Beyond Getting Rid of Stupid Stuff in the Electronic Health Record (Beyond-GROSS): Protocol for a User-Centered, Mixed-Method Intervention to Improve the Electronic Health Record System

Introduction

Background

Substantial evidence indicates that electronic health records (EHRs) contribute greatly to clinician burnout [1-5]. This burden arises from factors like EHR usability or lack thereof, perceived loss of autonomy, and documentation; this leads to less clinical time with patients and clinicians creating various workarounds to the problem with the associated potential to compromise execution of care consistent with patient safety and quality [1,6]. Clinician burnout and dissatisfaction can adversely impact provider engagement, which in turn, can negatively impact patient safety and health care quality [7,8].

In an effort to alleviate the EHR burden imposed on clinicians and its adverse consequences on the quality of health care delivery, Hawaii Pacific Health implemented a program called Getting Rid of Stupid Stuff (GROSS). In this program, clinicians were asked to come forward with anything in the EHR that they thought was poorly designed, unnecessary, or just “plain stupid” [9].

This protocol is a description of how we plan to implement a modified and extended version of the Hawaii Pacific Health system's GROSS program in our medical center at Mount Sinai Hospital in New York City, NY. Our program will be called Beyond Getting Rid of Stupid Stuff (Beyond-GROSS).

Hawaii Pacific Health GROSS Experience

Hawaii Pacific Health is the largest private health care organization in Hawaii with 4 medical centers, 592 beds, 6950 staff, and 1764 physicians [10]. The GROSS program seeks direct input from clinicians about various aspects of the EHR and documentation that is not useful or counterintuitive.

Categories of requests received included the following: documentation that was never meant to occur and would require little consideration to eliminate or fix, documentation that was needed but could be completed in a more efficient or effective way with newer tools or better understanding, and documentation that was required but for which clinicians did not understand the requirement or tools available to them.

After 1 year of implementation, a total of 188 requests were received in all 3 categories by the GROSS team. Suggestions from other disciplines were not presented. Also, suggestions related to issues other than EHR improvement were not permitted [9].

The results showed the following: There were more responses from nurses (n=146) than physicians (n=42), the vendor (Epic EHR) was supportive of the effort, there was an overall organizational acceptance of the project by clinicians, and there were minor changes in the EHR based on suggestions from users. Data about physician engagement were pending at the time of publication.

Mount Sinai Beyond-GROSS Program Objectives and Justification

The issue of burnout and clinician engagement is now a widespread concern among all stakeholders, including government and expert organizations, and the concept of the Quadruple Aim of health care delivery has been widely adopted across institutions [11-13]. The Quadruple Aim was born out of the need to add provider satisfaction and well-being to the initial Institute of Health Improvement's Triple Aim of better health, lower cost, and better care [12].

Apart from the contributions of technology (EHR) to the dissatisfaction of clinicians, the sociocultural and work processes also play an important role in the determination of successful implementation. The interplay of technology and process efficiency described in sociotechnical constructs is very important for overall success [14-18]. In essence, a superb technology application or EHR deployed in an inefficient system will not succeed [19]. Based on this premise, our Beyond-GROSS project will involve soliciting feedback from clinicians about workflow and process issues in addition to EHR-specific problems (see Figure 1 for a diagram of overall project workflow).

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Beyond-GROSS dovetails with our existing EHR governance structures and other efforts of the Mount Sinai Health System to alleviate the issue of EHR burden through its various EHR optimization workgroups. Apart from the required initial mandatory online EHR training for all new clinicians at Mount Sinai Health System, there are governance mechanisms to increase EHR use proficiency among clinicians and to optimize and standardize the EHR configuration, navigation, and content. These include ambulatory and inpatient EHR optimization working groups, which are collaboratively led by members of the Clinical Informatics Group and Information Technology (IT). The Clinical Informatics Group is a unit reporting to the Chief Medical Information Officer (CMIO). These working groups are comprised of members from many clinical departments and lead analysts from the EHR applications teams. Clinicians can bring EHR change requests to these bodies through their department’s members. The working groups discuss proposed changes, seek additional departmental feedback as needed, and make decisions. Then, the analyst representatives ensure that build changes are made. Mount Sinai Health System also operates an EHR physician champion program whereby the physician champions in each department serve as resource persons for other clinicians who need help using and navigating the EHR. In many cases, these departmental physician champions are also representatives to the EHR working groups.

Our intervention adds the first mechanism through which clinicians can directly report issues via the EHR. It expands request categories and captures more granular aspects of requests. The intervention expedites fast fixes where possible and appropriate channeling for resolution. The Beyond-GROSS team members, a multidisciplinary subset of the Clinical Informatics Group including the Deputy CMIO, triage reported issues for type of resolution needed (eg, user education, EHR quick fix, potential workflow issue with EHR component); appropriately channel requests outside of the team as needed, including directly to Epic analysts and existing EHR working groups; and guide requests through to resolution.

Methods

Intervention Setting and Population

The program will be implemented in the Mount Sinai Health System, New York City, NY, which is composed of 8 hospital campuses, 13 ambulatory surgical centers, and over 6600 primary and specialty care physicians. We plan to start by conducting a pilot program in a service line of the main campus of the Mount Sinai Hospital and gradually scale the project across the health system over 2 years.

Participants in the pilot will be comprised of clinicians in our academic gastroenterology practice spanning inpatient, outpatient, and endoscopy services, which includes 25 attendings, 14 fellows, and 5 nurses, with a patient volume of more than 6000 endoscopy procedures and 26,800 outpatient visits. This division is an excellent pilot group because it has an engaged workforce comfortable with using technology and a focus on wellness and quality, and it is comprised of a variety of team members across 3 key settings who are all using the EHR to support care delivery.

Intervention Design and Procedure

The overall design will be mixed methods utilizing both qualitative and quantitative methods of data gathering and analysis in a Plan-Do-Study-Act (PDSA) iterative approach of quality improvement.

The project will solicit suggestions and input from front-end clinicians (physicians and nurses) about the EHR and workflow issues they encounter during their daily tasks. They will be also encouraged to come forth with suggested ways of overcoming the issues raised. Our initial pilot will take place over a duration of 4-6 months with the intention to implement the program throughout our health system over a period of 2 years. Lessons learned from data analysis and project evaluation will be incorporated in a PDSA fashion every 8 weeks as we scale throughout the organization.

Data Collection Tool, Data Management, and Analysis

We will be soliciting input from clinicians through a form built in the REDCap data capture application with a link to the form conveniently located in the homepage of the EHR for easy access when they encounter documentation that can be optimized (see Figure 2 for Beyond-Gross icon “G” embedded in the EHR) [20]. Clicking the icon opens the form in a browser for data input by the clinician. The G icon was embedded in the EHR (Epic EHR) with the help of an in-house Epic analyst (see Figure 2 for the “G” icon in EHR with link to the REDCap database).

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The technicalities involve creating a new activity in text located at the top tab. Parameters like link title and URL were set, and filters were placed limiting the activity to only the Gastroenterology Division. The new activity was also added to the desired roles so that only physicians and nurses in the designated department would see the Beyond-GROSS link “G” in their top tab once they log into Epic.

The data from the form are then automatically stored in our health system’s secure instance of the REDCap database for further analysis by our team. The REDCap form is made up of 2 sections: The first section contains questions relating to the potential issues raised by the frontline clinician and specific issue, location where the issue occurred, and best way to follow up with requesters (see Textbox 1 for form content and description); this corresponds to questions 1 through 11 in the form. The second aspect of the form is for completion by an assigned Beyond-GROSS team member for further analysis of the requester’s input. This section was set up in REDCap to be visible only to an authorized Beyond-GROSS team member for the purpose of analysis; this corresponds to questions 12 through 33 of the survey (Table 1). A sample of the overall request instrument can be found in Multimedia Appendices 1-4.

Follow-up on input received and analysis of data input include the items listed in Textbox 2.