A CASE FOR INCENTIVIZING HEALTHCARE INFORMATICS TRAINING
Issue
In the last decade, physician burnout has quickly escalated into a major public health crisis. Burnout can be defined as a chronically distressed state that is characterized by negative attitudes and decreased empathy towards patients, depersonalization, and a decreased feeling for personal accomplishments. Manifestation of this issue evidently lends itself to a large burden on the mental health of physicians and, consequently, a decreased contribution towards health systems and patient outcomes. There is a growing body of published evidence that supports this and chief among them is a recent paper published by a collaboration of multiple groups that includes the Massachusetts Medical Society, the Massachusetts Health and Hospital Association, the Harvard T.H. Chan School of Public Health, and the Harvard Global Health Institute (Jha et al., 2019). The authors highlight the issue and presents multiple solutions towards rectifying this public health crisis.
The prevalence of physician burnout has been estimated to impact nearly half of all physicians in some capacity. Alarmingly, it appears to be trending worse. In a survey that was conducted in 2016 and again in 2018 by the Survey of America’s Physicians Practice Patterns and Perspectives, physician burnout increased from 74% to 78% (Jha et al., 2019). Further, in a 2017 survey of all practicing physicians in Rhode Island conducted by Gardner and colleagues, burnout attributed to electronic health records (EHRs) may be as high as 70% and is independently predictive of burnout symptoms (Bakken, 2019).
Indeed, the dire situation has caught the attention of major players in the United States with multiple calls to action issued. In 2016, ten CEOs of leading healthcare organizations reviewed the data on physician burnout and subsequently declared this as a national issue in Health Affairs that needs to be urgently addressed (Jha et al., 2019). Unfortunately, the pervasive nature of burnout is not limited to only physicians and extends to all healthcare workers. In recognition of this, the Institute for Healthcare Improvement (IHI) published a white paper in 2017 that provides a framework for improving joy in the workplace. The National Academy of Medicine has also responded with the creation of an action collaborative in early 2017 aimed at improving clinician well-being and resilience.
To adequately address this crisis, an understanding of what led to these high rates of burnout amongst physicians is paramount. While there are many reasons that have likely contributed, one of the pivotal events that occurred is the Institute of Medicine’s 1999 publication of “To Err is Human”. The report primarily underpinned the dangers of medical errors due to bad systems, not bad people. Simply stated, the design of systems should assist clinicians in doing the right thing and prevent them from doing the wrong thing. Ultimately, this led to President Bush committing to having all Americans on electronic health records during his 2004 State of the Union Address. However, it wasn’t until the American Recovery and Reinvestment Act (ARRA) of 2009 under President Obama that this vision was realized since it was the ARRA, and specifically, the Health Information Technology for Economic and Clinical Health (HITECH) act, funded the rapid adoption of EHRs through incentives and penalizations under the Meaningful Use Program.
The ambitious timeline for conversion of an entire nation from paper to EHRs was heavily criticized. The existing healthcare infrastructure, multiple groups (e.g. patients, clinicians, payors, etc.), and supply of health information professionals were simply not ready to embark on such a feat. In the annual report to Congress in 2018 from the Office of the National Coordinator for Health Information Technology (ONC), which is the principal federal entity responsible for implementing a nationwide health IT infrastructure, reported that most hospitals and health care providers have successfully adopted EHRs (Technology, 2018). In fact, as of 2015, 96% of non-federal acute care hospitals and 78% of office-based physicians adopted certified health IT. However, adoption does not translate to success as demonstrated by the fact that EHRs are consistently considered the primary contributor to physician burnout. Between multiple calls to action and published reports, more granularity is provided as to what about EHRs is the issue.
At the heart of it, interoperability plays a large role (Bakken, 2019; Jha et al., 2019; Technology, 2018). While adoption rates of EHRs is already high, the rates of electronically exchanging health information with external providers or health organizations (48-90%), electronically finding patient health information from outside sources (34-61%), integration of health information with external sources (31-53%), and having patient health information readily available to clinicians at the point of care (36-51%), is counterintuitively low (Technology, 2018). The reasons could be further narrowed to 1) technical barriers due to a lack of standards development and adoption, 2) financial barriers in developing, implementing, and maintaining the constantly changing requirements of health IT systems, and 3) trust barriers in which patient information and access to it is restricted by competing vendors as such information is considered a competitive advantage over other vendors.
Another contributing factor in physician burnout is the usability of EHRs (Bakken, 2019; Jha et al., 2019; Technology, 2018). This is somewhat influenced by the lack of interoperability within the system, but there are additional reasons that roll into this. As we have shifted from pay per performance to quality and value-based care, the increasing burden of documentation for measurement of both process and quality outcomes has created an environment in which clinicians spend more time with their computers and at home documenting and decreased time with patients. Documentation is usually not relevant to the patient’s care and typically doesn’t integrate with the natural workflows of the providers. Moreover, health information professionals that are designing and building these systems are limited in optimizing these tools as they spend more time creating solutions that adhere to federal regulations rather than improve the user experience since the former has driven incentive payments.
Considering the aforementioned points, an administrative solution of improving the supply and training of health information professionals should be pursued. Historically, Congress has earmarked funding towards this at the onset of HITECH. However, training of such individuals was arguably not adequate given that our nation had little to no experience in implementing EHRs, let alone the responsibility of training such individuals. This solution will appropriately provide funding for training that appropriately defines the specific issues highlighted above.
Policy Discussion
Considering physician burnout (and clinician burnout) is widely recognized and championed by multiple provider and healthcare organizations, the support for the policy would likely be unanimous amongst physicians, healthcare workers and hospitals and health systems. Health plans and the pharmaceutical industry would likely be supportive of such a policy as well since informatics transcends beyond EHRs and into all domains of the healthcare ecosystem. An increased supply of competent health information professionals would be well suited to address the interoperability and data challenges of health plans with independent providers, hospitals, and pharmacies. Similarly, the pharmaceutical industry would benefit with better integration with these entities from a research, development, and supply chain perspective.
The primary consumer of this policy would be health information professionals. Certainly, this would be a welcomed policy within the health informatics community as it would provide more options for professional development, career advancement, and job opportunities. However, there may be a small minority that may be neutral or against such a policy as it would also increase the barrier of entry towards careers within health information technology. From a distal perspective, all other groups such as providers and health systems are consumers that would likely benefit, including patients. Improvement to our nation’s health information infrastructure would certainly allow physicians to provide better care and improve not only the provider experience, but the patient experience as well since they interact with these systems through patient portals.
Employers of all groups, primarily those of health information professionals, would likely be supportive of such a policy as well. However, there may be potentially a concern if such training leads to increased wages and a larger budget due to additional training. Albeit, since most health information professionals work within healthcare organizations, the likelihood of acceptance is greater.
Identify the Players
The key stakeholders that would support such a policy would likely be federal agencies, professional healthcare and health information organizations (e.g. American Medical Association, American Medical Informatics Association), hospitals and healthcare systems, and last, but not least, individual healthcare workers. Regarding potential enemies, there likely aren’t many groups that would be opposed to such legislation as the benefit crosses multiple groups and the main risk is the opportunity cost of investing in other federal initiatives. Potential candidates for enemies may come from a pool of undecided groups or individuals as there could be various consequences of enacting such policies as mentioned earlier such as increased wages and budget for health information professionals and an increased barrier of entry towards a career in health information technology. Thus, employers of these individuals (e.g. hospitals and health systems) and health information professionals may constitute a group of potential enemies or undecided as the initiative progresses.
Hill Strategy
To maximize the passage of such a policy, it may be best to begin with the House since this would likely fall under the purview of the Committee on Energy and Commerce and specifically the House Energy Subcommittee on Health since they handle health information technology. For the 116th Congress, the current Chair and Ranking Member of the Committee on Energy and Commerce is Frank Pallone (R-New Jersey) and Greg Walden (D-Oregon), respectively. The current Chair and Ranking Member of the Subcommittee on Health is Anna Eshoo (D-California) and Michael C. Burgess (R-Texas), respectively. These four individuals should be high-priority targets for lobbying and a substantial amount of effort should be allocated for them.
Hearings may be considered another opportunity to increase public awareness of this issue and galvanize further support. However, the benefits of doing this may not be as impactful compared to leveraging the press and media since there is already a wealth of information available about the types of initiatives that should be pursued given the barriers identified. Further, a hearing that solicits public opinion may not garner additional yield about public opinion given that the lay public are likely not aware of immediate impacts to the clinicians and technical challenges that exists.
As opposed to hearings, the press and media may be an effective way of increasing public support of such initiatives as it’s much more scalable and unidirectional than hearings. The issue of physician burnout is a simple concept for the lay public to grasp and allocating additional resources (e.g. taxpayer funding) is an intuitive solution given the association of burnout with EHRs. The press and media could also target the potential candidates who are considering a career within health information technology and serve as another avenue to gain support for the policy.
The White House will likely be a supporter of this policy as there has already been multiple federal initiatives targeted at improving physician burnout of which included allocation of additional resources to health information technology. However, this isn’t a guarantee either since there were some concerns from the health informatics community (e.g. Health Information and Management Systems Society, American Health Information Management Association) during the budget proposals for Fiscal Year 2019 that called for total elimination of funding for the Agency for Healthcare Research and Quality (AHRQ) in addition to major cuts to the Office of the National Coordinator for Health IT (ONC) amounting to $18 billion. With that said, those cuts never manifested, and the Trump administration announced the launch of the MyHealthEDate initiative, among a few other Health IT initiatives, in March of 2018 that aimed to improve interoperability and increased patient access to healthcare data.
Likely Result
Historically, health policy related to health information technology has received bipartisan support. Substantial amounts of resources have been earmarked for health IT infrastructure and training in the past and the likelihood that this policy will receive bipartisan support is high. With that said, the democrats in Congress will unlikely make a difference as there likely won’t be much, if any, controversy. Conversely, with the slow progress the ONC has made towards the implementation of the provisions stipulated by the 21st Century Cures Act as it pertains to health information technology, the outcome historically may hold true, but may lag in comparison to previous initiatives. Certainly, other political issues, such as the recent government shutdown due to political gridlock with the border wall has contributed and likely will continue to contribute to the delay of enacting our solution.
Can We Change the Outcome
Given the high chance of success and bipartisan support for such a policy, there would unlikely be a need for a modification in the policy to impact the outcome. Obviously, there may be small tweaks that could be considered with the specifics of the solution, but the association between EHRs and physician burnout are quite salient and the solutions to improved physician well-being and resilience have already been identified. Granted, contingency plans are never a bad thing and this administrative policy could be de-escalated from a federal initiative to a state or local one. There are many ways states and local organizations could be involved in improving the education and training of health information professionals by way of offering reduced or free tuition for Health IT courses and certificates. Institutions or universities with a virtual course infrastructure would be excellent candidates for this as well given their ability to offset much of the overhead costs if the course and training materials were available virtually. In fact, free virtual courses offered by the ONC and administered by various universities as a federal initiative has been trialed and successful in the recent years for this exact issue.
In summary, additional funding and training towards health information professionals is a policy that makes sense and addresses all the underlying issues that underpin physician burnout. Electronics health records aren’t going away anytime soon and a timely response to better address this issue is sorely needed. Congress should act fast and prime the pipeline for the next generation of health information professionals.
References
Bakken, S. (2019). Can informatics innovation help mitigate clinician burnout? Journal of the American Medical Informatics Association, 26(2), 93–94. https://doi.org/10.1093/jamia/ocy186
Jha, A. K., Iliff, A. R., Chaoui, A. A., Defossez, S., Bombaugh, M. C., & Miller, Y. R. (2019). A CRISIS IN HEALTH CARE : A CALL TO ACTION ON physician burnout. Massachusetts. Retrieved from http://www.massmed.org/News-and-Publications/MMS-News-Releases/Physician-Burnout-Report-2018/
Technology, T. O. of the N. C. for H. I. (2018). 2018 Report to Congress Annual Update on the Adoption of a Nationwide System for the Electronic Use and Exchange of Health Information. Retrieved from https://www.healthit.gov/sites/default/files/page/2018-12/2018-HITECH-report-to-congress.pdf