Welcome everyone. We are at the top of the hour so we'd like to kick off our webinar, you are joining the in basket management and provider well being webinar today thank you for spending an hour of your afternoon or morning, wherever you're located with us. We are lucky enough to have Dr. Goldberg from University of Pennsylvania and Dr. Wong from Providence Heart Clinic in Portland, Oregon joining us and presenting for us today. Before I hand it over to them we'll get a couple housekeeping things out of the way, Dr. Wong if you want to advance. Thank you. Quick introduction Dr. Goldberg is the vice chair of medicine and informatics and, and the section chief advanced heart failure and cardiac transplant at University of Pennsylvania. Dr. Wong is the medical director of general cardiology at Providence Heart Clinic in Portland, and we are very excited to hear all that you're going to teach us about in basket management and what that has to do with provider well being. Before I hand it over that you will see that we have a couple of things just to point out to you the chat box will be located on the bottom of your zoom pan panel you will be able to find a link to the handouts in there, if for whatever reason you feel free to chat us and one of our technical teammates will help you with that. If you have any questions for Dr. Wong or Dr. Goldberg we're hopefully going to have a few minutes at the end of the webinar that they'll be able to answer those so please enter those into the question box, and we will keep an eye on those. And for now I will hand it over to Dr. Wong. Thank you. Thank you everyone. Thank you, Katie. I want to thank everyone on this team for inviting us from med axiom and the ACC. I want to thank Rick and Stephanie Mitchell for putting this on team for putting this together. I also want to thank my colleagues here in Portland, Oregon, Danielle Christianson and Leslie Jones Larson for helping me put this slides together. Leslie couldn't join us today at the last minute. And I'm excited to have this conversation with Dr. Lee Goldberg to share our experiences from our two organizations with the audience. So, this will be kind of a four part talk. First we'll open with some local and published experience in terms of showing the fact that EHR is becoming an increasing source of clinician burnout. The second part is that we want to highlight that clinician well being is a ACC strategic priority. The third part, which we want to emphasize is that addressing in basket management at the system level is vital to the success of our clinical practice and program, and we will share our organizational experience. Beyond that, we want to also share with the audience and hopefully by the end of this hour that you will agree with our belief that the in basket management is important beyond provider wellness in advancing care, improving quality, safety, patient experience, and achieving the financial sustainability of our clinical programs. So I want to share some to me heart wrenching data from my own organization. These are real data from my colleagues. For example, this is my colleague, who is a dad of three children. He's a general cardiologist, and these are signal data coming from EPIC, our electronic health record, and you'll see these two dotted lines mark the beginning and ending of our patient encounter day. And these colored blocks show how much time he's spending in notes and letters, in in basket, in clinical review orders, or other EHR activities throughout the day. And you can see during the morning, he's documenting. He has a short break during the lunch hour, and then he has a busy afternoon, but beyond the clinic day, his work continues into the night. He takes a brief break to probably read a story to his children before they go to bed, and then he gets up again to do some more documenting, sometimes even working into the early morning hours. This is my colleague, a physician mom who has a young child, so her work habit is slightly different, such that she sometimes gets up before 4am to prep her chart and address in basket messaging. She has a busy clinic day, and then she feeds her child, goes back to work, puts her child down to sleep, work a little bit more before she starts the next day at 4am. This is what I call a seasoned physician, which is the code word for one of us, slightly older physicians who may not be as savvy with EHR, and you can see the significant EHR burden that he is experiencing beyond his clinic day into the night, and starting very early in the morning. You may say maybe this is because these are older physicians, they're not savvy with EHR. Well, this is the data for our youngest physician who grew up in the age of EHR, and you can see throughout the day he takes no break. He also has a young baby, so he has to feed the baby and give the baby a bath, but then he gets back into the EHR to work from basically 7am till 10 in preparation for the next day. On a national level, we see published data confirming the same. This is a study coming out of Yale New Haven Hospital and Group, and the blue bars show in-person visits versus the kind of brownish color bar, which are telemedicine visits during the pandemic. Indeed, COVID-19 has worsened what we've been experiencing, and you can see the blue line, which are patient call messaging going up during the pandemic, and the yellow dotted line is the number of incoming patient messages doubling over the pandemic. Indeed, we're spending 15% more time in in-basket per physician. So if you feel like we are at a rapidly running chocolate belt, you're not alone. Sometimes you feel like you're fighting a losing battle. So if you're feeling overwhelmed, burned out, distraught, hopeless, you're not alone. Even back in 2005, there was a New England Journal of Medicine article highlighting the fact that physician suicide is higher than other professions and double that of the general population, particularly for female physicians. In 2019, there was an annual internal medicine article highlighting that the cost of physician burnout on a national level is $4.6 billion in terms of turnover cost and physician needing to cut back in their clinical practice. In March of this year, the legislation signed into law a Dr. Lorna Breen Healthcare Provider Protection Act to provide more funding and support for provider mental health and support to reduce burnout. Dr. Breen died of suicide at the height of the pandemic. So those of us who have been working on clinician wellness is familiar with the Stanford wellness model, looking at wellness as a goal to improve professional fulfillment. And this work in three domains, addressing, improving personal resilience, but developing a culture of wellness and efficiency of practice on a system level. And although I really agree with this model, I would say, you know, this, the, our wellness is not about our professional fulfillment. It's, and that if you've survived, getting into medical school, thriving in medical school, getting into great training programs, residency and fellowship. And if you're like me, an immigrant, a woman in cardiology and a person of color, I think you'll agree that we are plenty resilient. So we want to call it out and say, don't fix me. There's nothing wrong with me, but fix the system that is burning us out. So I was very happy to see that last year, the ACC formed a wellness task force and Dr. Laksimi Mehta and group issued a joint opinion from the ACC, from the HAESC and the World Heart Federation. Calling out the importance of systemic intervention to address clinician well-being. So in 2014, Dr. Bodenheimer from UCSF published a piece calling out that in order to care for our patients, we must first care for our providers. Adding to the triple aim of improving patient outcome, lower costs of care and improving patient experience, a fourth aim of improving provider experience. In the ACC joint opinion paper, Dr. Mehta and group put this enhanced clinician well-being at the core of the quadruple aim. I don't think this is because we are Madonna's and that we are so self-centered, but rather, if you recall, every time before you take off in an airplane, you are instructed to put the oxygen mask on yourself before putting it on a child or person in need. Because without our well-being, we are not able to take care of our patients. So next I want to share with you a project that Providence at the system level has done to focus on EHR optimization. This is a Providence system level physician enterprise investment of $15 million to address provider engagement, reduce burnout through technical innovation and system optimization. This was a project that was provider focused and ambulatory focused, and it was provider led through rapid process improvement over 12 weeks. And after the project completed, there was significant effort in terms of dissemination and further iterative engagement of the providers. So what did we do? From a cardiology standpoint, we started out with the signal data to see where are the pain points. The signal data are the graphs that I showed you at the beginning of this talk. Then we went and interviewed our subject matter expertise, conducted virtual interviews of our frontline providers, collected provider surveys, formed a specialty advisory group, and developed pilot validation and implementation. So we started out by hearing the voice of the provider. Our survey data is consistent with what was published through ACC survey in that you can see on this bar, 50% of the providers are either neutral, somewhat dissatisfied, or very dissatisfied with their EHR. So 19 cardiology providers from five Providence regions worked for 12 weeks with our IT team to address the issues, the pain points that were brought up through the provider survey. The optimization focused on mainly six domains. I don't need to go into too much detail because Dr. Goldberg's talk will focus on these EHR optimizations more. But just in big buckets, the six domains were data visualization, right? Why are we fishing a needle in the haystack to find the information we need? Can we use technology to make the data more visible to our clinicians? The second is documentation template. Can we standardize our template? Can we pull in information automatically? Really think about it, the way we're using EHR is still the same as if we're trying to have a paper chart, a static piece of paper to communicate. When in fact, really, each of us when we're looking at a patient's chart, we're still going into the primary data, looking at the ECG tracings, echo images, monitor tracings. Really, the static documentation is only to fulfill legal and billing purposes instead of to communicate between providers. How can we optimize our documentation so that it is easy and it is effective to communicate between providers? The next domain is addressing patient advice messaging. You saw in the earlier paper, I cited that during the pandemic, since the pandemic, there has been a doubling of incoming patient advices. Indeed, our current patient population and future generations will expect to be able to have asynchronous communication with their providers, just like how they communicate with travel agencies or restaurants. We need to figure out how to do this. How can we do more automation in terms of patient data collection? How can we standardize staff review and shared processing in terms of care teams so that we're not using a clinician's time to manually address each of the messages? The next domain is resulting. As cardiologists, we order lots of tests, and we need to be able to communicate. Now, the patients can view the results sometimes before we even do. So setting up a standard workflow, which includes staffing and APPs, and addressing the patient directly through their MyChart message is going to be important so that we can save both staffing and clinician time. Next part is order simplification. How can we standardize our orders, save favorite actions? For example, in our EHR in Epic, you can have one person be the leader in this preference list setup and have the rest of the team follow that person and adopt that set of preference lists so that you don't have to constantly define the preference list update and push it out to each individual. Lastly, we need to have the staff have a standard workflow and empower them to work at the top of their license. At the end of this optimization project, we do have a very comprehensive dissemination pathway, which includes a portal, recorded videos in total and in small bits, as well as education modules, one-on-one training, in order to have all of our busy clinicians benefit from the work that we've done. So moving to the next project that we've done in our last MedEx webinar in the spring conference, we shared and got a lot of interest from our colleagues about a pilot that we're doing in terms of using APCs who are working remotely to help address in-basket burden. And this is our primary care colleagues' data to show that they are able to have eight full-time virtual APCs covering 15 primary care clinics. And this allows these APCs to be able to work remotely and have better work-life balance and certainly help the clinical team. And because this is what they do every day, all day, they're much more efficient than those of us who are also being pulled from different directions when we are trying to address in-basket in the office. And we think this is a way of the future, and from a cardiology standpoint, we would like to learn from them. In the next step, I want to also share our thoughts in terms of, we think of these in-basket management and EHR use as part of our comprehensive digital strategy, meaning that from a video visit to a telephonic visit to a MyChart message, a e-visit or a e-consult with our primary care providers, referral review and resulting, each of these actions may have zero or a few work RVU related, but the work RVU is not the total picture. We need to think about each of these actions, how much does it cost our providers? How much time does it cost our staff? But on the other hand, how much value does each of these actions bring to the patients in terms of advancing their care? And how much monetary value does it bring to the practice? And you can see, not everything is in congruency, right? So in our previous MedAxium discussion about in-basket management and turning it into a return on investment, we invite all of our physician leaders and administrative leaders to think about these actions in terms of what's the cost and what's the value and what's the margin, instead of purely how much work RVU there is. And that will help you decide how to invest in your staffing time and personnel to each of these strategies. So in brief summary, I want to point out that although we started this conversation from addressing the in-basket from the clinician wellness standpoint, I want to say that all this work goes much beyond clinician well-being, but rather these strategies is the way of the future. It advances care beyond in-person encounters. It helps improve patient quality and safety. It enhances patient experience. And finally, will make us sustainable. So next I want to hand this to Dr. Goldberg. So thank you so much. And I have to say I was smiling during your presentation because I feel like we're of the same mind. We're working really in parallel. And so I want to give you some experience or some flavor of what we've been working on at the University of Pennsylvania. And I think you're going to see the same themes kind of reviewed again. And I think that's very validating when you see two different institutions confronting similar problems and coming up with some of the same solutions. And so I think you'll see that pattern. So for us, I really want to drill down on some of the work that we've done specifically to in-basket. We too have done a series of practice-based and divisional-based sprints where we've gone in and looked at the entire workflow, the note generation, letter generation, appointment scheduling, etc. And really worked on that. But I want to focus a little bit on the in-basket because that has really become the major issue for us with COVID. So the in-basket has become a significant burden on providers and staff. And that's because, as you've seen, the volume of messages increased rapidly. In some practices, 40, 50, 60% on average in the mid-30% range in our practices. And part of this was our fault. As we were responding to COVID, we encouraged patients to register for our portal to allow for communication and self-scheduling and bill pay and radiology scheduling and all of the functionality. But we also then gave them access to messaging their care teams, etc. And then when COVID happened, we really rapidly shifted patients to the portal because we had many of our staff working remotely and many fewer staff available to answer phones. And so if patients could message us, we could route those messages to staff that were working off-site and then have them call the patient back or respond via the portal. And so this was a way for us to cope with the crisis of COVID. Now, prior workflows that were email or paper-based did not always translate well to the EHR. And that's where we had some new concepts that we had to really sort out. And that is the concept of a pool where messages are sitting essentially in a bin and multiple different staff members with multiple different roles may be logged into that pool to be able to handle that. And that's a little bit differently than we did with the paper where we handed the paper to individuals along the way. The other thing that's happened, and many of you can understand this, is that the EHR oftentimes evolves and changes. There's always upgrades, etc. And our staff have really struggled to learn the new features, some of which may actually be very helpful with dealing with these problems, but they either didn't know about it, didn't have the time to do it, didn't have the right training. And then, of course, we've had a significant increase workload with a big shift of this workload towards physicians and APPs and other providers, with really no increase in revenue, in some cases, less revenue coming into the practice. So the next slide. So we wanted to define EHR usability as one of the things that we wanted to think about. And so usability is the extent to which any technology can be used effectively, efficiently, and satisfactorily based on its design and integration into the context of use. And I think many times when we're thinking about the EHR, it's oftentimes not really considered in context, that how are things different, say, in the cath lab as compared to an ambulatory practice, as compared to inpatient, and what tools or views do you need in order to be able to work effectively, and so that the EHR is supporting us, etc. So the question is, does the EHR make it easier to provide quality patient care? And at Penn, we have a saying that we say, we want to make it as easy for our providers to do the right thing. And the right thing is amazing world-class quality patient care. And we want the EHR to support that. We shouldn't be tripping over ourselves. We shouldn't have the EHR encouraging us to cut corners or have workarounds, but rather the EHR is really promoting us to provide quality care. And so we've been looking at a slightly different model called the provider task load framework. And essentially we're looking at usability and burnout. And we recognize that usability really impacts workload. The more usable the system is, the lower the workload. But when the workload is high, that impacts burnout. And so therefore, we want solutions when we're thinking about things in our sprints or when we're doing optimization to impact usability and task load in order to make things easier and minimize professional burnout. And you'll see in the diagram on the right side of the slide, it just talks about redundancy, almost dazzling displays that actually cause us not to be able to focus on what's important. Sometimes notes that are so bloated, you can't find what you're looking for. Sometimes lack of standards. So every time I look at a note from a different provider, it's different. There's the physical and mental demands that are put on you for task load. And then from usability, you know, there's issues around frustration and anger around the EHR slowing us down, but also how it makes it easier for us to have errors and safety events. And this all culminates into professional burnout where people are really just exhausted, feel depersonalized, and really feel like they're not making the personal accomplishment that they wanted to when they went into medicine. Next slide. So we know from data, this is ACC data from a survey in May of 2022, that 65% of our providers in cardiology agree that increasing volume of in-basket messages has created a burden that has been very difficult to manage. And you can see the message types. Pace of messages are up 69%. Test result messages, 58%. Care team member messages, back and forth between care team members, 55%. And this has led to a significant burden on the staff. And so what are the kinds of things did our colleagues come up with where they thought that we could improve or manage this volume better? So one thing would be rerouting messages to staff who can handle them so that the clinical team doesn't necessarily have to deal with, say, administrative scheduling or billing type questions, even referrals, et cetera. You know, applying filters to screen out non-patient care messages in some way. Maybe bill for patient inbox messaging. And at the very end, I'll tell you a little bit about a pilot that we're doing to try to address that. And then if you look at the level of burnout of these individuals, a third of them are definitely burned out, are definitely burning out or burned out due to the strategy, due to the stress that they're under based on the in-basket. Can I get the next slide, please? So what are the sources of in-basket messages here at Penn? And we spend a lot of time kind of thinking about this. So we had results, which include labs and imaging and all of that. Some of them are inside, some of them are outside. Some of our outside labs have interfaces that feed into our system directly and come in as in-basket messages, but some come on the old-fashioned fax machine from other hospitals, etc., and we have to manually key those in, and then those generate additional results and work. We have the patient portal messaging. We have clinical questions between clinicians or others. We have documents that come in, disability clearances for surgery, authorizations, etc. We have the prior authorization and insurance staff messaging us in our in-basket about peer-to-peers or additional documentation required to authorize things, clinical communications between clinical staff on a particular team, so between me and, say, the nurse and the APP that I work with, and then appointment scheduling and rescheduling. So these were the categories that we had. So we developed multiple projects that have been working in parallel. These are kind of the order that we've been working on them. The first was we had a major initiative. We started with one small practice, and I've rolled this out across the entire Department of Medicine, across all of our entity hospitals, to have all of our staff in the ambulatory areas working at the top of scope. Now, we don't say here top of license, and that's because some of our staff, our administrative assistants and our medical assistants, at least in Pennsylvania, they're not licensed per se, but they do have a job description and a legal scope that allows them what they can handle and do in the EHR. The second is results routing that's automated and streamlines and supports clinicians and staff. It triages and puts important messages at top so that staff can quickly see what they need to do and have a work queue that makes sense and is manageable. Message triaging, which is something we've been working on a lot over the past few weeks, this is patient messaging coming in and allowing patients to actually select what are they messaging us for so that we can pre-distribute those messages to the right pools. And then lastly, you already heard about this, but workflow redesign, and that is looking at existing workflows and practices, especially practices that are really drowning with this, and trying to leverage existing EHR tools, look at their staffing, provide the right type of training, and really understand how the humans in those practice are really interfacing with the EHR and the equipment that they have in order to come up with a workflow that makes sense and is supportive. Next slide. So for top of scope, the concept here was to allow every staff member to complete tasks for which they are trained, qualified, and credentialed to perform. And I do want to highlight that this may vary from institution to institution and state to state. So sometimes I'll go to a presentation and I'll think to myself, gee, our MAs are not allowed to do that, or our own internal structures in our institution does not allow that staff member to do that task. So this does require some communication within your institution around what the rules of engagement are for staff. And if this has not been defined, which we had some examples of that here at Penn, we really did need to sit down with people at baseline in order to decide what the scope was going to be for each of our staff members. Sometimes we updated job descriptions, we provided additional training to some staff, and then we did need our regulatory teams to understand from state to state what was allowed from a licensure perspective. Now the goal on the right side of this slide is to distribute the work among the team, and I'll give you examples of different roles. So administrative staff can handle non-clinical messages, and this would include scheduling, prior auth requests, even setting up peer-to-peers, et cetera, for our staff. The administrative staff can handle that. Our medical assistants, depending on the practice, will append medication refills that are coming in from patients so that they can be assigned with one click. They can enter and route labs if necessary, so labs that need to be manually keyed. We have a group of medical assistants in our practice that spend part of their time doing that. They can even send out standard patient education. For example, during flu season or someone calls with symptoms of a runny nose or this or that, we have some standard education that we provide patients on what over-the-counter medications are safe, et cetera, and MAs can kind of distribute that standard information through a smart phrase out to the patients and kind of decant some of the standard messaging so that other staff doesn't have to handle it. Now, our nurses who are licensed, they can pen the medications, although in our institution, they cannot forward them to the…they require co-signature from a licensed provider, but they can answer clinical questions. They certainly can do triage. They can implement standard or patient level protocols, and what I mean by this is for an individual patient, say, in my heart failure practice, we may have a protocol that if their weight is up so many pounds, they would double their Lasix or take Metolazone. If we've documented that on the chart, the nurses can actually implement that protocol with the patient and even pen labs and follow-up for us in kind of an automated standard way, and then across the practice, you can have protocols that are standard across a subspecialty practice to respond to certain common clinical scenarios that the nurses can follow, provided that those have been agreed upon and signed by your clinical staff and your leadership. And then the nurses also now, something new at Penn, can resolve what we call expected or normal results. So, if results come in and we started someone on spironolactone, the potassium and the creatinine are stable, the nurses can document that and then done that message. If it's abnormal or unexpected, they can send it to the clinician for follow-up. Now, for expected abnormal results, for example, if you work in a renal clinic and the creatinine is three and it's been stable at three for years, that's technically an abnormal result, but it is expected and within the range you would expect. You can have protocols to have the nurses handle that without necessarily having a provider deal with that. And then lastly, our APPs obviously partnering with the physicians and they're implementing treatment plans and developing them, prescribing or co-signing prescriptions. Really, our APPs in our practice are the group that really handle escalations, patients that are sick or unstable or have worrisome symptoms, you know, we're rapidly getting messages to the APPs and they do a fair amount of triage. You can be seen urgently in the office, who should be sent to the emergency department, et cetera, and they partner with the physicians. You can almost interchange a physician in that role. Next slide. So, for the implementation, we really had to set expectations and that meant educating every team member on what their role is, figuring out how we're going to handle escalations and make sure that they're handled quickly and taken seriously and that the staff feels supported. So, if an MA gets a message that they're worried about, they need to know that if they route that message to someone else or they flag that, that they know that someone's going to be responding to that, that they feel supported. We needed to make sure they had access to the right pools and we found that in some practices, not all the staff could log into the pools correctly. We needed to provide some training for our MAs in particular. Some EHR tasks were new, like entering labs. We had to train them on how to do that and validate that and kind of watch them for a while to be sure that they were competent at that. And then we had to be sure that our staff had appropriate security and privileges within the EHR based on their scope. And then lastly, we really did need to establish cross-coverage as needed for each role. So, if I work with my nurse normally and she's managing my patient pool, but then she's on vacation or out or yesterday was doing CPR training, for example, another nurse is actually cross-covering that pool to make sure that we're constantly involved in managing the messages coming in. Next slide. Now, for our results pool redesign was really three interconnected projects. The first was to identify and map all results pool to the correct departments. They were named so many crazy things going back to 2007 here at Penn that we didn't even know, you know, it was like Bill's result pool and named after some building that we've since knocked down. And so, we really needed to go back and map all of our results pools to who are these people and are they in the right departments. And then we had to retire almost 3,000 obsolete or duplicative pools that were really putting us at risk, meaning that we didn't know who was logged into these pools, were we managing these results, et cetera. We did want to create a new pool structure going forward and really standardize this across the entire enterprise in all ambulatory areas, but did start in the Department of Medicine, which was a focus on provider-based pools. So, really linking to the physician or the APP and then having their results go in there and then having additional staff log into those provider pools in a way that creates clinical teams working within the practice. And the goal here was to avoid sending duplicative messages. We had scenarios at Penn where the message was going into my personal in-basket as well as to the pool, but they're two separate messages. So, if I take care of it in my in-basket, it had no impact on the pool. So, someone would have to open that and then see whether or not I had handled it. And it was a lot of duplicative work. And when we found that, we realized we could buy back a lot of time if we could reduce that double work. We also wanted to have accountability. If these messages are in that pool, tag, you're it until you pass it off. And so, we wanted to be sure that every message had an accountability that we could go back and look at and understand how can we improve things or if things came off the rails, where do we need to re-educate or refocus the staff? And then the third project was redesigning the workflows. And that was really helping people understand how to log in and out of pools, how to forward message, how to use taking responsibility, which is what our EHR calls something where it's sitting in the pool, but you say, hey, I'm going to own this, but I'm not done with it yet, so I'm leaving it in the pool. And then at the practice and program level, we really needed to work hard on determining team workflows. Ironically, in cardiology, this is our nature. We've already been working as teams, but when I go out to some of the other practices across our health system, this is a new concept for them. And so, we really wanted to determine those team workflows and then obviously leverage the top of scope once we've established those teams. Next slide. So, this was our best practice pool design and we just presented this actually to now all of our ambulatory practices across medicine and we're about halfway done converting all of our divisions to this mechanism. But essentially, every provider has four pools. One has all of their results. One has their messages from patients. We call it MyPenMedicine, but it's the patient portal messages. One has clinical messages from other providers or clinicians in the system. And then the fourth is an administrative messaging pool. They're named by your division and then your name and then what type of pool it is. In other practices, we have division name, location, and then provider name and the type of pool it is. And we're trying to standardize that so that I, in cardiology, need to send a clinical message to my colleague in GI named Smith. I would know like what their pool name would be named so that I could forward a message to them and that would end up in their pool. And we want to have the same process for both MDs and APPs, so every provider in the practice has these pools. And then we want to have the ability again for staff to check in and check out. The advantage of this when we piloted this in cardiology was that we could pull very accurate data workbench reports out of Epic to really see how many messages go into each of these pools and how many staff are checked in and for how long. And we could understand what our staffing needs were in a way that we could never ever do it. So we actually did some staffing analysis and tried to determine what are equitable workloads. And they were tremendously variable. And again, there's some reason for that. And again, some messages are more complex than others. And so we have to take that local into account. But it really enabled us to develop workflows that made sense and could be optimized because we actually had data for the first time around how many messages were coming in. In the past, just for GI, for example, in our institution, they had one gigantic pool for all 45 providers. And so it was very hard to manage that and track it. Now we have one for each provider. Next slide. So the advantages of this were we had consistent pool structure, which I have to say our IS department was actually pretty happy about. When we onboard someone, we know exactly what pools to create. When we off-board someone, we know exactly what pools to retire. In the old days, no one knew what pools to retire because they were named crazy things. Again, we could assess workload. We can have other providers message the correct pools. And then the idea was to align the teams doing the work with the right pool. So for example, in my practice, I have a bunch of my heart failure docs that go out to satellite sites. Sometimes the satellite site provides nursing support and administrative support for that provider when they're there. And therefore, there is a separate set of pools for them at that location. And we automatically route any patient that was scheduled at that location to those pools. Then I have some providers who actually our support staff downtown supports them for the two days a month that they go out into a local practice. And so we actually only have one set of pools. And all those messages actually come back to us because the local pool, we're really just leasing space, but we're not using their staff. And so we're able to do that downtown. So we really can align the teams doing the work with the appropriate pools. Next slide. Now, other advantages allow us to triage messages to the appropriate staff. We're trying to reduce the number of messages that our physician and APPs are seeing that are non-clinical. And again, this has really helped us work at top of scope, including handling normal or expected results. And then interestingly, sometimes staff do need to log into multiple pools. Say there's a holiday or a lot of people are out at a meeting or whatever else, you can recreate a large practice-based pool by just having the staff log into five providers and create one gigantic temporary pool, and then they log in and out. And so in those areas where, for example, there are certain days of the week where that program is there in clinic, the staff want to be able to see all the results coming back together for team meetings or whatever, they can do that. And then they can log out and cover their individual staff. Next slide. So message triage is the next project that we're taking on. And we're in the midst of doing this now, but we want to allow patients to categorize messaging for automatic routing. Prescription refills allowing single clicks. And we have some refill protocols here that are automated at Penn that allow you to know whether or not it's safe to renew that prescription or not just by looking at it. We want to be able to get clinical questions and concerns to the right staff, but then also administrative stuff. We want to have clinical teams review only clinical messages. And then interestingly, we've started this new thing where we're providing patient education that is consistent across the enterprise. What I mean by that is we now give patients instructions through our portal how to message us, what's appropriate, and what to call it. If it's a problem with, I need a refill, click on this. And we give them more education so that the patients have the right expectations and also know how to use our portal in a way that supports our workflows on the backend. Next slide. Now our workflow redesign is our last project, and we really wanted to focus on team-based workflows. And this meant that we had to carve out time to allow teams to meet, to really discuss the ideal workflows, the expectations, and really share the commitment of the leadership and especially the physicians and APPs to support the agreed upon workflow. So if all the staff are doing the right thing, but you have a provider that never takes care of their in-basket or doesn't log in when they're supposed to for escalations, you only create chaos and real frustration among the staff. So you need to have that meeting in order to have the teams really work as a unit. And that creates new cultural things that you have to overcome. And also different ages of different providers are more or less comfortable with this. The next thing is we needed to train all staff. And so I was smiling when Dr. Wang was showing her technique for doing this. We have on-demand shoulder-to-shoulder. We're actually providing it this week because we had a major upgrade of our system on Sunday. And so we have shoulder-to-shoulder teams out right now helping staff deal with that. We have micro-learnings, which are usually under a minute, but can be up to two minutes, of little videos on how to do a very specific thing in the EHR, how to optimize something, how to customize it, how to complete a task. And then we have paper tip sheets that we oftentimes will hang up in the clinic around certain common tasks that people need that are updated. All of these are available on a website where anyone can access them. We've incorporated following the workflow into our job description. So our MA jobs now include entering labs and pending prescriptions, et cetera. But then we also can use that when we're doing their job evaluations and we're giving them performance reviews, we can really look, are they following these workflows? They're in the job descriptions and they're part of their culture. They're part of their career with us is following these things. And this is something that's new for us culturally as an institution, and I think is going to make the biggest difference, especially for our MAs and our AAs whose role sometimes was very variable from practice to practice. And then last time, last thing was team meetings to really celebrate our successes, reevaluate, think about innovation. Sometimes the best ideas have come from the staff that are sitting in the exam rooms. And so bringing those ideas up and trying to operationalize them is critical. And then celebrating successes, showing them the data, how they've improved. We do what we call a feedback Friday in our practice where patients have sent comments back through our patient survey system, and we share those with the individual teams that touch those patients. I had a great experience. It was really wonderful you explained to me. Thank you for responding to my message quickly so that the staff sees that their work actually impacts the patients that we care for. Next slide. Now governance is really critical. So to be successful, a strong partnership between IS and your EHR analysts and your operation and clinical teams is critical. And Dr. Wong started the whole webinar by saying this was driven by operations. We strongly believe that that's true. As a matter of fact, our EHR transformation group that provides the support sits in our practice operations group, not in IS and not in the CMIO's office, but actually sits as an operational group because we feel that it's critical to our day-to-day management. You do need regular structured governance meetings at the practice, division, department, entity level, etc. And these groups need to be empowered to make decisions around workflow within the guidelines or the guardrails that have been established for either that department or that entity. And whenever possible, you want to encourage consistency across practices like pool structures and routing, but you do need to allow some flexibility based on the staff that's available and also what types of disease states or what types of clinical challenges they have in the individual practices. Next slide. So the ACC has a series of clinician well-being resources that are available to you via the web portal. We have specific ones that are COVID that you can see there on the right, resources for clinician well-being. But more importantly, I was on Lakshmi's task force and continue to be active there. And there's a clinician well-being portal that's absolutely amazing and has real, real concrete resources for our clinicians to help them overcome a lot of the challenges that we've had, not only in COVID, but just in a real changing landscape among clinicians. Next slide. So I'm going to hand it off now to Dr. Wang to talk about conclusion and then we'll open up for questions. Great. Thank you, Dr. Goldberg. That was awesome. So much detail. So rich. So in conclusion, I think both of us have covered the fact that digital healthcare is evolving and complex and that we have to live with it and we have to make it better. The in-basket burden is a key contributor to healthcare inefficiency and results in clinician burnout. We believe that addressing clinician burnout is a core responsibility for health systems and leaders. As ACC, lending a voice to advocacy, reducing administrative burden, redesign payment model, optimizing technology, and delegating work to appropriate staff are all important tactics. In the end, we need to build a culture of design thinking and critical making, which means iterative improvement. This culture will be paramount to organizational success and MedXM and ACC, and we are here to help you. And now we're open for questions. Thank you both so much. That was wonderful information. We do have a few questions. Before I read those off, if anybody has any additional ones, go ahead and put them in the question box now, so we can have an opportunity to ask our doctors here. The first question is from Todd Wood. It says, are providers given protected time for optimization, such as viewing materials, making EHR setting changes, et cetera? With what frequency do you anticipate continuing these efforts, given the constant EHR design changes? Lee, do you want to start? Yeah, I can start with that. So we have given, and this was a cultural shift for us about three or four years ago, we have now given some dedicated time for clinicians to be able to optimize. Sometimes we do that as part of a sprint, where we plan a month or two in advance that we're going to have the analysts in the practice for a period of weeks, kind of looking at workflows and redesigning things. And we literally carve out time and adjust the clinic schedules appropriately. What we've done in cardiology is we have once every other month, a town hall meeting where we've talked about COVID, we've talked about racism, we've talked about all kinds of important topics in that town hall. We've actually also dedicated optimization to that town hall. And the last time we held it was two weeks ago before our upgrade. We had 107 providers show up for our town hall on, hey, here's what you need to know about the upgrade. And then several of us said, hey, these are really cool things you might want to try that might really help you, some features that we've curated for you. So we have tried to identify opportunities, both in existing meetings and structures, but we have had to at least quarterly give people a short period of time in order to do some shoulder to shoulder training, et cetera. The rationale for that in our center has been that if we make that investment of time, it will actually pay off because those providers will be more efficient, less burned out, and less likely to make errors, more likely to have patients feel like they're really being cared for. And so that's kind of the trade-off that we've had. Yeah, I would say about the same for us. I mean, it depends on your role, right? If you're a leader or you're tech savvy, you may be involved in more of the design work, which may or may not come out of your administrative time. In terms of adopting these optimization changes, the clinicians are given options. Previously, we had onsite informatics as support, and now we have there on team. So you could pose your question, and then the individual will come to your desktop, can look at your desktop, can call you to work through your issues. So that would be my answer to Todd's question. Great. Thank you. Next question, and Dr. Goldberg, we'll start with you. With the ongoing staff shortages of nurses and MAs, how has this impacted some of these changes slash pools that have been created? Yeah, so that, like all of you, I think that's been a challenge for all of us. And that's where we really tried to look at what's the right workload. And we just can't say, oh, so-and-so, so-and-so, we have a vacancy, so you nurse is going to log in and cover three more providers. So we actually have our practice managers evaluate the volume and messages in each one of the pools so that they can reallocate the coverage appropriately. And this has been a challenge. We've had a couple of practices where we've actually delayed the implementation of the pools because the staffing did not meet the minimum that we thought was ready to go. And so we've had to be flexible. So I presented, obviously, the ideal situation. It doesn't always work out like that in real life, so we've had to delay. I will say that once a practice is up and running and kind of gets the hang of this, cross-covering the pools becomes second nature to the team. And it's actually easier if you do have a vacancy, or like we had someone out on FMLA for a month for a medical issue. The other team members were able to actually cross-cover and divide that up even by the day of the week. And we found that it was a lot less painful than it had been in the past for us to fill a temporary gap like that. We used to have float staff or whatever, but now we're so short-staffed that we really don't have that. But the pools give us and the practice managers some flexibility in managing that. But the reality is, like all of us, we are resource constrained. So there are times when you have to kind of default to some other mechanism because you just don't have the people to do the work. Yeah, go ahead. I would agree with what you just said, Dr. Goldberg. In addition, I would say improving efficiency of how these messages are routed. We have these weekly check-ins between clinicians and the RNs or the MAs, just very short 30-minute check-in alternating weeks so that we can discover efficiencies. How can we minimize routing to the staff? I mean, try not to kick the can down the road, things like that. And we prioritize this kind of work. Just like how we need to have a staff rooming the patient, we need to have these roles filled. Sometimes we have to use agency, which makes the expense high. Sometimes we have to have the nursing supervisors and MA supervisors and leaders go back to clinical rotations. Great. And we have one last question in our last minute here. It's a two-part question. If the APP is managing pools virtually, is the expectation that the doctor will see more patients in clinic? And then secondly, looking at the financial piece of increased salaries for APPs and non-billing time, how do you get non-patient facing time approved for the APPs? Yeah, I think that the answer would be two-part. One is, indeed, because currently we have scheduled blocks on physician time or APP time, so we do need to squeeze more patient encounters into our day in order to pay some of these FTEs. The second is we are actively moving towards value-based care contracts where the reimbursement is not purely encounter-based. And I can add that we look at it in two ways, at least in our practice. One is exactly what you said. We do expect our docs, if we have the APP supporting them in the clinic or in the back office, then that should free up the physician. In our practice, the emphasis is on new patient visits to reduce our lag and get people in the door. And we know that financially, those are the patients that also generate all the procedures and whatnot, or at least many of them. So we do really track the new patient visit volume as we add the APPs into the mix. The second is a little bit softer, I admit, but every time we have a physician leave who's burned out, we end up spending a lot of money. And we've quantified that. You saw it's in the millions of dollars in one of the earlier slides. We have that number quantified here at Penn. By the time we hire somebody new in that role and get them up to speed and get their practice rebuilt, it's a lot of money. And so for some physicians who are really struggling or drowning, who are very busy clinically, adding the APP to offload them and preventing that physician from burning out and able to manage their work is actually important financially to the health system, even though it may not necessarily be a huge incremental increase in patient volume. It's to actually save that cost of having that person burn out. And that is a psychological barrier. But I have to say here that our administration was willing to listen to that and seem to understand the importance of that. And so that's the other way that we've justified it. But that means that those physician schedules are full and those people are busy. So it has to really be a decanting of the work, so to speak, in order to justify that. And we have some metrics that vary from department to department that we use to try to help us with that to fully justify adding an additional APP to a practice. Great. Thank you both so much. We're at the top of the hour. We thank you both for your expertise and knowledge and sharing that with our attendees. And thank you for those who did attend. If you have any follow-up questions at the end, feel free to reach out to MedAxiom, and we can funnel those through to Dr. Goldberg and Dr. Wong. And you will be able to find the recording of this probably early next week on MedAxiom's Resource Center. So with that, thank you everybody, and have a fantastic afternoon. And we will see everybody soon. Thank you all. Thank you so much. Thank you. Bye-bye.

in-basket management

clinician well-being

healthcare providers

burnout

EHR usability

work redistribution

clear workflows

teamwork

collaboration

EHR workflows