In this episode of the AMA STEPS Forward® podcast, Marie Brown, MD, talks with guest Nigel Girgrah, MD, chief wellness officer at Ochsner Health, about how “quick win” system adjustments such as implementing badge logins, synchronizing refills and decreasing EHR clicks can improve practice efficiency and reduce physician frustration. To learn more, check out the related AMA STEPS Forward® toolkit.
- Nigel Girgrah, MD, chief wellness officer, Ochsner Health
- Marie Brown, MD, director of practice redesign, American Medical Association
Introduction: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA's STEPS Forward® program is open access and free to all at stepsforward.org.
Dr. Brown: Hello listeners and thanks for joining us today. My name is Dr. Marie Brown, AMA director of practice redesign and I practiced in Chicago for over 30 years in internal medicine. I'm speaking today to Dr. Nigel Girgrah. Welcome Dr. Girgrah and thank you for joining us. Why don't you tell the listeners a little bit about yourself and your background?
Dr. Girgrah: Great to be here. Thanks for the invitation. So, I am a practicing transplant hepatologist. Moved down to Ochsner Health, which is in Louisiana back in 2007. And I've had a number of traditional physician leadership roles. And over the years had an interest in physician well-being and burnout. And this sort of evolved into chairing a physician well-being task force, which ultimately led to a report out to our executive team and the development of this role, which is chief wellness officer. And over the past few years, I've stood up Ochsner's Office of Professional Well-Being.
Dr. Brown: Your focus pre-pandemic was on what exactly?
Dr. Girgrah: Yeah. Well, we started the Office of Professional Well-Being in 2018 and spent the better part of the year measuring burnout and being fairly deliberate about putting forward a strategic plan. We'd partnered with the AMA and some of the resources were very helpful in doing that. And our strategic plan, which we presented in 2019, basically was focused on a few areas but had four main strategic pillars. One pillar was around promoting advanced team-based care. The second one was around practice automation and innovation, which is largely work within our EHR. A third pillar was around resilience. I was very intentional about not wanting to really lead with that because I didn't want our physicians and APPs to think that I was just suggesting that yoga would be the cure-all for everything. And then our last strategic pillar was around communication and how we communicate with each other.
So, we had some momentum. We had project management support. We had work groups that had been put together around each of those four areas I mentioned, Marie. And then the pandemic hit in March of last year. I'm sure you remember that along with New York and California, we were an incredible hotspot. I think we had the largest number of COVID-related hospitalizations per capita for a while. So that kind of disrupted things, we had to pivot. But I think some silver linings have come out of the pandemic.
Dr. Brown: Yes and the challenges have just been amazing. And I'm sure that the efforts that you put into physician well-being, which started long before the pandemic, thank goodness you were doing that because we don't see an end in sight quite yet, do we?
Dr. Girgrah: No. And you mentioned surge four and Hurricane Ida. It's been a few months unlike anything I've seen as a professional, Marie.
Dr. Brown: All the more reason that it's so important that we talk about what the systems, the organizations can do. We say often that burnout manifests in individuals, but it originates in the system. So, I'd really like to hear some of the things you did regarding practice efficiency. And we all know that the EHR is a source of some frustration amongst us practicing physicians. So, can you share some of the maybe quick wins that you discovered either pre or during the pandemic?
Dr. Girgrah: Yeah, so pre-pandemic, we worked with our workgroups that I mentioned. And I always like to state that the Office of Professional Well-Being is not going to do everything on its own to improve the professional fulfillment of our physicians and APPs. It has to be an office that influences, an office that strategizes, that puts strategy before tactics. But we also recognize that physicians can be impatient, and we certainly had to come up with some quick wins.
I think, probably, the first quick win was around tap and go. So badge login, which we invested in, and for busy practitioners constantly logging in and out of the computer can be a lot of work. So, this was a win. And for some very busy physicians, this can shave 20 minutes off their day. So that was an example of a quick win. Marie, we also identified something which we call lazy orders. So, when we order a CT scan or MRI and put that order and a number of questions come up that probably involve about 20 clicks. And it occurred to us that our EHR is asking us those questions, but our EHR knows the answer to maybe half those questions. So, we managed to take some of those clicks away, which I think was something that was well-received by physicians who are certainly ordering these radiological studies.
Dr. Brown: Yeah. I think that's a really important point that getting rid of the unnecessary work that takes us away from patient care is critical. And some people have called this click busters or click buster award. And 20 clicks here, 30 clicks there like the tap and go, that could be 30 clicks a hundred times a day. So, do you have any sense of how much time you saved with even just those two interventions?
Dr. Girgrah: Yeah, I probably wouldn't be able to tell you about the lazy orders. I think just perception from the part of the physicians and APPs was that it just took away a lot of the frustration with ordering these procedures. When we did or estimated time studies I think the badge login, depending on how busy you are, can remove 20 to 30 minutes of unnecessary time.
Dr. Brown: That's fantastic. Is there a way that you celebrated it or shared the good work you were doing so that it built trust amongst the end user so that they were a little bit more motivated to listen or to offer some other ideas?
Dr. Girgrah: Yeah, we spent a lot of time on the art of communication and developing a communication rhythm. I sent chief wellness officer updates quarterly. Certainly, these wins were announced through system channels. Actually, it's sort of funny, when I was presenting the plan to the group practice back in August of 2019, Dr. Sinsky was with us, and she was giving a presentation and she gave her presentation before mine, and she asked the audience and this was before we announced the badge login. I'm sure Ochsner must have this. It saved some time and there were some grumblings in the audience. And so it was great timing to be able to announce, five minutes later, that we were implementing this the next month.
Dr. Brown: Yes, I'm sure that was well received, and you were happy to be able to do that.
Dr. Girgrah: Yeah. Some of the other quick wins, we introduced Epic back in 2012. We were alarmed to actually look at, holistically, all the in-baskets that existed throughout the system. And there were 18 million unneeded or unaddressed messages in people's in-baskets. Obviously, that was alarming to our compliance folks.
Dr. Brown: And was that in one year? Sorry? Was that in—
Dr. Girgrah: No, cumulative over eight years. Eight to nine years.
Dr. Brown: Yeah. 18 million is pretty significant.
Dr. Girgrah: Now some of those are significant because it may be missed opportunities with patients, unreturned calls. But it was an opportunity to really look at unnecessary or duplicative message types and actually remove them going forward. One example is our primary care physicians. Every time a patient of theirs goes to the emergency room, they'll get a notification when the patient arrives, a notification when the patient's been seen and a notification with the disposition. And I guess that's nice, but when you hear from our primary care physicians, they basically just want one message that summarizes all those events. So that was an example of message types that we could sort of simplify or shave.
Dr. Brown: And I bet there were probably, once you turned those off, the impact was probably tens or hundreds of thousands, over the course of a year, that really were unnecessary and distracting the doctor from the patient in front of them because they weren't going to see that patient maybe for another week or month.
Dr. Girgrah: Yeah. Like many of these initiatives, it's certainly a win for our physicians, it's a win for our patients' quality and safety and also, it keeps our compliance officers happy. So basically a win for everyone.
Dr. Brown: So just changing the, getting rid of, I think we lump them together called ADT—admissions discharges and transfers, could save hundreds of clicks per provider per day, which would translate into probably almost another hour.
Dr. Girgrah: Well, I would think these things are adding up. Again, as you've alluded to, not one intervention by itself, but I heard from one of our physicians before I took this role, it was death by a thousand cuts. And removing each one of those cuts systematically or trying to remove as many as you can.
Dr. Brown: So, it sounds like you worked closely with the IT team. How did you engage the players across that larger system?
Dr. Girgrah: Yeah. Well, it's certainly about shared accountability and as I mentioned, the word influence. But really getting the IT leaders, our CIO on board—our chief medical informatics officer on board, having them part of the workgroups that I described, having individuals from the IT departments involved in those workgroups, explaining that a win in this area may be a win for their folks. I've talked to many folks that work in our IT departments and I didn't realize how hard it was for them to often be the receiver of angry physicians complaining about different things. So, I think everybody is pleased when they can contribute to improving the workflow and work environments of a provider.
Dr. Brown: Absolutely. And the well-being of the physician, the APPs and the leadership is critical to making these changes. Any other quick wins? I know as an internist and geriatrician, my inbox had often been filled with medication refills and it seemed an opportunity for some efficiencies there.
Dr. Girgrah: Yeah.
Dr. Brown: Did you take any of that on?
Dr. Girgrah: Well, this I can't really take credit for, but, well, maybe I will. Now, this was a project that came out of our pharmacy team around the time that the Office of Professional Well-Being started. And I think it's an excellent example of this concept of promoting advanced team-based care. So originally a quality and safety initiative, but very quickly became a provider well-being initiative. We looked at different message types that our primary care physicians were getting in Epic. And the most common, if not one of the most common, were messages around refill requests. And we came up with a low-tech model at first that got a little more high-tech. So, we piloted a program in one of our community hospitals on the North Shore. The model of the refill clinic was a pharmacist armed with three and now it's up to five, medication access specialists and supplemented with a third-party vendor, a software that's able to extract patient data points, things that would be important when making a determination about whether it's safe to refill a prescription.
And with this, we were able to take away about 70% of pharmacy refill requests. And this is truly an example of allowing folks to truly practice at the top of their license. So, these are refills that are essentially removed from the physician's in-basket. So that was successfully piloted on the North Shore. Time studies, depending on how busy the physician was, it could give back 25 to 40 minutes to the physician. And this is time that they can spend away from a computer, time that they can either spend directly interacting with patients or time they can spend with their families or loved ones.
Dr. Brown: That's fantastic. And we know that the number one driver of physician well-being is being able to deliver quality care and quality care is not looking at the computer and unburdening your inbox. So, 70% is quite impressive. Do you know if you, at the same time, did they try to switch from—for chronic medications—90 pills with one refill to refilling them for a year or more?
Dr. Girgrah: Yeah, depending on the scenario, we can refill medications up to a year when patients are due for their annual or lab work follow-up, whichever comes earlier. So again, that's part of the physician-developed protocols or algorithms as to how frequently these prescriptions can be refilled. And I mention that because while this is work that was taken away from the physician, these were physician-improved algorithms.
Dr. Brown: Yes.
Dr. Girgrah: So, it does empower physicians in a way and make them feel like they're kind of in the driver's seat in terms of making these decisions. And also, it's an example of a win, not just for our physicians but for our patients. So quicker response time, finding care gaps and potentially correcting them. Some wins in terms of diminishing medication errors, drug/drug interactions, adverse events. So, these were not just good things for our physicians but good things for many different stakeholders.
Dr. Brown: Fantastic. I know when I started doing annual prescription renewal, my request for refills for chronic meds within six months went down by 50% and that meant calls from pharmacy, faxes. And now and this is probably the case in your organization too, when somebody calls for a refill, something went wrong, there's an opportunity for an improvement there because they can be addressed once a year. And either the patient missed their appointment, or we didn't fill them when we had the time to do it, when we saw them in for all of the medicines, all of the chronic medicines, we call that synchronized annual prescription renewal.
Dr. Girgrah: Yeah.
Dr. Brown: So, listening to you with just your wealth of information, and it's so inspiring what you've done, but just the three or four things that you've shared. Ten minutes here with the tap and go 20 minutes here with the lazy orders, the refills; clearly, you helped practicing physicians get an hour or two back in their day to do what they want to do, which is care for patients, build that very important trust, relationship to motivate the patients, to answer their questions and then maybe even get out on time so that they can get home to their families.
Dr. Girgrah: I remember a couple of stories, Marie. A very busy physician on the North Shore, we'll call him Dr. T, and he told me that one day after we implemented the refill clinic, that he returned home on time and his wife asked him if he'd quit his job because it was just so surprising to her that he'd appeared at home on time. Another physician, very busy physician with a high acuity patient panel, recounted that he was able to hang Christmas ornaments in the office with his staff just with the time given back. So yeah, I do think it's an illustration of being able to give time back to not just our physicians but many members on the team.
Dr. Brown: And our families. Well, the stories are inspiring. Can't thank you enough for joining us today, Dr. Girgrah. And thanks to you, the listeners, for joining us as well.
Dr. Girgrah: Thank you, Marie.
Dr. Brown: Thank you.
Outro: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.