Late on a Friday, I sit reviewing some of my patients’ old medical records instead of heading home to be with my family. I’ll likely be doing it next Friday, and the one after that.
This wasn’t my idea. The health system I work for discovered that some patients for whom CT scans were ordered never got them over the ensuing two to three years. So administrators decreed that clinicians like me must review the records of each patient who needed a CT scan, find out if the test was missed, determine if the missed test needs to be rescheduled, and report as to whether we reordered the scan or deemed it unnecessary.
For each patient, the procedure involves a mind-numbing and demoralizing number of mouse clicks and keystrokes. This project was aimed at reducing medical injury, but is instead wreaking administrative harm.
That these hours could be spent in countless other ways — especially caring for patients and our families rather than tending to our computers — raises an obvious question: Is the system we created to fix the system even working?
Two things before I go any further: First, neither I nor my colleagues question the importance of reconciling uncompleted tests for our patients. Second, we are committed to pitching in. We have dedicated our careers and out-of-office time to making health care better and safer for our patients. We go the extra mile every day to be sure that diagnoses are made; tests conducted, read and responded to; and treatments performed.
We do this despite the clunkiness of an electronic health record system that was given an “F” for usability, that systematically robs us and our families of hours of off-the-clock time, and that has been minimally improved despite the years of feckless platitudes in national taskforce reports regarding EHR-mediated burnout.
The problem of patients’ unperformed scans needed to be resolved. But by their doctors? Alone? On their own time?
Like the Centers for Disease Control and Prevention, my colleagues and I can distinguish between natural disasters and human-made calamities. The real-life challenges of our patients, which led to the missed CT scan appointments, are natural, inherent in any system involving the messiness of real life. But our lonely after-hours slog to clean up this problem was a human-made trauma. It wasn’t an emergency, and it wasn’t solely a clinical responsibility. The missed scans had been accumulating over several years. The EHR system and its caretakers had neither notified clinicians when their patients had missed their appointments nor had they configured a follow-up system for rescheduling each missed scan in real time. Yet the mandatory cleanup of this managerial mess abruptly became an urgent priority on doctors’ task lists.
To learn more about how this painful reconciliation process had been formulated, I called my department’s quality director. He referred me to the hospital’s project manager, who told me that requests for a more collaborative, user-friendly, and less hasty process had been dismissed by headquarters.
So this administratively driven mandate, this digital drudgery, was dumped on clinicians who had no participation in the decisions about whether, when, or how to accomplish this task and without the benefit of any electronic streamlining. Hence the workaround of a 1990’s era spreadsheet, the nostalgic joy of MS-DOS era copy and paste, the bliss of multiple dives into the electronic health record for each patient, and the attestations I had to type to resolve each of these incomplete orders.
That was a pure distillation of administrative harm.
Administrative harm, like clinical harm, has long been recognized in medicine, but little discussed until recently. It can result from an intervention — like the one I had been tasked with — or from a failure in one of five domains of administrative responsibility. These realms encompass the tangible, essential assets needed to support the delivery of health care; in the words of the late Paul Farmer, staff, space, stuff, and systems. The administrative harm to my Friday nights stemmed from a systems defect.
In the spirit of the National Academy of Medicine’s “To Err is Human” report, I filed an incident report — just as I would if I made or observed a medical error — even though the harm to me didn’t fit in any clinical category. My health system properly exhorts its clinicians to apologize to patients who have experienced medically-derived harm, also known as iatrogenic harm, and offers classes and mentoring on how to deliver such apologies.
It seemed only fitting to me that if the clinical-administrative review were to judge that this quality improvement project resulted in injurious and preventable adminogenic harm, an administrative apology should follow. I’ve been waiting three months and have heard nary a hint of regret or apology from the system’s quality and safety infrastructure.
This infliction of administrative harm was largely preventable. Engaging a broader spectrum of decisionmakers — including administrators, IT personnel, and fulltime clinicians — would have been more respectful of worker’s professionalism and time, and more palatable and more effective than a unilateral email edict solicitously headlined, “Action Required.” These groups could have been tasked to collaboratively study the backlog of unperformed CT scans and iterate ways of resolving those cases, as well as streamlining IT processes to support that work.
The joint decision from such a group ultimately may have entailed me and my peers sifting through our cases, well aware of our clinical intent and our patients’ circumstances. But we would have done so using an IT system respectful of and optimized for our work, rather than the clunky, retro, and risky cut-and-paste slogs of my Friday nights. That process would have harnessed the EHR, rather than harnessing clinicians to the EHR.
From a technical standpoint, such a process is feasible. Our IT system daily flaunts its capabilities, pelting clinicians with messages that pop up in the EHR reminding us to tend to patient-specific administrative priorities, such as “The dietitian has classified the patient with moderate protein calorie malnutrition. For this to be recognized, it requires your documentation. Please press F2 and select a choice from the drop-down menu.” IT resources currently directed at ensuring healthy reimbursement from insurers and other payers should equally support the health of patients and clinicians.
There is sufficient money within the system for this purpose. To cite just one example, data from the Lown Institute’s Hospitals Index on pay equity shows that my hospital spends more on the pay for its CEO team relative to the pay of our rank and file workers than 94% of all U.S. health systems. Clinician-administrator teams could reallocate a small fraction of that excessive administrative compensation to adequate IT support, rebalancing priorities to reduce these systemic administrative injuries to frontline personnel.
Prevention, a centerpiece of the best medical care, should likewise characterize the approach to administrative harm in health care. Brief, periodic assessments can furnish early warning signs of the risk of administrative injury. One example of a succinct, pertinent survey is the three-question Stanford Personal-Organizational Values Assessment Scale: (1) My input is valued in important administrative decisions? (2) Our organization’s goals and values fit well with my goals and values? and (3) Administration values my clinical work? Each question is answered on a scale from 0 (not at all true) to 4 (completely true) and aggregated as a score from 0 to 12. The lower the score, the worse the divergence in values. Such a clinical-administrative vital sign can be used internally as well as in benchmarking with peer institutions that use the scale.
Early detection can mitigate the proliferation of administrative harm. Thousands of clinical quality improvement projects are implemented in health systems every year in the U.S., but too many, like my Friday night work, are unmonitored by prospective inquiry or post-implementation survey. A better approach comes from a UCLA primary care performance improvement project, which included a rare survey of the clinicians whose performance was being measured and nudged. Before and after questionnaires revealed that the publication of peer comparison data not only failed to achieve the primary aim of improved health maintenance metrics but also eroded job satisfaction and increased burnout among the clinicians.
The researchers concluded that well-intended but maladroit quality improvement efforts such as theirs (and the one I was “asked” to conduct) can contribute to a system that “harms physician well-being.” Based on their investigation, UCLA has refined its improvement initiatives by adding more overt leadership support and continuous frontline feedback to reduce administrative injury.
As I finish my improvement exercise for the day, my pinging inbox reminds me that I am perilously close to the deadline for the next quality improvement mandate. The cheerily exhortatory message informs me that Healthstream online training modules await in which I will learn to optimize my coding to ensure the financial health of our hospital system. Tonight, as I close down my computer, my scores on the Stanford Personal-Organizational Values Alignment Score are these: 0 for input valued, 2 for the fit of goals and values, and 2 for clinical work value, a woefully misaligned 4 out of 12.
Someday, I hope that our health systems will be as dedicated to reducing administrative harm to their workforces as they are to preventing clinical injuries to their patients. Until then, I’ll brace myself for more misaligned Friday nights harnessed to my EHR toiling at unilateral quality improvement, instead of squandering the time in those “countless other ways.”
Walter J. O’Donnell is a pulmonary and critical care physician at Massachusetts General Hospital and Harvard Medical School in Boston. The views expressed here are those of the author.
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