March 2019

‘Stupid’ Program Gets Results
By Selena Chavis
For The Record
Vol. 31 No. 3 P. 22

A Hawaii health system adopts a refreshing approach to address documentation issues.

Any health care professional who has watched the evolution of EHRs over the past decade is familiar with clinician outcry related to negative workflow impacts. It’s a primary driver of recent efforts by the Office of the National Coordinator for Health Information Technology to develop a strategy that will reduce physician administrative burdens.

While many are quick to blame EHRs, a July 2018 article in the Annals of Internal Medicine suggests that it’s the approach taken to documentation that may be the real culprit. Building on that premise, Hawaii Pacific Health, a not-for-profit health system, embarked on a journey to identify and eliminate meaningless documentation tasks and improve workflows.

The effort culminated in the launch of “Getting Rid of Stupid Stuff” in 2017. As of late 2018, the organization had approved 87 requests from nurses and physicians to eliminate documentation processes with 29 additional requests in progress. Another 46 requests had been assigned to work groups.

“One surprise has been how well this has resonated with our own employees, and actually how interested others beyond our walls have been,” says Melinda Ashton, MD, executive vice president and chief quality officer at Hawaii Pacific Health. “It seems that having our leaders be willing to declare some of our own work ‘stupid’ has been refreshing in some way.”

Beth Wolf, MD, a physician adviser to 3M Health Information Systems and the medical director of HIM for Roper St. Francis Healthcare, notes that the initiative represents the kind of “culture of curiosity” needed from today’s progressive, forward-thinking health care organizations.

“A culture of curiosity requires that you ask, ‘Why do we do it this way?’” Wolf explains. “That is powerful. It sends the message that there are no protected interests.”

Getting Rid of Stupid Stuff: A Deeper Look
According to Ashton, Hawaii Pacific Health started the initiative with the understanding that “Stupid is in the eye of the beholder. Everything we might call stupid was thought to be a good idea at some point.”

The project was birthed following concerns that the organization’s EHR made it easy to click on a response and move on without really considering what was being documented.

For example, Ashton points to a feature added after the EHR was deployed in the documentation workflow called the rounding row, which was initially designed to monitor whether rounding was actually occurring. However, the organization found that nurses were choosing the first item on a list of possible choices to document that they had done hourly rounds on their patients.

“When a small group of our nurses doing an evidence-based practice project on hourly rounding interviewed some of their colleagues, it was clear that they didn’t know what they had documented and, moreover, we had nurses spending 1,700 hours per month documenting about their own activity rather than documenting the care they provided to our patients,” Ashton says. “That struck us as stupid—although clearly well intentioned at the outset—and the program was born.”

In another example, an emergency department physician requested a review of a process that entailed printing an after-visit summary, having the patient sign it, and scanning the document back into the system. The team queried other health systems and the legal team at Hawaii Pacific Health about the value of the signature and determined it was not needed. Subsequently, they were able to streamline the workflow.

Ashton and her colleagues identified the following three categories where they felt staff would make requests:

• documentation that was never meant to occur and would be easy to eliminate;

• documentation that was needed but could be completed in a more efficient or effective way with new tools or better understanding; and

• documentation that was required but clinicians did not understand the requirement or the tools available to comply.

Since the program began, requests have been received for all categories; some requests were addressed with quick fixes, others sent to work groups, and some denied due to patient care, operational, or compliance issues.

Findings/Lessons Learned
One of the most interesting findings, according to Ashton, was the program did not receive as many responses from physicians as expected. Currently, optimization teams—which teach staff EHR tips and tricks—are soliciting more input from physicians.

The fact that nurses at Hawaii Pacific Health were more engaged in reducing workloads than physicians is not a surprise to Jay Anders, MD, chief medical officer of Medicomp Systems. “This behavior sings to me because it is representative of one of the most common problems with EHRs and health care in general,” he says. “Physicians are so busy—or perhaps so preoccupied—that they don’t engage in certain activities that could potentially save them hours of time. If physicians would engage in their EHR programs and give constructive criticism about what they do and don’t like—that is, the things they think are ‘stupid’—then things will get better.”

Wayne Crandall, CEO of NoteSwift, finds that it’s more likely for administrative teams rather than physicians to seek help with workflow issues. “Physicians don’t want to change what they have already learned. Physicians do complain about these issues, but they don’t have the time to impact it,” he says.

Besides pointing out the lack of physician engagement, Ashton notes that Getting Rid of Stupid Stuff revealed that Hawaii Pacific Health had various documentation requirements for nurses and other support staff, a situation that the organization is addressing. “First, we are implementing a standard handoff tool and approach—IPASS—for all of our nurses across all four of our hospitals,” she says. “After that is completed, we will tackle the end-of-shift daily note, and eventually will migrate from care plan documentation to hopefully more meaningful plan-of-care thinking and documentation.”

Can ‘Stupid’ Be Eradicated in Other Organizations?
Industry professionals are quick to point out that with the right backing, the same process improvement initiative created by Hawaii Pacific Health can be replicated at other organizations. The key, according to Wolf, is having a robust change management strategy that supports end-user satisfaction. In short, engaging those working in the trenches.

“This champion [Ashton] apparently had a special desire to facilitate change with boots-on-the-ground involvement,” Wolf says. “If you don’t have the people doing the work provide insight into how they can do it better, you are never going to get the same level of engagement and satisfaction. That all makes common sense in terms of outcomes.”

Anders agrees that engagement, especially from physicians, is key. “In my experience, if you are asking physicians to do something that takes them away from delivering patient care, you might need to find a way to compensate them for their time,” he says. “Practices must also examine their various documentation needs and find ways to push tasks to the lowest appropriate levels.”

For example, Anders says that rather than requiring physicians handle all documentation, have a nurse meet with the patient to document the patient’s health status. Then, the physician can focus on the critical questions required to make a diagnosis or to optimally treat the patient.

“By examining existing workflows and identifying the skillsets of individuals, practices can more appropriately assign various tasks and save physicians a tremendous amount of time,” Anders says.

While getting people involved from the ground up is vital, Crandall also points out that hospitals, in contrast with their more flexible ambulatory partners, must default to robust and intricate sets of standard operating procedures (SOPs). “They have to take into consideration their environment needs and SOPs and see where they can optimize. As we talk to these varying organizations, everyone has different processes, and you have to be able to adapt to that,” Crandall says. “The danger or fear in [eliminating documentation steps] is not achieving the entire specific patient diagnoses or orders. When you look at what they did [at Hawaii Pacific Health], that was not the case.”

Compliance, Value-Based Care Issues
Ashton says that compliance concerns are always a consideration with the Getting Rid of Stupid Stuff program, adding that the team knew that while some document processes would seem stupid to frontline staff, they were still necessary. “For items nominated as stupid that are required, it was our plan to improve our education about why documentation was necessary,” she explains. “This is what has happened. Our staff are fully aware of needing to be compliant with rules and regulations, and once they understand the reason, we don’t have a problem.”

Even though a change is not feasible, there’s value in hearing staff concerns, Ashton says. Through those insights, it’s possible to better educate staff as to why certain documentation processes are important.

Wolf believes that balancing compliance with the burden of documentation processes can be difficult for many organizations. She emphasizes that if physicians were skilled at documenting before EHRs, they have likely made a “decent” transition to electronic workflows. If not, then EHRs amplify the problems.

Wolf compares documentation with using the self-checkout at a grocery store, noting that “It’s great when it works perfectly. Otherwise, it can be painful. Those are the kinds of administrative burdens that physicians balk at.”

In the era of value-based care, complete, accurate documentation is critical, which means health care organizations must engage their physicians, Wolf says. “I believe value-based care will have a positive effect on documentation,” she says, noting that it should lead to a more complete note. “The first step is engaging physician leaders who can then engage their peers. Even if documentation is not at the top of your list, you still want to perform well.”

Ashton hopes that new reimbursement models will drive down administrative burdens. She points to the example of a physician colleague who works for two institutions but takes different approaches to documentation. When he bills for an interaction, his notes are more extensive. In contrast, his documentation burden is less within a bundled payment system.

“Additionally, we know that in other countries where the same EHR system that we have is used, their burden of documentation is far less than ours, suggesting that an awful lot of what we do is driven by our payment system,” Ashton says.

HIM’s Role
Industry professionals agree that HIM is critical to any process improvement initiative related to documentation.

Speaking about her own HIM department, Wolf says it is in a prime position to identify inconsistencies and inefficiencies. In addition, it is poised to become the recipient of positive outcomes when processes are improved as a result.

“We understand that we are there to support the physicians and how they record information for patients, and to serve as a repository for that information,” Wolf says, noting that better physician workflows can subsequently improve HIM performance. “We recognize that system efficiency leads to happier physicians, who in turn are more likely to accommodate requests and complete their records on time.”

Anders emphasizes that correcting or getting rid of “stupid stuff” requires organizationwide collaboration. “Regardless of who provides the details, documentation must include certain elements to justify payment. This requires collaboration across the organization to ensure the correct patient information is collected and properly documented, that the physician signs off, etc,” he says. “There indeed may be plenty of tasks that can be delegated to staff members besides the physician, as well as activities that can be totally eliminated.”

Ashton says that due to the success of Getting Rid of Stupid Stuff, the program has been extended beyond the original EHR focus to other parts of the organization. “Early on, one of the leaders in HR said, ‘We have stupid stuff, too,’ and they committed to finding it with help from their staff,” Ashton notes.

Asking the hard questions can bring about positive change, Crandall says. “Sometimes people overthink problems and sometimes they ‘overprocedure’ things,” he says. “This initiative reached down to the people on the floor, and that enabled them to make easy changes. And it didn’t affect any patient outcomes. It just started with looking at their daily routine.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications, covering everything from corporate and managerial topics to health care and travel.