of healthcare as we know it today?”

 I think one of the things that’s important, too, is if you step back, maybe they weren’t taking good notes before health records. They weren’t doing a great job.

 Yes, they weren’t legible. So you’re adding something new to their job. They didn’t record what was happening before. So adding something new is more work. It’s better than nothing.

Well, I think that’s the opportunity, right? How do the health-tech vendors, how does a company like Geneia, fit in and actually make a difference? Perhaps we’re creating new problems, but at the same time, we’re certainly solving some of the old ones.

 Well, I think there’s a certain degree of burden that can be lifted off physicians by spreading it across the care team. There’s a lot that can be done across a care team. The physician can be the quarterback, but there are a lot of other team members who can be thinking about pre-visit planning. They can actually be looking at documentation. They can be using analytic systems to see where there are gaps in care, where there are gaps in coding, and filling those in on behalf of the physician, so that the physician doesn’t have to do that when they’re at the most valuable point of their day, with the patient. There’s afterwork that can be done. There are certainly recorders, scribes who have been in offices. When I started out over 30 years ago in healthcare, I was a transcriptionist. And so I could do a darn good history and physical exam in my head now because I typed them up so often.

 I could type hepatosplenomegaly. But, in all honesty, there were other people who could do that on behalf of physicians, and we’ve gotten rid of transcription services that physicians relied on to do that afterwork documentation that was necessary, such that they could really meet with the patient. More of that could be done. There are other creative ways of doing that without necessarily having to involve the physician.

This is where we’ve made a call out to other health IT [information technology] companies, which is to involve the physician in the design: design of the process, design of the system. What’s going to work with them? And involve the patient: What’s going to work for the patient? Because, ultimately, physicians go into practice because they want to heal, they want to treat patients. That’s what they’re looking for, and so preserving that relationship is the most important thing. And so from both of their perspectives, ask what’s going to work and how can we modify systems around them, so that we can empower them.

 I completely agree with you, and I’m agreeing also with what you mentioned earlier, Janae, that the EMR isn’t completely to be blamed for this. Given the fact that we have clinical information systems today that allow for us to share these massive troves of data across multiple geographies, multiple clinicians and collaborators — there are so many advantages to digital information systems. But it really does go back to what you mentioned earlier. The design of those solutions was done wrong.

Design thinking was not what we did in creating the solutions that we have today. We did not engage end users. The first time we engage physicians with that EMR solution that they’re going to be using on a day-in/day-out basis is after that RFP [request for proposal] process is done, after we go live with the solution. And then we have this training and we buy them pizza and we give them a cheat sheet, and we say, “Hey, good luck with it.”

Oh my goodness, that is not the way to engage in the process of designing this solution. So the process of design thinking entails the end users — the clinicians, the patients as you rightly said &mdash; being involved in the very co-creation of these solutions before a single line of code is ever written, to make sure that they’re consistently involved in the iterative processes of design thinking. So it’s really important to make sure we get them in early, often, and consistently.

I couldn’t agree with you more, Rasu. I don’t think we were doing design thinking. I don’t even think we were thinking, right?

We were creating systems that doctors were really just hired to sell. They were never part of the process, and I think clearly all of you are agreeing that this needs to be done with physicians for physicians as opposed to without.

 I think too, if you look at it, we moved from a 3x5 inch card to a giant electronic record that has a lot more 3x5 cards involved in it. And we’re not utilizing technology to do what technology is good at….

 We’re creating the 3x5 card, and that’s something that can help us find a huge opportunity. And design thinking is something in creation now that’s popular, and I really like that. What we have is better than the 3x5 card, but technology can process images, like you said, so much faster. It can become a tool for physicians to use rather than just your free time at home, which right now, it’s like your hobby after work. But it could actually help you at the point of care.

Tech Requires Design Thinking to Improve UX & Care

Who were the pioneers in this space? So we know Mayo Clinic has done a lot in this area. Are there any other pioneers in this space that you all look to as cheerleaders who are really blazing the trail for us?

 I like a lot of people because I’ve been looking for solutions. There are people who can automate scheduling where you can say, “OK, what’s really happening in this person’s life, how is their behavior changing?” And you can use something like artificial intelligence to inform your decision making, so the person who is doing the scheduling doesn’t have so much stress. There are so many tools, so I feel like we can be here all day making a list.

 I’ll give you a specific example. As we talked about earlier, I’m new in my role as chief strategy officer at Atrium Health, with 50 hospitals across the North and South Carolina areas, and we just acquired another hospital group down in Georgia in Navicent Health. So we are clearly a hospital organization that is continuing to grow, which is the trend across the board.

And what was refreshing for me was the first week in my job, we had a senior physician council meeting. And this is with the CEO, me, and the chief medical officer in the room with about 16 of the top physician leaders across the organization. And the No. 1 topic of discussion at that highest level was on physician burnout. So it really does start at the top. The mission statement for the Atrium Health organization is Health, Hope, and Healing for All. And it’s that level of empathy that we need to bring to the discussions at the very highest level, so that we’re able to really call out the specifics of the issues at hand and then get to the solutions that we need to be going for.

Well, it sounds like we should all get a job at Atrium Health.

That’s very encouraging to know that in hospital systems that perhaps aren’t even out there as pioneers, it’s being discussed at the C-suite. Heather, do you have any examples of pioneers in this space that you guys have worked with that are trailblazing in this area?

 Sure. So Paladina Health is a direct primary care organization, and I think they rightly understand that 85 percent, 90 percent of healthcare is driven by primary care. And so they have a very strong focus on the cultural health in their organization and what they can do to help support physicians and include them in the design of the clinical system. So they certainly are one, and I think they are working hard to preserve the physician/patient relationship in a unique way by providing more direct access to the physician. But also, I think they monitor and measure the physicians differently, so that they take some of the treadmill pressure off of the doctors as well.

I think we were talking about this a little bit earlier, but physicians having a greater sense of control over their day, over their work — that on its own relieves some of the feelings of burden. It certainly helps them to feel like they’re thriving a lot more in their environment. And so giving back some of that control is what they’re really trying to do with the physicians and their organization.

We’ve seen that also with VillageMD, where they’ve had great success. We work with sort of a local branch in New Hampshire, and they’ve had great success in recruiting physicians out of some of the bigger hospital organizations because they feel like they’re valued. They have great control over their day. They have more resources in the practice. They have integrated behavioral health, they have social workers, they have nutritionists. And so there’s more of a team that supports the physician. When there are challenges with a patient, they can turn to other team members to help that patient as well. Everything doesn’t fall onto them. And because they feel more supported by a team, they’re much happier. And so they have great retention and great recruitment in a time where it’s really tough to bring physicians on board. There’s a real shortage, and it’s tough to keep physicians satisfied, and they’ve had great success.

 I love what you said about the treadmill effect and also about people who have good retention. Because I think a lot of times we look at people who are leaders. Mayo Clinic has published a lot, but let’s look long term. Are they funding their programs and their findings? I always want to say to follow the money and look at employee retention, look at how physicians are after your groundbreaking study. I don’t know. I wouldn’t say anything specific, but I’d be willing to wager that many of these things that are supposedly groundbreaking don’t actually lead to better physician life long term.

Navigate the digital transformation with confidence. 

Pioneering the Fight Against Physician Burnout

It’s clear that technology is one aspect of this, but the harder part is the cultural component. And we heard a little bit about the culture at Mayo Clinic and Atrium Health. How could technology play a role in helping to shift the culture? Because that’s the hardest part. We have the technology. We have all kinds of stuff that can help our doctors get more control, but it’s the cultural shift that needs to work.

 It’s interesting, and I think it’s important for us to take a step back and look at some of the big scenes, the dynamics that affect how we use technology to influence what it is that we’re doing in terms of providing care.

For the longest time as we’ve been rolling out EMRs [electronic medical records] in the instantiations that we have today, we’ve been designing those solutions for regulation. And regulation inherently is not bad — it’s there to protect us, it’s there to protect the patient: HIPAA [Health Insurance Portability and Accountability Act] and 

ICD-9 [International Classification of Diseases, Ninth Revision]

 codes and all of that. When do we start designing for empowerment, empowerment of the clinicians and of the patients and all of that? I think designing for empowerment versus regulation is important. Designing for regulations has caused burnout. I think designing for empowerment will cause joy, which was a point that you made earlier.

And I think the other thing we need to look at thematically and from a cultural perspective is how today, we’re inundated with bureaucracy in healthcare. What’s really happening is, as we shift not just the conversations but the way that we’re measuring outcomes and measuring satisfaction, we shift from volume-based healthcare to value-based healthcare. We’re quickly moving from bureaucracy to meritocracy. So rewarding merit, I think, is going to be critical. And all of these instantiations of how culture is shifting will then suddenly influence the direction of how we embrace technology and the design or the redesign of the solutions that we’re using every day.

Those are excellent points. And so much in the health-tech industry, we talk about patient engagement, right? We talk about all kinds of ways and technologies to engage the patients. But ultimately, if we think about technologies that can create physician engagement, the patient engagement aspect is going to follow. So any thoughts on technological innovations or physician engagement that can help shift the culture?

 I think it varies, and you actually see a bit of a bifurcation for newly graduated medical students as compared with people who are further along in their career and the methods by which you engage them and their inclination to use technology first versus technology as a burden.

Well, they’re intuitive for some and not as intuitive for others.

 So the digital natives, as they graduate from medical school, what’s that going to look like?

 Exactly. There are expectations around using fax machines.

 They’re going to record with Instagram?

I know. Someone asked me to send them a fax the other day and I thought, “Are you kidding?”

 And for much of the country, that’s exactly the way physicians, physician practices, still communicate.

 But I wonder about that because everyone thinks the fax is awful, but really it’s an e-fax, and I can take a picture on my phone, sign it on my phone and send a fax on my phone, and get it uploaded into the exact file that I want it at.

 Yes, and what’s worse is that there are companies who come to you and say, “But we’ve got a perfect solution. We can actually PDF the whole thing and put it in our EMR.” Oh my goodness. When will we realize that PDF is not a digital format? My goodness, we cannot mine for the data sufficiently in PDF.

 Really. If it can translate to Microsoft Word, why can’t we mine PDF?

 It’s a struggle — it really is. There are discreet data elements with the technologies that we have at hand, and we’re still struggling with fax machines, and the PDF is only a slightly better solution. We can do better.

 Engagement is so individualized. It really is based on what people’s values are, what’s important to them. It’s not just different generationally, but it’s really different from person to person. It’s why it has to come from the top of an organization because it’s going to take a lot of work, it’s a lot of emphasis.

There’s a great reward associated with it. If you actually invest the time and energy, you will have happy physicians, you will have better health outcomes and you will have happier patients. But understanding what’s meaningful to each physician in order to engage them, that’s a necessary component. And so it’s not just the technology solution. I think technology can be an enablement method, but really, it’s actually getting to understand what ticks for each individual physician, what are they looking for and what’s meaningful to them.

 Well, I’m gonna. A lot of times we talk about how it has to come from the top. And I know in my experience, I wasn’t at the top. And I decided I didn’t care. So I don’t think it has to come from the top. I think physicians can say, “Look, this sucks.” And they can find ways to make their voice heard, whether that’s partnering or something else. One of the greatest technology tools we have is something like social media where you can say, “This isn’t OK,” and they can’t stop looking at you because it’s out there.

Sure. That’s a fantastic point. I think it goes to culture, because to your point, whether it comes from the top or the bottom, it’s about having a culture of being receptive, right?

 You think I’m from the bottom? I like to say I was in a different place.

 I think we’re in general agreement. I would think that what we need to do is to speak up. So whether it’s at the top or the bottom, we can’t shove this under the carpets any more. We have to speak up. We have to haul it out. We have to then understand the specifics of what it is that we can do together collectively to address physician burnout.

I think those are all amazing points, guys. There’s one more closing thing I want to ask all of you. This is ultimately about resources, right? We talked about spending money in PDFs, we talked about spending money on fax machines, and physicians are burned out. And today actually, rightfully so, whether you’re at the middle, the bottom or the top, it shouldn’t matter. What are some quick thoughts on resource allocation and where that fits in here? Because we have the data, we know when we have a shortage of nurses or shortage of doctors on certain floors. So how does resource allocation fit into this?

 It’s interesting when you look at hospital operations and the specifics of what you measure around the widgets. And heads in beds, for example, has been a metric that we’ve used for a long time. And as we look at value-based care, that metric is changing. It’s not about heads and beds any more — it really is about how we make sure that we’re able to provide care and get those patients out of the hospital beds as quickly as possible, because that defines the new success.

Now, you overlay that with physician burnout and the things that we’re measuring around physicians. There are still measures in place, so as a radiologist, how we are measured today is by number of studies dictated and report turnaround time. Pure volume-based metrics. And that is just absolutely wrong. I’m not saying that volume-based metrics are going away. What I’m saying is, if we continue to incentivize physicians with those volume-based metrics, we’re going to get more of the same, and that’s not good enough for us.

 I agree. The reimbursement system has really dictated a lot of this. There are so many cases where a low acuity patient who might be on blood pressure medication but is well managed could be monitored by a nurse. They don’t have to present for a visit all the time, but yet because of either quality standards or reimbursement, we’re dragging people into the office. It creates a greater burden on the physician. It could be managed better by someone else.

But there hasn’t been reimbursement for some of those types of services in the past, and that’s changing now, whether it’s because of value-based contracts or because CMS [Centers for Medicare & Medicaid Services] is allowing for certain care coordination services or monitoring services now. I think there’s an opportunity for that to change so that not everything has to be done by the physician. Other people can actually manage or monitor, and maybe even to a greater effect if you have social workers who are interacting with patients who may be at home and have transportation barriers. That might result in better outcomes and save the right patients to present to the physician. But much of this has also followed regulation, but it’s also followed reimbursement.

Podcast: Nuance, Tech & Fighting Physician Burnout

Physician Burnout: Health Tech's Potential to Impact Culture

It’s clear that health systems have access to tools that can at the very least measure physician burnout, or possibly help us with a cultural change in physician burnout. But what do we think about the future? It’s hard to type, it’s hard to keep up with the medical record. What are some of the future technologies out there that can shift us into a whole different mindset?

 I’m really excited about technology. If you look at the evolution of how physicians have interacted with the science and the art of practicing medicine, it’s interesting. We used to walk around with our bags from door to door.

 No, but we used to. In the black and white era, that’s what we used to do as physicians.

 Right, and then came Geeta with her fanny pack. But then with the advent of processes, and with the advent of regulations, we started noting things down on paper, which we then put in folders, right? And then came EMRs [electronic medical records]. And we converted this analog culture to a digital culture, actually quite blindly. So now we have e-folders. And we have e-phones, so these are now digital phones. And then what happened in terms of documentation, instead of scribbling notes down on paper, what we started doing was transcribing. Typing things out initially but then transcribing into a phone line, remember that? Transcribing into a phone line and there would be someone else out in the Philippines or the room next door typing out those notes for you.

 There you go. What we did to put you out of business, out of a job was ….

 We replaced it with voice recognition, right? And voice recognition, in many ways, I describe as typing with your tongue. Because what we did when we spoke into those Dictaphone mics was speak out the very words that we then wanted transcribed by the VR, the voice recognition technology. Instead of us typing with our fingers, we’re speaking things out.

And then evolution has happened, going from just regular voice recognition to now leveraging natural language processing (NLP), and the next leap forward, Geeta, to your question there, is artificial intelligence, right? Natural language processing, where it’s looking at the syntax and the context of the specific terminologies, the medications, allergies, the immunizations, problems, labs [laboratory reports], structured documents, the unstructured narrative of my postoperative surgical note, or the radiology report that I’m writing. The NLP, really mining for that information and structuring the information in the documents that I’m trying to create. Pulling out specific codes that might be of relevance, risk stratifying the specifics of the diagnosis that I’m putting in place. Artificial intelligence, that’s where things are really moving toward, coming in and adding additional insight in ways that were just not imagined possible.

So, Rasu, you’re reminding me of when I was a young, new doctor on rounds, and we’d have the attending physicians — they looked a little bit like you, Rasu &mdash; and they would have those bags full of different physician reference guides, and I had my BlackBerry. And I remember they would say, “OK, so what do you think this is? What does the rash look like?” And I’d just really quickly look, “Oh well — tick, tick, tick.” So it’s clinical decision support, right? You’re talking a lot about clinical documentation.

But what about clinical decision support? I’m a rheumatologist, this rash could be five things and I can’t remember the fifth. Where does something like that play into this? Because I would be a lot less burned out if I had some help.

 Remember, before the BlackBerry, I had the PalmPilot.

 No. One of the solutions that I had in the PalmPilot was the diagnostic tool set, right? Remember that?

I was able to very quickly find out a DD, a differential diagnosis, with a certain set of symptoms. And it was interesting. It was technology trying to come and play a role in the process of providing care. How that’s evolved today is clinical decision support algorithms that are inherently built into your electronic medical record systems. Add-on solutions that are being piled on to the electronic medical record solutions that bring in context around the longitudinal record; bring the evidence-based guidelines and clinical best practices and protocols and aid in the diagnosis; and interpret the specifics of what we’re actually doing at the point of care. So it’s really interesting to see how it’s evolved.

 I think for me the real evolution I saw was when a few years ago, if you started searching for suicides, the top thing at the search results for Google was the suicide hotline. And we talk a lot about the point of care, all those things. People are searching online. There’s a reason we call it Dr. Google, and I think the future of care is that Dr. Google is going to have some real doctors back there. So they’ve taken these large technology companies that are already where people are at, like Facebook and Google, and they’re saying, “Look, we need to help these people. We can see that people are sick. They’re searching for ways to kill themselves, so let’s go ahead and have support there.”

Health Tech’s Potential to Impact Culture

From Paper and PalmPilots to AI: Understanding Health Tech's Evolution

The other thing is, people are not just searching online for the answers. They are searching for doctors online, right? Telemedicine, virtual visits.

 Or they’re searching their Facebook mom groups.

 I found my doctor in my Facebook mom group.

 You get terrible medical advice, but you can find a good doctor.

So where do virtual visits fit into this? Your work at Geneia is all about this. So talk to us about that, Heather.

 Well, we talk about this all the time at Geneia, and we have 10,000 people turning age 65 every day and will do so for another 15-plus years. So these are baby boomers who have different expectations about how they want to age in their home. We don’t have enough caregivers to care for that population, and certainly not with the rate of chronic disease that we have in our population. We have over 100 million prediabetics, and we have to find new and creative ways of treating and caring for this population. There aren’t enough physicians or any other clinicians to help support the population. So we do support people in the home through remote patient monitoring. We’ve allowed — we’ve really supported people to stay independent.

We have patients who we care for who are 100 years old but have been able to maintain a strong lifestyle in their home. We’ve also been able to understand and provide contextual information about that patient, in terms of humidity levels and pollution levels and other information about that patient that might be exacerbating their situation. We also have been able to even go in and course-correct where we’ve seen their blood oxygen level might be low, and breathing exercises have been able to get people off of supplemental oxygen.

So there are simple things that you can do by capturing more biometric information. But when you’re capturing that volume of data, you really need more sophisticated systems. That’s where AI [artificial intelligence] plays a great role because it’s perfectly positioned to help support mining through volumes of data in that way, because physicians can’t manage all of the alerts that might come through managing populations in that way and being notified. So you need a way to quiet down noise that might be false-positives and really only alert when there are real situations that present for a physician, and/or other clinicians, other nurses or other caregivers can then be monitoring patients in the home. So it’s a perfect application and is necessary for the population that’s aging.

Regarding telemedicine, for me as a rheumatologist — we’re pretty rare, we deal with rare stuff &mdash; I remember early on in my career getting a call from this primary care physician somewhere in rural America who said, “There’s a newborn here that has this rash; I’m terrified it’s lupus. Will you help me?” And I didn’t know who they were, and they didn’t know who I was. This was before the smartphone. I just said, “Describe it, describe it to me and I can give you a sense for what to do.” And now, zooming ahead, even if that doctor had texted me a picture, it would have gone a long way.

So I would love to hear from you, Rasu, on this because in telemedicine, clearly the technology is there, that’s not the issue, right? It’s the reimbursement, it’s regulation. So where does it fit into the future for physician burnout because it seems like such an asset?

 It is an asset. What’s interesting about telemedicine in general, as you rightly pointed out, is that it’s actually been around for a while. There are multiple iterations of telemedicine — there are multiple add-ons in terms of capabilities and services. But it’s really interesting. A lot of folks today are talking about telemedicine. There are a lot of businesses proliferating around telemedicine, leveraging the cloud and the power of these technological capabilities.

I think the reason for that transformation happening right now is that there’s starting to be more of a reimbursement movement toward telemedicine, to a point where I say that telemedicine is an overnight success story that was 30 years in the making. Everyone’s now talking about telemedicine — it’s great, but reimbursement is a big factor.

And we’re going to see more of this happening in 2019. The CMS [Centers for Medicare & Medicaid Services] is talking more about this as well, and I’m really bullish about the fact that with additional reimbursement around telemedicine, what we’re going to be able to do is to leverage these technological capabilities of not just having synchronous and asynchronous communication capabilities between clinicians across multiple care teams and patients who are in remote locations, but also capitalizing on the power of video. Capitalize on the power of voice. Capitalize on the power of these devices that allow for you to monitor things remotely and allow for us collectively to then look at the care that we’re providing to our patients in a much more longitudinal manner.

It really has to be about the care continuum because then it starts the conversation about how we humanize care and not just focus in on that one episode of care.

 I really like telemedicine. I had a friend who was a nurse, and then she fell and hurt her back. And she couldn’t do her job anymore. She really couldn’t do it. So she was able to pivot into helping people on the phone and doing telemedicine. And she still had that same level of pay, she still had the same job.

So telemedicine, in a way, allows us to give physicians and nurses, other caregivers, more options. If you have a career and you’re super unhappy, maybe you could take time with the telemedicine crew. We need to rethink the way that we’re giving physicians options. This isn’t just a way for patients to get it. I love not having to go to the doctor, I love that. But I also think it’s great to be able to connect with a doctor who’s happier in their job as a virtual M.D.

Sure. I think all of these are excellent points. And one of the things that Rasu mentioned was the womb to tomb. Janae, I know you just had a baby, right?

For the first few months, you’re at the doctor all the time, right?

 Yes, and it’s horrible. This is the last thing I want to do, bringing my 2-week-old to the doctor to check out this rash, just in case. That’s exactly what I wanted to do today, as opposed to sleep. I really wanted to just pack it all up and go.

 Absolutely. And you know the advent of telemedicine and the fact that it’s actually taking off is driven in large part by convenience, right?

 We have these technological capabilities today. We’re taking selfies of each other and immediately Instagramming it and texting it out to our buddies. Well, what about the medical selfie? This is happening today, right? We’re taking a picture of our rash and we’re uploading it to a service. And in the cloud is an AI algorithm that’s really analyzing that rash and then feeding back to me whether I should be worried about it, the acuity of that rash.

And it’s the same thing with cardiac murmurs, and we’re all really in awe of the announcements that companies like Apple and others are making. Samsung is working actively toward this as well. Simple devices that consumers now have can measure rhythms that could really predict if you have a serious problem, if you’re going to die from a heart attack, if you’re going to have an arrhythmia that’s going to kill you right there. And it’s been uploaded to the cloud, and there are these algorithms that are recognizing these patterns and aiding the clinicians.

So I’m bullish about technology. I think it’s important for us to make sure that technology plays a role in physicians being better in the task that they signed up for in the first place.

I don’t actually think it’s the technology, though. I think it’s the consumer. Why? The consumer is saying, “Why can’t healthcare be convenient? Why is healthcare not convenient?”

 I would probably pay a lot of money for a nap as a new mom — a lot of money. So if being able to reach my physician and take care of my infant is easier, I’ll pay money for that because it matters to me.

 Sure. And a lot of Americans are in rural areas, and so they don’t have access to specialized physicians. I see this in my own community. I’m in the northern part of our state, and there’s just no access to child psychiatrists, subspecialties, and so telemedicine really gives access in areas where people can’t drive the distance and may not be able to get in. And so it really does provide for care that’s really needed in the community.

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Nuance, Tech & Fighting Physician Burnout

Telemedicine Can Benefit Patients & Physicians Alike

It’s really clear that one of the cultural shifts for physician burnout will come from the consumer change, the consumer expectation and the technology being able to do it. So Heather, in a recent blog post, you wrote about how physicians are always rushed, and how technology could help them not have that rushed feeling and that urgency.

 Sure. Usually when a physician goes into the room, they’re trying to log into the system, they’re trying to find the patient, and they’re trying to pull up the problem list. And so much of that is them feeling like they’re in the hot seat as they’re just trying to assess what’s going on with that patient at that point in time and navigate through the system at the same time. And they realize that, “Oh, wait, you might have had laboratory tests, and I’m not finding the labs. Where are those labs? You’ve had a consult with another specialist, where is that?”

And a lot of that burden can be managed by proper planning ahead of the visit. And so if you have other care team members who, before a patient presents, are doing morning huddles and looking at who’s coming in for the day. Do we have all their labs? Do we have the specialist visits in? Oh, there are open gaps in care. Have we addressed those? Do they need a prescription refill? Why don’t we make sure that we get that ready ahead of time so it’s all ready for the physician, and some of that preparation is already done.

So when the physician enters the office with the patient, they can begin with a dialogue instead of a feeling of panic that they are in the hot seat and cannot find information that they ultimately are accountable for. And so it just changes the tone, the tenor, of the appointment altogether when they can present in that way. They don’t need to be hunting down all of this information. Other caretakers — it can be a medical assistant; it doesn’t even have to be a nurse &mdash; can be helping in the preparation.

And those practices that perform morning huddles end up having better outcomes, higher satisfaction. It’s a central tenet. Medical homes are actually practicing that. And in the past, when I’ve looked at health outcomes across sites that did morning huddles versus others, there were much better outcomes and a much higher degree of coordination even among the physicians in the practice altogether.

 Your point about the morning huddles resonates with me because I completely agree with you on that. I always say that the funny thing about clinical work flow in general is, if it doesn’t work and if it doesn’t flow, then that’s not workflow, right? Look at morning huddles and the specifics of how you have residents or fellow trainees maybe aiding in the work that you’re doing, or if you have scribes or PAs [physician assistants] who are helping you as well. Go down to the specifics of how that’s actually working, how those huddles contribute to the overall efficiency of that workflow.

And then you marry that with the advent of technology, technological capabilities, and you suddenly realize that all of that scut work that used to be done can also be done by technology. AI [artificial intelligence], for example, could mine for relevant bits of information such that when contextually represented and presented to you at the point of decision making, it could actually make a tremendous amount of difference in reducing burnout for the physicians.

This idea that your physician is going to see you for 8 to 10 minutes once in six months, possibly twice if you’re lucky, is ridiculous, right? And the opportunity we have with technology is to extend that visit: pre, during, post, whatever the technology might be. Janae, do you have any thoughts on that, particularly with a new baby in the house?

 I really think there are so many opportunities for technology to make things easier. And actually, I have a physician who uses technology that way, and I sought them out. I asked, “Hey, who is good at these things?” And then I sat down with him and talked to him about it. Ideally, they’ll be able to get that picture really quickly, but I don’t have to spend tons of my time, and they don’t have to waste their time. I don’t like wasting time.

It is ultimately win-win, right? Because now you have a physician who’s also satisfied with their job, has better tools, and has better assets.

Leveraging High-Tech Tools in the Fight Against Physician Burnout

How to Ease the Time Pressure That Contributes to Physician Burnout

It’s funny, the other thing that we never really talk about is how as physicians, we actually love technology. The stethoscope, the MRI [magnetic resonance imaging], the CT [computed tomography] scans, the da Vinci robot, right? We actually dig technology.

 Yes, especially radiologists. We love our cool technologies.

That’s all they’re about. Rheumatologists just like to think.

 Yet in many offices, they still manually take a blood pressure and then go and key it into the system. They manually take a heart rate and they go key it into the system.

But my point in this is saying that this idea that the stupid doctor doesn’t want to use the technology or doesn’t want to get with the program is not fair, right? Because we love technology when it works.

When it works the way we need it to and it helps us do what we need to, and when it doesn’t get in the way. So my stethoscope doesn’t get in the way of my visits. The MRI and the CT scan don’t get in the way of my visits. So I’d love to see health technology move into a place where physicians love technology, which we actually do at our core if it helps us do our job and it doesn’t interfere with the relationships.

 What’s really interesting is with the everyday use of technology and the various things that we do, whether it’s ordering a cab, i.e. Uber, or booking a restaurant, there’s just so much adoption of technology because it just flows naturally into things. And then we go into a hospital system and everything is so darn artificial. Because technology is an impediment to care. And I always say that innovation done right makes technology invisible. So how do we make technology invisible? It’s not about technology. It’s about that workplace. It’s about that human interaction that we need to be having more.

And it’s really important for us to understand that we say time is money, but if you speak to physicians and say, “All right, what’s really important to you?” they’ll tell you, “What’s important to me is that I want to go home on time. And I want to put my kids to bed. I want to spend time with my children.” There are priorities that they have, and it’s not just around kids, but around things that drive and motivate them. Their families, their social circles, those are valuable. And if you’re able to feed to that and use technology to help with the things that need to get done, but not have technology be an impediment to care, I think we start moving in the right direction.

 Yes, I think we’ll pay for the things that matter. Not all of our financial decisions make sense, and technology should be able to help us make better health decisions, but it also should recognize the human aspect and say, “Let’s meet you where we are, where you are and improve your health.”

Well, thank you everyone for being part of the panel today. And as we close out, I’d love to get some final thoughts from each of you on this really important topic of physician burnout. Janae, why don’t we start with you?

 No pressure. I think my final thought is that technology should be doing what technology is good at. And physicians should be able to do what they’re good at. And overall, our system is not really going in the right direction, but we have a lot of people who care about healing. And when technology can facilitate healing and facilitate better mental health, that’s when we know we’ve succeeded. And I think it’s going to happen. I think it’s going to happen because people have been fearless about not taking no for an answer, about having their voice be heard, and that connection is what’s going to heal us.

 I absolutely agree with you, Janae. I think it’s important for us to bring the care back in healthcare. I think it’s important when it comes to physician burnout for us to call things out as they are. Right? Physicians on the ground, executive leadership at the top. We need to call things out as they are. I didn’t go into medical school to become a scribe. I didn’t go into medical school so that I could document and bill and type notes. I went to medical school to make a difference in the lives of fellow human beings so I could impact them at scale. That’s why I went to the medical school.

We’re in an environment today where we’re data rich and information poor. We have at our fingertips technologies and capabilities that can aid us in being more human in the very care that we’re providing. We need to step up the game. We need to address the issues head on. We need to make sure that technology becomes our greatest asset, not our most lethal liability.

 I’m an optimist, and I think sometimes it takes a crisis to call attention to a situation. And I think we’re at that point now where there are a lot of catalyzing forces that want to solve this. So, I think it’s been hidden for some time, and now that we’re finally at a tipping point where there is some very positive momentum in the right direction, I think that we’ll come to some strong solutions.

And I do think that despite the fact that we feel as if we’ve had technology around for a long time, we’re still at a pretty nascent stage as it relates to technology and healthcare. We’re still first or maybe second generation, and so there is a long way to go in terms of maturation. And so it will naturally get better as well. And if we combine the two, I do think that we can put some energy behind solving some of the challenges and advancing technology in a way that supports good process, and not necessarily just following regulations.

I agree with all of you. I’m really energized by the discussion and the fact that we’re even talking about it because I do think physician burnout is a crisis. And it’s a patient crisis, right? I think connecting the dots between burned out physicians with poor quality care for patients is really key.

And finally, it’s really clear that health technology has a role to play, for good or for bad. And I think it’s time that we start making strides in health technology with physicians as opposed to doing health technology to physicians.

Thank you all for your contributions to this discussion. On behalf of our panel, we thank you for joining us and we hope you found the 