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Survey: Physicians Struggling with Changes

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US physicians continue to struggle to maintain morale levels, adapt to changing delivery and payment models, and provide patients with reasonable access to care. The combination of these factors leaves a majority of physicians feeling that they lack time to provide the highest level of care. These findings are based on a biennial survey of more than 17,000 U.S. physicians commissioned by the nonprofit Physicians Foundation.

According to the research, titled “2016 Survey of America’s Physicians: Practice Patterns and Perspectives,” 80 percent of physicians report being overextended or at capacity, with no time to see additional patients. This remains steady with the findings reported in the 2014 survey from the foundation. Not surprisingly, 54 percent of physicians surveyed rate their morale as somewhat or very negative, with 49 percent saying they are either often or always feeling burnt out.

In response to these and other challenges, 48 percent of surveyed physicians plan to cut back on hours, retire, take a non-clinical job, switch to “concierge” medicine or take other steps that will further limit patient access – an increase from those who answered similarly in the 2014 survey. These patterns are likely to reduce the physician workforce by tens of thousands of full-time equivalents (FTEs) at the time that a growing, aging and more widely-insured population is increasing overall demand for physicians.

“Many physicians are dissatisfied with the current state of medical practice and are starting to opt out of traditional patient care roles,” said Walker Ray, M.D., Physicians Foundation president and chair of its research committee. “By retiring, taking non-clinical roles or cutting back in various other ways, physicians are essentially voting with their feet and leaving the clinical workforce. This trend is to the detriment of patient access. It is imperative that all health care stakeholders recognize and begin to address these issues more proactively, to support physicians and enhance the medical practice environment. ”

The survey was conducted online from April 2016 through mid-June 2016 by Merritt Hawkins, a leading physician search and consulting firm, on behalf of the Physicians Foundation. The findings are based on responses from 17,236 physicians across the U.S. The overall margin of error for the entire survey is less than one percent.

Impact of Physician Morale on Patient Access

This survey, conducted biennially since 2008, has consistently demonstrated that the professional morale of physicians is declining. In addition to challenges in morale, 62.8 percent of those surveyed are pessimistic about the future of the medical profession. About half of survey respondents would not recommend medicine as a career to their children. Close to one-third would not choose to be physicians if they had their careers to do over. This sentiment has larger implications outside of the profession itself, given that physicians manage larger clinical teams comprised of nurse practitioners, physician assistants and more who also play a pivotal role in health care economics.

Physicians identified regulatory and paperwork burdens and loss of clinical autonomy as their primary sources of dissatisfaction. Respondents indicated that they spend 21 percent of their time on non-clinical paper work duties, while about two-thirds (72 percent) said third-party intrusions detract from the quality of care they can provide.

What is also consistent in each biennial survey since 2008 is physicians’ primary source of professional satisfaction: the patient relationship. In the 2016 survey, 73.8 percent of respondents listed this as the most satisfying aspect of their jobs, followed by “intellectual stimulation” at 58.7 percent. Similarly, in a patient survey commissioned by the Physicians Foundation earlier this year, 95 percent of patient respondents reported they were satisfied or very satisfied with their primary care physician’s ability to explain information in a manner they understand, while 96 percent feel their physicians are respectful of them. Physicians noted that issues such as a lack of clinical autonomy, liability concerns, struggle for reimbursement and decreased patient face-time can all negatively impact the patient-physician relationship – thereby undermining physician satisfaction.

Challenges with Health Care Reform

As a central player in determining patient treatments and care plans, physician participation and leadership is critical to transforming health care from a system driven by the volume of services to one focused on the value of services. However, the survey indicates that the majority of physicians are not convinced to sufficiently engage or support the mechanisms of health care reform to achieve its stated aims.

Only 43 percent of physicians surveyed said their compensation is tied to value. Of these, the majority, (77.2 percent) have 20 percent or less of their compensation tied to value. Additionally, only 20 percent of physicians surveyed are familiar with the Medicare Access and CHIP Reauthorization Act which will greatly accelerate value-based payments to physicians.

Another perceived barrier is the new ICD-10 system, which added thousands of new codes intended to allow physicians to be more efficient, bill more precisely and improve patient care. However, the majority of physicians have not realized these benefits. Most surveyed indicated that ICD-10 has had little to no impact in practice efficiency, revenue or patient care.  Similarly, physician’s opinions of electronic health records (EHR) have not improved, with even more physicians stating that it detracts from patient interaction compared to findings of the 2014 survey. Only 11.9 percent of respondents indicated EHR has improved patient interaction, while the remaining 89.1 percent say it has had little or no impact or has detracted from patient interaction.

Finally, physician assessments of Affordable Care Organizations (ACO), which covers 15 percent to 17 percent of the U.S. population, have not changed appreciably since the earlier 2012 biennial survey. The percent of physicians that agree ACOs are likely to enhance quality and lower costs decreased, while there was an increase in physicians who feel ACOs are unlikely to increase quality or decrease cost.

Additional Key Findings

• Employed physician respondents see 19 percent fewer patients than practice owners
• 46.8 percent of respondents plan to accelerate their retirement plans
• 20 percent of respondents now practice in groups of 101 doctors or more, up from 12 percent in 2012
• Only 17 percent of survey respondents are in solo practice, down from 25 percent in 2012
• 27 percent of respondents do not see Medicare patients, or limit the number they see; this number is 36 percent for Medicaid patients

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Meet a Hospital Hero: Ania Renteria


(From time to time, the blog features recipients of the IHA Iowa Hospital Heroes Award. These outstanding hospital employees come from across the state and work at hospitals of every size. They exemplify the courage, caring and community focus that are the hallmarks of the hospital mission in Iowa. The 2016 Hospital Heroes will be introduced next month at the IHA Annual Meeting.)

Though only 4 feet 11 inches tall, there are few who have a heart as big as Ania Renteria, an MRI technologist at Iowa Specialty Hospital-Clarion. Many heroes are defined by one single act that may only impact a few lives, but Ania is a hero of a different sort. She touches many lives, in big and little ways, every day. The impact of this type of hero is truly beyond measure.

Ania’s entire life exemplifies serving the needs of others without expectation of recognition. She is someone who is selfless and acts out of the kindness of her heart. Knowing no inconvenience when it comes to helping others, she consistently goes above and beyond in all aspects of her life. Her job is no exception as Ania is the go-to person for the radiology department. She never shies away from a challenge, including being the first to volunteer when the hospital was slated to receive its first MRI and needed a certified technologist.

In addition, Ania is the example throughout Iowa Specialty Hospital for excellence in service and quality. With a warm and friendly personality, people are instantly comfortable around her. Even with a busy schedule, she treats every patient as if they are her only priority. Ania often comes in early and stays late to accommodate her patients’ schedules and is always willing to help out coworkers.

Just a few of her heroic deeds include when she personally went to a patient’s home to change the dressing on a wound, both before and after work, and when she called an anxious patient the day before a scheduled exam to have them tour the MRI suite, providing extra comfort and reassurance.

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Meet a Hospital Hero: Barbara Miller


(From time to time, the blog features recipients of the IHA Iowa Hospital Heroes Award. These outstanding hospital employees come from across the state and work at hospitals of every size. They exemplify the courage, caring and community focus that are the hallmarks of the hospital mission in Iowa.)

Barbara Miller has had a phenomenal impact on the quality of Great River Hospice since its inception. The program’s first social worker, she set the stage for social work’s role in hospice and developed meaningful programs, including:

  • Quilts: Barbara organized a service in which volunteers make quilts for every Great River Hospice patient – more than 3,000 to date. It has become a tradition that family members, friends and caregivers sign the quilts and many quilts are displayed at visitations.
  • Grief support group: Barbara developed a monthly community grief support group and her leadership has made it successful. She has the gift of becoming part of attendees’ inner circle in a way that makes them comfortable with opening up and sharing, which leads to healing.
  • Veterans’ recognition ceremonies: Barbara designed a recognition ceremony for our patients who are veterans and their families. It includes a video that honors their service to our country, a certificate and a pin.
  • Bereavement programs: Barbara implemented several bereavement programs that have a very good reputation in our community.

Barbara works hard to meet the needs of every hospice patient. For example, when a patient who lived alone and had no family needed help at home, Barbara stepped in. She organized a volunteer group to go to clean the patient’s home, do his laundry and prepare a home-cooked meal.

Additionally, Barbara helped developed Great River Hospice’s annual memorial service and she attends the visitations and funerals of many hospice patients because she knows the importance of showing her continued support.

Barbara’s family joins her in her mission. They have hosted Thanksgiving dinners at the hospice house and prepared breakfasts for hospice families. A son and daughter-in law cook monthly meals for families and one daughter is co-chair of the Annual Great River Hospice Fun/Run.

Barbara’s service comes from her compassionate heart. Her quiet heroism has affected the lives of many people in our community who have grieved or are grieving the loss of loved ones.

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EHR ‘Alert Fatigue’ Plagues Providers

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(This article, by Shefali Luthra, was provided by Kaiser Health News.)

Some people receive constant reminders on their personal smartphones: birthdays, anniversaries, doctor’s appointments, social engagements. At work, their computers prompt them to meet deadlines, attend meetings and have lunch with the boss. Prodding here and pinging there, these pop-up interruptions can turn into noise to be ignored instead of helpful nudges.

Something similar is happening to doctors, nurses and pharmacists. And when they’re hit with too much information, the result can be a health hazard. The electronic patient records that the federal government has been pushing — in an effort to coordinate health care and reduce mistakes — come with a host of bells and whistles that may be doing the opposite in some cases.

What’s the problem? It’s called alert fatigue.

Electronic health records (EHRs) increasingly include automated alert systems pegged to patients’ health information. One alert might signal that a drug being prescribed could interact badly with other medications. Another might advise the pharmacist about a patient’s drug allergy. But they could also simply note each time that a patient is prescribed painkillers — useful to detect addiction but irrelevant if, say, someone had a major surgery and is expected to need such meds. Or they may highlight a potential health consequence relevant to an elderly woman, although the patient at hand is a 20-something man.

The number of these pop-up messages has become unmanageable, doctors and IT experts say, reflecting what many experts call excessive caution, and now they are overwhelming practitioners.

Clinicians ignore safety notifications between 49 percent and 96 percent of the time, said Shobha Phansalkar, an assistant professor of medicine at Harvard Medical School.

“When providers are bombarded with warnings, they will predictably miss important things,” said David Bates, senior vice president at Brigham and Women’s Hospital in Boston.

Now, doctors, health information technologists and software vendors are trying to fix the problem.

Research on this human-computer interaction is starting to explore the degree of risk posed by excessive alerting versus the benefits the alerts produce. The companies selling electronic health records say advances are moving their systems toward more targeted, relevant warnings, instead of broad-brush signaling.

“This is an issue that everyone’s going to have to wrestle with eventually,” said Bill Marella, executive director of patient safety operations and analytics at ECRI Institute, a nonprofit organization that studies health care safety and quality issues. In April, the institute ranked design and implementation of new health IT systems as its top safety concern for 2016.

Some hospitals and health systems are already paving the way.

Take Children’s Hospital of Philadelphia. In 2012, the inpatient facility switched over to a new electronic health record, said Eric Shelov, a physician and the hospital’s associate chief medical information officer. Immediately, he said, practitioners began seeing far more alerts, to the point that doctors were overriding almost all of them. The problem, Shelov said, is that “if you see enough nonsense, you’re going to start ignoring it.”

That has consequences. In one instance at Children’s, doctors ignored relevant information about how a patient might respond to a drug, Shelov said, because it appeared alongside heaps of other superfluous notifications — warnings, for instance, about drugs that posed minimal risk of interfering with each other. Consequently, the patient received medication that induced a potentially lethal reaction.

The hospital caught the mistake in time, but the incident spurred a series of changes. A team of pharmacists, doctors and other clinicians have sorted through what triggered alerts in their system, turning off the ones they decided weren’t actually relevant or necessary. That has helped. But it’s still an ongoing battle, Shelov said. “It’s a little bit of trying to turn off the firehose.”

Systems such as Cleveland-based MetroHealth, the University of Vermont Medical Center and Group Health Collaborative of Southern Wisconsin have undertaken similar projects. Still others, like Brigham and Women’s, are working on it.

But figuring out what merits a computer warning takes time, manpower, expertise and money. Not all hospitals have those resources, Bates said. It’s inherently subjective. Some stakeholder groups have put out recommendations, and hospitals like Children’s have presented on ways to combat alert fatigue. But individual hospital task forces often end up deciding for themselves what’s risky enough to warrant an alert.

Patients, meanwhile, aren’t standing beside their doctors as they scroll through their medical records, noted Helen Haskell, a patient safety advocate. Patients can request access to their records, but that’s a static page they’ll see only after getting care. That means that, while this hyper-alerting poses a danger, there’s no way for consumers to know if, say, they got worse care because the doctor missed a warning.

“It’s very rare that patients are granted that perspective,” she said.

Software vendors say they’re trying to make their systems smarter.

Epic Systems, outside Madison, Wisconsin, for example, has been hearing feedback for years from doctors about redundant or irrelevant alerts, said Bret Shillingstad, a physician who works on Epic’s clinical informatics team. They’ve added in functionality for hospitals to turn those alerts off. They’re working now to develop software that might target alerts based on things like a patient’s health condition or recommend medications that better match someone’s overall profile. Then there are simpler adjustments, like changing a system so that if a patient needs a vaccine, reminders just go to the primary care doctor, not the orthopedist, too.

In the long term, system designers are trying to better consider the nuances of a patient’s medical needs so that they can use fewer warnings and send them only when they matter, said Terry Fairbanks, an emergency physician and director of MedStar Health’s National Center for Human Factors in Healthcare in Washington, D.C. For instance, people with advanced cancer often need doses of morphine that might be unsuitable for other patients. A smarter system would warn doctors about that morphine order for patients who don’t have cancer but would treat it as normal for someone in the disease’s late stages.

Such a change could limit distractions so that physicians act upon pressing reminders — like notifications highlighting if a patient is at risk for sepsis, which can be deadly if it’s not noticed early.

But there’s still debate. Haskell said she would argue doctors should always be warned about certain medications and drug interactions.

“All of these alerts have really reduced medication interactions. It’s a service,” she said. “It just needs to be refined.”

But there’s clearly a cultural shift underfoot, added Phansalkar, who also works as director of informatics and clinical innovation at Wolters Kluwer Health, which supplies drug information to electronic health record systems. Alert fatigue is no longer “just something providers complain about,” she said. In health care, people are trying to devise more effective, nuanced ways for electronic systems to improve care.

“Because it’s so easy to put an alert to address a problem, that’s people’s natural, knee-jerk reaction,” said Douglas Gentile, medical director of clinical information systems at the University of Vermont Medical Center. But “as you add those, it creates additional problems. And you get collateral damage.”


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Meet a Hospital Hero: Joseph Hoagbin


(From time to time, the blog features recipients of the IHA Iowa Hospital Heroes Award. These outstanding hospital employees come from across the state and work at hospitals of every size. They exemplify the courage, caring and community focus that are the hallmarks of the hospital mission in Iowa.)

For nearly 40 years, Dr. Joe Hoagbin has been a member of the CHI Health Mercy Council Bluffs medical staff, caring for three generations of patients from southwest Iowa while advancing health care on multiple fronts.

After graduating medical school, Dr. Hoagbin took a position as an emergency physician at Mercy. He planned to stay for a year, but because of wonderful relationships with physicians, nurses and patients, he never left. He led the emergency department for 26 years, followed by chief of staff and other roles that led to him being named chief medical officer almost 10 years ago.

During his years in training, Dr. Hoagbin recognized the importance of team work in health care. On his first night of work at Mercy, he wanted to change the power imbalance between physicians and nurses and asked the nurses to call him “Joe.” The nurses said they could not do it but would call him “Dr. Joe,” which is the name he is known by at Mercy and throughout the region to this very day.

Emergency medicine was a new specialty when Dr. Hoagbin began his career. He established the standards for patient-centered quality emergency care, bringing a spirit of team collaboration, excellence in care and outstanding patient satisfaction that continues to this day. Dr. Hoagbin demonstrated his vision and leadership in establishing the Council Bluffs emergency medical services system (EMS) as well as other EMS systems throughout southwest Iowa. At one time, he was medical director of 13 EMS programs in the region.

Dr. Hoagbin has always been an innovator and looked for processes outside the box. He dislikes the phrase: “That’s the way we have always done it.” He’s been known to quote famous physician Dr. Rudolf Virchow, who said, “For as long as you live, always stay dissatisfied with the status quo.”

In 2009, he was awarded the highest honor in Alegent Health, the Spirit of Mission Award. The award recognizes individuals who have gone above and beyond, demonstrating excellence in relation to four core values: reverence, integrity, compassion and excellence.

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