"The Culture Has Changed": UC Davis Health's Multifaceted Approach to Improving Workflow | healthsystemcio.com (2024)

Having dissatisfied physicians is never good. But when a few turns into many, the only way to quiet the noise is by working together to create solutions.

The challenge? Creating an environment in which physicians and other care providers can voice concerns and vent frustrations. For UC Davis Health, the answer was to establish a Clinical Informatics department, which they did about seven years ago.

That, however, was only the beginning. In recent years, the system has embarked on several initiatives to leverage user data — and information gleaned from conversations — to more effectively identify pain points and drive toward solutions.

“Physicians want to be heard; it’s an intrinsic human trait,” said Melissa Jost,Director of Clinical Informatics and Clinician Health & Wellbeing at UC Davis Health. Recently, she spoke with healthsystemCIO about the innovative programs her team has implemented to improve optimization training and communication (and consequently, increase retention rates among physicians). She also talked about how they’re addressing workflow hurdles, and how her unique background has positioned her well to deal with these challenges.

The EMR Paradox

The situation in which UC Davis Health found itself circa 2017 was far from unique, particularly when it came to EHR-based frustrations. “We have this interesting paradox where we had implemented technology to streamline data sharing and make clinical documentation easier,” she said. “And yet, it was inhibiting people from getting their work done.”

Many physicians felt not only that adoption was happening too quickly, but that it was happening to them, rather than with them. “We knew we needed to do something,” said Jost. By establishing the Department of Clinical Informatics, UC Davis Health hoped to create a bridge between IT and clinicians, and most importantly, build trust.

Jost and her team (which, at the time, included volunteers from IT) sought to accomplish that by looking at the data and identifying sticking points. “We would come to physicians and say, ‘I noticed this anomaly. Can you tell me about this?’” she noted. Oftentimes, it was a training issue — either they didn’t know a tool existed or didn’t know how to use it. “Sometimes, the technology wasn’t configured in a way that made sense in their workflow.” And while at first, physicians weren’t always receptive to feedback, significant strides have been made since then. “We’ve taught our training team how to have those conversations,” she added. As a result, “the culture around EHR optimization has really changed.”

On the Hill

One factor that has helped Jost is her previous experience — and not just seven years spent working as a project manager on Epic implementations (although that did certainly help). Before coming to UC Davis, she interned for Congresswoman Doris Matsui, a role that exposed her to briefings and hearings around electronic records — and sparked an interest in the topic. She also learned firsthand about the power of community organization, a principle she still carries with her.

“When you think about it, physicians are a huge community, especially within the hospital system,” said Jost. “If you can get physicians to band together, state what their challenges are and start to be one voice, that becomes very meaningful in driving change.” And by truly listening to what those challenges are and why they happen, leaders can get to the root of the problem and begin to make changes.

Once her team identified the source — in this case, training and communication — they started to piece together a strategy for improvement.

Externship program

One of those is the Practice Experience Program (PEP), a 10-month externship program for graduate students in Health Informatics and related fields. The goal was to create strategies to address EHR usability issues by providing students with “foundational experience in Clinical Informatics,” increasing participants’ workload capacity through meaningful projects, establish a hiring pipeline, and providing opportunities to gain leadership and mentorship skills.

“You can’t get a job in the EMR field unless you have certification, and you can’t get certified unless you have a role in the field,” Jost said. “We wanted to help people get jobs in the field.”

So far they’ve achieved that, as two former “externs” now work within the department, and a few others have landed roles with other healthcare organizations. “That’s our biggest marker of success.”

Clinician onboarding

Another core initiative is a one-year program designed to improve the clinician experience and maximize retention by optimizing the onboarding process and facilitating long-term professional development. “We wanted to provide our physicians with the skills to be successful in that first year,” she said. It can be a taxing time, especially for those coming out of a fellowship or residency that are “ramping up their patient volumes quickly.”

Rather than offering one-time instruction, her team believes it’s critical to provide real-time communication coaching throughout the year, with a focus on patient, family, and trainee interactions. As appointment times continue to shrink, it has become increasingly vital to “set the agenda by saying, ‘here’s what we’re going to cover today and here’s what we can’t,’ and guiding that conversation,” said Jost.

The onboarding program comprises optimization and efficiency training at the 30, 60, and 90-day marks, with annual training after that. “We also present in the clinics on a monthly basis, and physicians can get peer coaching through workshops,” she added. In addition, physicians have access to UC Davis’ myriad well-being resources if they seek ongoing support.

Personalization plans

Perhaps the most important benefit of the initiative, however, is that it enables physicians to “set aside dedicated time to work on personalizing their system,” said Jost. “We know now that individuals who are able to do that are more efficient and more satisfied with their tools.” The harsh reality is that physicians who see 18 (or more, in some cases) patients in a day don’t have a lot of time to sit down and update order preference lists and templates. By reviewing the data to see where physicians spend the most time and which tools have been personalized, her team can devise a plan to start to improve processes.

And although there was some resistance initially, once people started to receive training and see value, “that sentiment quickly shifted,” she said.

One piece of advice she offered? Focus first on super users and champions. “You have to recognize that not everyone is ready to be helped at the time you’re ready to help them,” Jost explained. Instead, make yourself available to all users — even the skeptics. “Give people resources. Tell them, ‘I’m here.’ Eventually they’ll call you.” By zeroing in on early adopters, leaders can drive up usage, which will start to tip the scales.

Another helpful hint is to involve clinical informatics as early in the process as possible, which can go a long way toward building relationships with physicians. “We’re not seen as the IT department,” she noted. “We’re IT, but we were hired by the CMO or chief health information officer, which helps.”

Note bloat

However, as beneficial as these initiatives are, there will always be pain points, particularly given the burden facing care providers. One of the culprits, according to Jost, is note bloat, which makes it very difficult for physicians to document the right things in the right places. And so, they partnered with a number of areas, including compliance, to define the minimum note requirements, and help educate physicians on what needs to be added to the note and what can be left out.

Once that was established, her team worked across different specialties to create documentation tools where physicians could access all the information they need on one screen and wouldn’t have to hunt and peck,” Jost noted. “Those tools would then link directly to the latest and greatest note template for their service.”

The results have been impressive. By utilizing the progress note template, residents have saved 3.6 minutes per note,” she said. “When the program calculated that out, they saved 47 days over a year documenting progress notes for the residents. We saved a whole resident, basically.”

In-basket cleaning

Another area of focus for her team in-basket management, which became a critical priority when patient portal use skyrocketed during Covid. The flipside of having “one of the highest rates of patient portal usage in the Epic community” and having “very engaged patients,” according to Jost, is the mountain of messages that awaited physicians, especially primary care providers.

“They were feeling the burden,” she said. And so, she assembled an RN triage team to serve as the first point of contact for incoming MyChart messages. “Because of their increased licensure, they can use nursing protocols to respond to the messages or collect information if it needs to go upstream to a physician.” If it is escalated, physicians are able to make decisions faster, as they already have the pertinent data. “We saw a huge reduction in the amounts of messages that went to providers,” she added.

It was also an opportunity to “redesign clinical and operational workflow and implement the technology behind that, which felt like a true informatics project,” she said.

Fortunately, these types of initiatives don’t have to be limited to systems with the resources of a UC Davis, according to Jost. For example, even if organizations don’t have a nursing team at their disposal, teams can still review in-basket messaging and establish parameters to evaluate which messages needed to be forwarded, and to whom. “And potentially, some of those could be auto-expired, because those extraneous messages are slowing down your system,” she said. “Once we cleared those out, physician in-baskets were loading 50 percent faster. And when you’re doing this multiple times a day, it really matters.”

Jost, who shared her team’s story at the ViVE24 Conference, believes it’s critical for leaders to be willing to pass along their knowledge and experiences, especially with something as important as workflow improvement. “We want to inspire other organizations to adopt these things and make a better environment for the clinicians,” she added. And it doesn’t have to be dramatic; “you can make a difference with small changes.”