The Quadruple Aim

Back in 2008, Berwick, Nolan, and Whittington authored a paper outlining the Triple Aim of healthcare. It challenged US healthcare organizations to pursue three objectives: improve the care experience, improve population health, and reduce per capita costs of care. Most organizations have since invested heavily in EHRs. While information can be immensely valuable if leveraged properly, EHRs often add to physician workload.

In late 2014, Bodenheimer and Sinsky proposed the Quadruple Aim to alert the community to caregivers’ deteriorating conditions:

“In a 2011 national survey, 87% of physicians named the leading cause of work-related stress and burnout as paperwork and administration, with 63% indicating that stress is increasing. Forty-three percent of physicians surveyed in 2014 reported spending over 30% of their day on administrative tasks. Physicians spend more time on non–face-to-face activities (eg, letters, in-box management, and medication refills) than with patients. Even when in the exam room with patients, primary care physicians spend from 25% to 50% of the time attending to the computer. Between 2009 and 2010, primary care physicians at a Veterans Affairs facility spent 49 minutes per day responding to inbox-type alerts in addition to documentation of care provided. One-half of such alerts have little clinical significance or could be handled by other team members; 80% of the text in the alerts is unnecessary. The volume of alerts and texts overshadows important information that requires action. Moreover, the alerts create interruptions known to adversely affect patient care.

A 2013 survey of 30 physician practices found that electronic health record (EHR) technology has worsened professional satisfaction through time-consuming data entry and interference with patient care. Emergency medicine physicians spend 44% of their day doing data entry, with 4,000 EHR clicks per day; only 28% of the day is spent with patients. In a 2011 survey, over three-quarters of physicians reported that the EHR increases the time it takes to plan, review, order, and document care.” (Please see article for citations)

Because burnout imperils the Triple Aim, we must consider and improve the work life of health care providers. The authors offer the following suggestions to improve work conditions for primary care physicians. How many of the below has your organization automated with technology? Pre-visit planning can be automated in EHRs, staff roles can be expanded in EHRs, and prescriptions refill workflows can be optimized in EHRs with the aid of a patient portal.

  • Implement team documentation: nurses, medical assistants, or other staff, present during the patient visit, entering some or all documentation into the EHR, assisting with order entry, prescription processing, and charge capture. Team documentation has been associated with greater physician and staff satisfaction, improved revenues, and the capacity of the team to manage a larger panel of patients while going home earlier.

  • Use pre-visit planning and pre-appointment laboratory testing to reduce time wasted on the review and follow-up of laboratory results

  • Expand roles allowing nurses and medical assistants to assume responsibility for preventive care and chronic care health coaching under physician-written standing orders

  • Standardize and synchronize workflows for prescription refills, an approach which can save physicians 5 hours per week while providing better care

  • Co-locate teams so that physicians work in the same space as their team members; this has been shown to increase efficiency and save 30 minutes of physician time per day

  • To avoid shifting burnout from physicians to practice staff, ensure that staff who assume new responsibilities are well-trained and understand that they are contributing to the health of their patients and that unnecessary work is reengineered out of the practice

The authors also point out that an estimated 59% increase in staffing is needed to achieve the patient-centered medical home. How many of those functions can be automated with technology?



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