Late on a Friday, I sit and review some of my patients’ old medical records instead of going home to be with my family. I’ll probably do it next Friday, and the one after that.
It wasn’t my idea. The health system I work for discovered that some patients who were ordered CT scans never got them over the next two to three years. So administrators decided that clinicians like me should check the records of every patient who needed a CT scan, find out if the test was missed, determine if the missed test should be rescheduled, and report if we reordered the scan or considered it. unnecessary.
For each patient, the procedure involves a numbing and demoralizing number of mouse clicks and keystrokes. This project aimed to reduce medical injuries, but instead causes administrative harm.
That these hours could be spent in countless other ways—especially caring for patients and our families rather than looking at our computers—raises an obvious question: Does the system we created to fix the system work, even?
Two things before I go any further: First, neither my colleagues nor I question the importance of reconciling incomplete tests for our patients. Second, we are committed to pitching in. We have dedicated our careers and out-of-office time to making healthcare better and safer for our patients. We go the extra mile every day to be sure that diagnoses are made; conducted, read and responded to tests; and treatments performed.
We do this despite the clumsiness of an electronic health record system that was given an “F” for usability, that systematically robs us and our families of hours of off-the-clock time, and that has been minimally improved despite the years of flawless platitudes in national task force reports regarding EHR-mediated burnout.
The problem of patients not performing scans needed to be solved. But by their doctors? Alone? On their own time?
Like the Centers for Disease Control and Prevention, my colleagues and I can distinguish between natural disasters and man-made disasters. The real challenges of our patients, which led to the missed CT scan appointments, are, of course, inherent in any system that involves the messiness of real life. But our lonely after-hours slog to clean up this problem was a man-made trauma. It wasn’t an emergency, and it wasn’t just a clinical responsibility. The missed scans accumulated over several years. The EHR system and its caregivers did not notify clinicians when their patients missed their appointments nor did they set up a follow-up system to reschedule each missed scan in real time. Yet the mandatory cleanup of this managerial mess has suddenly become an urgent priority on doctors’ to-do lists.
To learn more about how this painful reconciliation process was formulated, I called my department’s quality director. He referred me to the hospital’s project manager, who told me that requests for a more collaborative, user-friendly and less rushed process had been turned down by head office.
So this administratively driven mandate, this digital drudgery, was thrust upon clinicians who had no participation in the decisions about whether, when or how to perform this task and without the benefit of any electronic streamlining. Hence the solving of a 1990s era spreadsheet, the nostalgic joy of MS-DOS era copy and paste, the joy of multiple dips into the electronic health record for each patient, and the attestations I had to type to record each of these incomplete orders loose.
It was a pure distillation of administrative damage.
Administrative harm, like clinical harm, has long been recognized in medicine but little discussed until recently. This can result from an intervention – such as the one I was tasked with – or from a failure in one of five domains of administrative responsibility. These realms include the tangible, essential assets needed to support the delivery of health care; in the words of the late Paul Farmer, staff, space, stuff and systems. The administrative damage to my Friday nights resulted from a system defect.
In the spirit of the National Academy of Medicine’s “To Err is Human” report, I filed an incident report – just as I would if I committed or observed a medical error – even though the harm to me did not include does not fit any clinical category. My health system properly encourages its clinicians to apologize to patients who have experienced medically derived harm, also known as iatrogenic harm, and offers classes and mentoring on how to deliver such apologies.
It seemed only appropriate to me that if the clinical-administrative review were to judge that this quality improvement project resulted in harmful and preventable adminogenic harm, an administrative apology should follow. I have been waiting for three months and have heard nothing of regret or apology from the system’s quality and safety infrastructure.
This infliction of administrative damage was largely preventable. Involving a broader spectrum of decision-makers—including administrators, IT staff, and full-time clinicians—would have been more respectful of the workers’ professionalism and time, and more palatable and effective than a one-sided e-mail order headed, ” Action required.” These groups could have been tasked with jointly studying the backlog of nonperforming CT scans and iterating on ways to resolve those cases, as well as streamlining IT processes to support that work.
The collective decision of such a group may have ultimately resulted in my colleagues and I sifting through our cases, well aware of our clinical intent and our patients’ circumstances. But we would have done it using an IT system that was respectful of and optimized for our work, rather than the clumsy, retro and risky cut-and-paste beats of my Friday nights. That process would have harnessed the EHR, rather than harnessing clinicians to the EHR.
From a technical point of view, such a process is feasible. Our IT system flaunts its capabilities daily, giving clinicians messages that appear in the EHR reminding us to look at patient-specific administrative priorities, such as “The dietitian has classified the patient with moderate protein calorie malnutrition. to admit it, it requires your documentation. Please press F2 and select a choice from the drop-down menu.” IT resources currently focused on ensuring healthy reimbursement from insurers and other payers should support the health of patients and clinicians alike.
There is enough money within the system for this purpose. To cite just one example, data from the Lown Institute’s Hospitals Index on Fair Pay shows that my hospital spends more on paying its CEO team relative to the pay of our rank and file workers than 94% of all US health systems . Clinic admin teams can reallocate a small fraction of that excessive administrative compensation to adequate IT support, rebalancing priorities to reduce these systemic administrative injuries to frontline staff.
Prevention, a centerpiece of the best medical care, should likewise characterize the approach to administrative harm in health care. Brief, periodic assessments can provide early warning signs of the risk of administrative injury. One example of a concise, pertinent survey is the three-question Stanford Personal-Organizational Values Assessment Scale: (1) My input is valued in important administrative decisions? (2) Do our organization’s goals and values match well with my goals and values? and (3) Administration appreciates my clinical work? Each question is answered on a scale from 0 (not at all true) to 4 (completely true) and summed as a score from 0 to 12. The lower the score, the worse the difference in values. Such a clinical-administrative vital sign can be used internally as well as in benchmarking with peer institutions using the scale.
Early detection can mitigate the spread of administrative damage. Thousands of clinical quality improvement projects are implemented in US health systems each year, but too many, like my Friday night job, are not monitored by prospective investigation or post-implementation survey. A better approach comes from a UCLA primary care performance improvement project, which included a rare survey of the clinicians whose performance was measured and pushed. Pre-questionnaires revealed that publication of peer comparison data not only achieved the primary goal of improved health maintenance metrics, but also eroded job satisfaction and increased burnout among the clinicians.
The researchers concluded that well-intentioned but poor-quality improvement efforts like theirs (and the one I was “asked” to carry out) could contribute to a system that “harms physician well-being.” Based on their investigation, UCLA refined its improvement initiatives by adding more open leadership support and continuous front-line feedback to reduce administrative injuries.
As I complete my improvement exercise for the day, my ping inbox reminds me that I am dangerously close to the deadline for the next quality improvement mandate. The cheery exhortation message informs me that Healthstream has online training modules waiting in which I will learn to optimize my coding to ensure the financial health of our hospital system. Tonight, as I close my computer, my scores on the Stanford Personal-Organizational Values Alignment Score are as follows: 0 for input being valued, 2 for matching goals and values, and 2 for clinical work value, a woefully incorrect 4 out of 12.
One day, I hope our health systems will be as committed to reducing administrative harm to their workforce as they are to preventing clinical injury to their patients. Until then, I’ll brace myself for more uneventful Friday nights spent on my EHR toiling away at one-sided quality improvement, instead of wasting the time in those “countless other ways.”
Walter J. O’Donnell is a pulmonary and critical care physician at Massachusetts General Hospital and Harvard Medical School in Boston. The opinions expressed here are those of the author.
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