Strategies for Health Organizations

Adequate staffing is closely associated with healthcare worker burnout and patient outcomes. Organizational approaches include:

• Establishing organizational policies on staffing, including appropriate panel sizes/caseloads
• Introducing new staffing strategies (e.g., internal travel programs, flexible staffing arrangements, remote or virtual staff)
• Engaging in training the future workforce

‍Evidence

Studies of California’s mandated minimum nurse-to-patient ratios have demonstrated improved nurse staffing, decreased burnout and job dissatisfaction, better patient outcomes, and in one study, return on investment.^1-3 Although a recent systematic review of mandated nurse ratios in hospitals and nursing homes found positive impacts on patient outcomes were not consistent across all studies.⁴ A study of patient care technician (PCT) ratios in hemodialysis clinics found that patient-to-PCT ratios in the highest quartile were associated with increased rates of early mortality and hospitalization and worse kidney transplantation outcomes.⁵ Studies of staffing committees have focused on the eight states with legislative mandates for nurse staffing committees.⁶ In Texas, the 10-year period post-staffing committee legislation saw an increase in nurses (particularly Registered Nurses) by 5%, and hospitals with the lowest nurse staffing made the greatest gains, as did for-profit hospitals and those in metropolitan areas.⁷ Patient acuity tools, often used by staffing committees, have been shown to increase nurse satisfaction, improve nurse-patient assignments, and increase nurses’ perceptions of receiving a fair assignment, being able to provide safe, effective care and having more time with their patients.^8,9 High caseloads have been shown to increase rates of burnout and decrease job satisfaction among counselors and primary care clinicians, where increasing panel sizes has also been associated with lower quality of patient care.^10-13

While many new staffing strategies have yet to be fully studied, leaders at several organizations have reported beneficial outcomes (see Spotlights below). One study of expert virtual nurses in medical-surgical units at two community hospitals resulted in increased staff and patient satisfaction, decreased discharge order-to-dismissal times, and significant decreases in labor costs.¹⁴

A “grow your own” strategy creates a direct pipeline for recruitment, supports training aligned with optimized teams and models, and can expand and retain the workforce. Physician residency in rural and community-based settings and nurse residencies have been shown to increase retention.^15-18 A scoping review of nursing academic-practice partnerships found stronger interprofessional practice and collaboration,¹⁸ which are factors associated with burnout reduction.^19-21 

‍Resources

Organizational Staffing Policies

California RN-to-Patient Safe Staffing Ratios provides the minimum staffing ratios required in the only state which has legislated minimum nurse staffing for hospitals. *See more about mandated staffing initiatives in the government section*

State nursing associations, such as the Oregon Nurses Association and Washington State Nurses Association, provide resources for developing effective staffing committees. 

‍American Nurse, the journal of the American Nurses Association (ANA) provides guidance for applying acuity-based staffing as well as information about a patient acuity tool for determining medical-surgical unit staffing. The ANA also offers a primer on considerations for staffing and use of software for acuity-based staffing decisions. 

The American Medical Association’s Panel Sizes for Primary Care Physicians is a toolkit that helps determine optimal patient panel sizes based on both patient and practice variables. 

‍New Staffing Strategies

The American Association of Critical-Care Nurses’ Resources for Staffing in Acute & Critical Care includes recommendations from their Nurse Staffing Task Force and case studies of nurse staffing solutions, such as internal staffing agencies, acuity-based staffing, and flexible service line staffing. 

The American Nurses Association provides information about the use of virtual nursing, including its benefits to patients and healthcare staff. 

‍Becker’s Hospital Review highlights 5 workplace flexibility strategies hospitals are implementing for nurses, including weekends-only positions, gig economy positions (where workers can work when and where they want to), and fixed-term positions, with options to go full- or part-time when their term is complete.

‍Training the Future Workforce

The National Health Center Training & Technical Assistance Partnership provides resources and training on team-based care, sustainable health professions training, and establishing postgraduate residency and fellowship programs, including nurse practitioner residency programs. The Education Health Center Guide is a resource toolkit for developing training for health professions students and/or residents in community health centers.

The American Organization for Nursing Leadership released a Nursing Leadership Workforce Compendium, including how to establish academic-practice partnerships.

‍Use of Apprenticeship to Meet Demand for Medical Assistants in the U.S. describes different models of medical assistant apprenticeships, key components of training, and potential funding to start and support programs.

‍Spotlights

‍Mount Sinai Medical Center and Montefiore Medical Center, both in New York City, established safe staffing ratios in response to nurse strikes and union negotiations. Wall-to-wall safe staffing ratios are in place at Mount Sinai Medical Center, while Montefiore has safe staffing ratios in their emergency department. 

‍Reading Hospital in Pennsylvania has published information about their staffing committees, including lessons learned. Nurses from Indiana University Health Ball Memorial Hospital in Muncie created a new patient acuity tool for their progressive care unit, studied its effects, and established plans for sustainability of changes and continued re-evaluation.

The University of Pittsburg Medical Center’s internal travel program, UPMC Travel Staffing, allows nurses, surgical technicians, and echo sonographers to travel across the entire system (with locations in New York, Maryland, and Pennsylvania) and/or within a single region for six-week assignments. Details about hourly pay, stipends, and other benefits can be found on the program's website. The program has improved nursing recruitment, according to UPMC’s Chief Nursing Executive.

Using technology similar to ride-sharing and food delivery services, Mercy Works on Demand is an online and app platform that allows nurses – both within and outside of the health system – to pick up shifts easily. Johnson & Johnson provide more information about the platform and how it has resulted in an improved nursing fill rate, reduced care delivery and resource costs, and lower agency nurse spending. 

‍Alleghany Health Network implemented a “digital nurse” program using a smart TV, smart Pad, and mounted camera, digital nurses help with admissions, discharges, patient education, and answering patient questions, easing charting and other burdens from nurses working in person. Ardent Health began using virtual nurses for intake (medication history, allergies) and completion of compliance-based protocols (sepsis, etc.) enabling those near retirement or with injuries to continue working. 

‍Dana-Farber Cancer Institute created a residency program for newly-licensed nurses to provide extensive orientation to ease the transition into oncology nursing practice. During the COVID-19 pandemic, they also created a fellowship to hire nurses without oncology experience, providing them 6 months of specialty training. Between these and other initiatives, RN turnover has returned to pre-pandemic levels. 

‍References

1. McHugh MD, Aiken LH, Sloane DM, Windsor C, Douglas C, Yates P. Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals. The Lancet. 2021;397(10288):1905-1913. 
2. Aiken LH, Sloane DM, Cimiotti JP, et al. Implications of the California nurse staffing mandate for other states. Health Services Research. 2010;45(4):904-921. 
3. Han X, Pittman P, Barnow B. Alternative approaches to ensuring adequate nurse staffing. Med Care. 2021;59(10 Suppl 5):S463-S470. 
4. Twigg DE, Whitehead L, Doleman G, El-Zaemey S. The impact of nurse staffing methodologies on nurse and patient outcomes: A systematic review. Journal of Advanced Nursing. 2021;77(12):4599-4611. 
5. Plantinga LC, Bender AA, Urbanski M, et al. Patient care technician staffing and outcomes among US patients receiving in-center hemodialysis. JAMA Network Open. 2024;7(3):e241722.
6. American Nurses Association. Advocating for safe staffing. 
7. Jones T, Heui Bae S, Murry N, Hamilton P. Texas nurse staffing trends before and after mandated nurse staffing committees. Policy, Politics, & Nursing Practice. 2015;16(3-4):79-96. 
8. DiClemente K. Standardizing patient acuity: A project on a medical-surgical/cancer care unit. Medsurg Nursing. 2018;27(6):355.
9. Eastman D, Kernan K. A new patient acuity tool to support equitable patient assignments in a progressive care unit. Critical Care Nursing Quarterly. 2022;45(1):54. 
10. Mullen PR, Chae N, Backer A, Niles J. School counselor burnout, job stress, and job satisfaction by student caseload. NASSP Bulletin. 2021;105(1):25-42. 
11. Broome KM, Knight DK, Edwards JR, Flynn PM. Leadership, burnout, and job satisfaction in outpatient drug-free treatment programs. Journal of Substance Abuse Treatment. 2009;37(2):160-170.
12. Paige NM, Apaydin EA, Goldhaber-Fiebert JD, et al. What is the optimal primary care panel size?: A systematic review. Ann Intern Med. 2020;172(3):195. 
13. Angstman KB, Horn JL, Bernard ME, et al. Family medicine panel size with care teams: Impact on quality. Journal of the American Board of Family Medicine. 2016;29(4):444-451. 
14. Schuelke S, Aurit S, Connot N, Denney S. Virtual nursing: The new reality in quality care. Nursing Administration Quarterly. 2019;43(4):322. 
15. Rush KL, Janke R, Duchscher JE, Phillips R, Kaur S. Best practices of formal new graduate transition programs: An integrative review. International Journal of Nursing Studies. 2019;94:139-158. 
16. Brook J, Aitken L, Webb R, MacLaren J, Salmon D. Characteristics of successful interventions to reduce turnover and increase retention of early career nurses: A systematic review. International Journal of Nursing Studies. 2019;91:47-59. 
17. Patterson DG, Shipman SA, Pollack SW, et al. Growing a rural family physician workforce: The contributions of rural background and rural place of residency training. Health Serv Res. Published online May 9, 2023. 
18. Davis CS, Roy T, Peterson LE, Bazemore AW. Evaluating the teaching health center graduate medical education model at 10 years: Practice-based outcomes and opportunities. J Grad Med Educ. 2022;14(5):599-605. 
19. Markaki A, Prajankett O, Shorten A, Shirey MR, Harper DC. Academic service-learning nursing partnerships in the Americas: A scoping review. BMC Nursing. 2021;20(1):1-15. 
20. Al Sabei SD, Labrague LJ, Al-Rawajfah O, AbuAlRub R, Burney IA, Jayapal SK. Relationship between interprofessional teamwork and nurses’ intent to leave work: The mediating role of job satisfaction and burnout. Nursing Forum. 2022;57(4):568-576. 
21. Körner M, Wirtz MA, Bengel J, Göritz AS. Relationship of organizational culture, teamwork and job satisfaction in interprofessional teams. BMC Health Serv Res. 2015;15(1):243.

Organizations are investing in team-based models through the following approaches:

• Optimizing team configurations (e.g., new staff and roles, supporting full scope of practice)
• Promoting positive team culture and structures (e.g., improving communication, changing team structures)

‍Evidence

Research has found team-based models that utilize health workers in expanded roles and at full scope improve well-being. For example, a model increasing the ratio of MAs to primary care providers and expanding their roles to include population health management, scribing, and between-visit management, was strongly associated with reductions in burnout among team members.¹ Chapman and Blash (2017) found that models which utilize MAs in relational, technological and documentation, cross-training, and supervisory or leadership roles improved staff satisfaction in primary care settings.² A study of burnout among hematologists and oncologists found that greater utilization of advanced practice clinicians was linked to lower burnout.³ Workers supported to work at the top of their license and/or training report greater satisfaction with their work.⁴ Narrow scope of practice has also been associated with burnout among family physicians and pharmacists.^5,6 

‍Positive team culture (communication, participation, effort, social support, respect, shared objectives) and teamness (shared goals, clear roles, mutual trust, effective communication, measurable process and outcomes, and organizational support) have been shown to reduce burnout in a variety of health workers.^7,8,9 Tight team structures (e.g., teamlets) have also been associated with lower staff burnout and improved patient satisfaction, quality of care, emergency department visits and hospitalizations.^7,10 However, a recent study showed no significant difference in primary care physician burnout associated with working in teamlets.¹¹ Evidence is also mixed but largely supports the use of interprofessional teams to reduce burnout, improve job satisfaction, and, in some cases, reduce intentions to leave.^12-17

‍Resources

The Agency for Healthcare Research and Quality (AHRQ) provides a number of resources to advance team-based care, including:

• Workforce Configurations to Provide High-Quality, Comprehensive Primary Care provides a white paper, published manuscripts, and case examples.
• TeamSTEPPS is an evidence-based set of teamwork tools aimed at optimizing patient outcomes by improving communication and teamwork skills among healthcare professionals. Resources include instructor-led or self-paced training, training simulation videos, and measurement tools

The National Academy of Medicine:

• Implementing Optimal Team-Base Care to Reduce Clinician Burnout provides guidance on implementing team-based care, highlighting key features of successful teams and sharing strategies for overcoming organizational and environmental barriers.
• Implementing High-Quality Primary Care Chapter 6 Designing Interprofessional Teams and Preparing the Future Primary Care Workforce provides an overview of the interprofessional team in primary care

‍Bodenheimer and Willard-Grace (2016) suggest guidelines for developing a teamlet model for primary care. 

The National Center for Interprofessional Practice and Education offers leadership, evidence, and resources to advance interprofessional education and collaborative practice.

‍Spotlights

‍UCHealth has two support positions in hospitals meant to ease the workload of nurses: patient care assistants who help nurses with basic care, and patient technology technicians who ensure that equipment on the unit is working properly and fix any technology-related problems that arise during the shift. UCHealth’s chief nursing executive has reported that the use of patient technology technicians on hospital units has resulted in dramatic improvements in time nurses spent managing technology: from 14% satisfaction to 96% satisfaction.

‍Trinity Health is creating a new team-based model for nursing care that serves as a tight team structure; it will include a floor registered nurse, either a certified nursing assistant or licensed practical nurse, and a virtual, on-screen registered nurse. Trinity’s CEO sees these teams, particularly with the inclusion of virtual nurses, as better able to anticipate patient and family needs.  

‍Cleveland Clinic Strongsville Family Health and Ambulatory Surgery Center, a multispecialty ambulatory location, serves as an example of utilizing advanced practice clinicians, promoting team culture, and designing interprofessional teams. They utilize a team-based care model in their primary care offices that incorporates medical assistants in two different roles, advanced practice clinicians, pharmacists, social workers, and registered nurses in two different capacities. 

Florida International University’s Green Family Foundation Neighborhood Health Education Learning Program (NeighborhoodHELP) enables medical students to engage in community-based work in interprofessional teams. House visits are made alongside nursing, social work, and physician assistant students, and law and education students are also available to assist with patient needs.

The Veterans Health Administration’s Patient-Aligned Care Team (PACT) model has used teamlets - a type of tight team structure including at least one clinician (physician, physician assistant/associate, nurse practitioner, etc.), one or two medical assistants, and sometimes a nurse or front desk staff member working together each day to care for a specific panel of patients - to lower staff burnout and improve patient satisfaction, quality of care, emergency department visits and hospitalizations.

‍References

1. Shaw JG, Winget M, Brown-Johnson C, et al. Primary Care 2.0: A prospective evaluation of a novel model of advanced team care with expanded medical assistant support. The Annals of Family Medicine. 2021;19(5):411-418. 
2. Chapman SA, Blash LK. New roles for medical assistants in innovative primary care practices. Health Services Research. 2017;52(S1):383-406. 
3. Lee AI, Masselink LE, De Castro LM, et al. Burnout in US hematologists and oncologists: Impact of compensation models and advanced practice provider support. Blood Advances. 2023;7(13):3058-3068. 
4. Optimize the care team. Institute for Healthcare Improvement. 
5. Weidner AKH, Phillips RL, Fang B, Peterson LE. Burnout and scope of practice in new family physicians. The Annals of Family Medicine. 2018;16(3):200-205. 
6. Blue CL, Gould ON, Clarke C, et al. Burnout among hospital pharmacists in Canada: A cross-sectional analysis. Canadian Journal of Hospital Pharmacy. 2022;75(4):326-334. 
7. Willard-Grace R, Hessler D, Rogers E, Dube K, Bodenheimer T, Grumbach K. Team structure and culture are associated with lower burnout in primary care. The Journal of the American Board of Family Medicine. 2014;27(2):229-238. 
8. Eckstrom E, Tilden VP, Tuepker A. Teamness, burnout, job satisfaction and decision-making in the VA Centers of Excellence in Primary Care Education. Journal of Interprofessional Education & Practice. 2020;19:100328. 
9. Mijakoski D, Karadzhinska-Bislimovska J, Stoleski S, Minov J, Atanasovska A, Bihorac E. Job demands, burnout, and teamwork in healthcare professionals working in a general hospital that was analysed at two points in time. Open Access Maced J Med Sci 2018;6(4):723-729. 
10. Nelson KM, Helfrich C, Sun H, et al. Implementation of the patient-centered medical home in the Veterans Health Administration: Associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use. JAMA Intern Med. 2014;174(8):1350. 
11. Casalino LP, Jung HY, Bodenheimer T, et al. The association of teamlets and teams with physician burnout and patient outcomes. J Gen Intern Med. 2022;38:1384-1392. 
12. Al Sabei SD, Labrague LJ, Al-Rawajfah O, AbuAlRub R, Burney IA, Jayapal SK. Relationship between interprofessional teamwork and nurses’ intent to leave work: The mediating role of job satisfaction and burnout. Nursing Forum. 2022;57(4):568-576. 
13. Körner M, Wirtz MA, Bengel J, Göritz AS. Relationship of organizational culture, teamwork and job satisfaction in interprofessional teams. BMC Health Serv Res. 2015;15(1):243. 
14. McCarthy LP. Social work burnout in the context of interprofessional collaboration. Social Work Research. 2021;45(2):129-139.
15. Smith CD, Balatbat C, Corbridge S, et al. Implementing optimal team-based care to reduce clinician burnout. NAM Perspectives. National Academy of Medicine; 2018. 
16. Lyon C, English AF, Chabot Smith P. A team-based care model that improves job satisfaction. Fam Pract Manag. 2018;25(2):6-11. 
17. Chang BP, Cato KD, Cassai M, Breen L. Clinician burnout and its association with team-based care in the Emergency Department. Am J Emerg Med. 2019;37(11):2113–2114.

Organizations are investing in solutions to reduce administrative and documentation burdens to improve workflows and promote worker and learner wellbeing by increasing time spent with patients and the community. Strategies include: 

• Reducing administrative burdens by identifying and quantifying administrative tasks, including electronic health record (EHR) documentation; by reducing and eliminating low-value tasks; and by altering policies and practices for documentation, trainings, and other administrative tasks
• Increasing capacity to “share” administrative tasks that cannot be removed/reduced (e.g., medical scribes to support documentation)
• Building and protecting time for completing administrative tasks during the workday
• Optimizing EHRs to reduce worker and learner burden and to ensure they are human-centered and interoperable

‍Evidence

Burnout and career dissatisfaction have been closely tied to administrative burdens,^1-3 as are poor patient outcomes.^4-6 Research has shown workers and learners spend significant time on administrative tasks, such as documentation in the electronic health record (EHR) and acquiring prior authorizations, and a recent study found a strong association between EHR usability and odds of physician burnout.⁷ With increasing administrative burdens, workloads increase⁸ and workers spend less time with patients.^9,10 Additionally, for some workers, such as physicians and advanced practice clinicians, administrative tasks accumulate during the day and must be completed after work hours, a phenomenon called “pajama time.”¹¹ Studies have also shown that administrative burdens such as prior authorizations can result in delayed care^12,13 as well as significant costs to organizations and healthcare systems.¹⁴ The Council for Affordable Quality Healthcare (CAQH) estimated healthcare systems spent $60 billion conducting the nine most common administrative tasks in 2022.¹⁴

Organizations have successfully implemented strategies to reduce administrative burdens.¹⁵ Studies show that workflow changes, such as flowsheet redesigns to reduce redundant charting and identifying an essential dataset to pare down admission history documentation, substantially decrease EHR documentation time and number of clicks.^16,17 When administrative burdens cannot be eliminated, expanding capacity to support documentation, such as through medical scribes and expanded roles of clerical support staff, have been shown to improve physician productivity and wellbeing without diminishing patient experience.^15,18-23 Regular training sessions and 24/7 support for workers to learn how to use the EHR more efficiently have also been shown to improve documentation efficiency, job satisfaction, and work-life balance.^24,25

‍Resources

Reducing Administrative Burdens

The American Medical Informatics Association developed the 25x5 initiative, which aims to reduce administrative burdens by 25% in 5 years. Their 25x5 Symposium delineates current challenges in documentation burden, highlights exemplars and successes, and prioritizes actions for providers and health systems, health IT vendors, and policy and advocacy groups.

The American Medical Association’s (AMA’s) STEPS Forward program provides multiple resources for reducing administrative burdens and improving workflows for physicians and other clinicians, including:

• The De-Implementation Checklist and Getting Rid of the Stupid Stuff modules, which provide guidance on identifying and reducing unnecessary, burdensome tasks as well as examples of organizational burdens that have been successfully changed. 
• The Workflow and Process podcasts, which provide information on administrative challenges and highlights examples of changes organizations, departments, and practices have made to improve their workflows. 
• EHR Inbox Management: Tame Your EHR Inbox offers guidance for helping physicians and advanced practice providers a step-by-step training for managing EHR-generated inbox messages.

The American College of Physicians Position Paper on Putting Patients First by Reducing Administrative Tasks in Health Care provides a framework to analyze and mitigate administrative tasks – including duplicative work.

The Institute for Healthcare Improvement Leadership Alliance’s Breaking the Rules for Better Care is a resource guide for healthcare leaders to identify and change processes or policies having unintended impact on workers. 

‍Optimizing Electronic Health Records

A National Academy of Medicine Discussion Paper on Electronic Health Record Optimization and Clinician Well-Being: A Potential Roadmap Toward Action offers strategies and approaches to optimize the EHR, including EHR optimization “sprints” and work design approaches, in-basket management techniques, documentation strategies and team-based workflows, EHR training, and artificial intelligence and “Add-On Apps.”

‍Sinsky, et al. (2020) outline metrics for assessing physician activity in the EHR and their uses for multiple stakeholders, including organizational leaders. One way to quantify administrative burdens is using the EHR access time stamp functionality. Zheng and colleagues (2020) outline additional methods and challenges for studying workflows and workarounds for EHR-related administrative burdens.

The AMA has multiple resources for improving EHR workflows including:

• Electronic Health Record Optimization: Strategies to Help Organizations Maximize Benefits and Minimize Burdens, a STEPS Forward toolkit
• Taming the EHR Playbook, which offers guidance for maximizing benefits and minimizing burdens of the EHR.
• Improving Care: Priorities to Improve Electronic Health Record Usability outlines eight EHR usability priorities. Organizations can use these as guidelines during conversations with vendors.

‍Waldren and Billings (2023), sponsored by the American Academy of Family Physicians, offer a guide to essential innovations that can relieve documentation-related administrative burdens.

AHRQ’s Digital Healthcare Research Workflow Assessment for Health IT Toolkit is designed for people and organizations interested or involved in the planning, design, implementation, and use of health IT in ambulatory care.

NAM’s Electronic Health Record Optimization and Clinician Wellbeing: A Potential Roadmap Toward Action & Checklist for Healthcare Leadership on Health IT and Clinician Burnout provide information on implementing health IT that supports clinicians in providing high-quality patient care. 

‍Increasing Capacity to “Share” the Burden

The American Healthcare Documentation Professionals Group provides a Medical Scribe ROI Calculator.

‍Spotlights

‍Hawaii Pacific Health utilized the AMA Getting Rid of Stupid Stuff program to work with employees to understand their EHR experiences and solicit tasks for elimination. De-implementation work led to 1700 nursing hours saved per month across the health system.

‍Sinsky, et al. (2013) describe 23 high-functioning primary care practices that implemented innovations to improve burnout, including sharing administrative tasks. Cleveland Clinic Strongsville, an example the authors highlight, found that sharing tasks not only increased revenue, visit numbers, and patient satisfaction, but also physician satisfaction and engagement from nurses and medical assistants.

‍Stanford Children’s Health designed a tailored EHR proficiency program for providers, factoring in provider-specific EHR use data, results of a needs assessment survey of providers, and observations of providers’ EHR workflows.

‍Memorial Hermann Health System optimized their EHR with the help of frontline nurses to decrease the documentation burden during the COVID-19 pandemic. Their case study provides guidance on selecting a team, incorporating the voices of workers, gaining executive support, and engaging staff in adopting the changes.

‍References

1. Adler-Milstein J, Zhao W, Willard-Grace R, Knox M, Grumbach K. Electronic health records and burnout: Time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians. JAMIA. 2020;27(4):531-538. 
2. Woolhandler S, Himmelstein DU. Administrative work consumes one-sixth of u.s. physicians’ working hours and lowers their career satisfaction. Int J Health Serv. 2014;44(4):635-642. 
3. NEJM Catalyst. Physician Burnout: The Root of the Problem and the Path to Solutions. June 2017. 
4. American Medical Association. 2022 AMA prior authorization physician survey. 2023. 
5. QuickStats: Distribution of hours per day that office-based primary care and specialist care physicians spent outside normal office hours documenting clinical care in their medical record system — United States, 2019. Morb Mortal Wkly Rep 2021;70:1752. 
6. Wisner K, Lyndon A, Chesla CA. The electronic health record’s impact on nurses’ cognitive work: An integrative review. Int J Nurs Stud. 2019;94:74-84. 
7. Melnick ER, Dyrbye LN, Sinsky CA, et al. The association between perceived electronic health record usability and professional burnout among US physicians. Mayo Clin Proc. 2020;95(3):476-487.
8. De Groot K, De Veer AJE, Munster AM, Francke AL, Paans W. Nursing documentation and its relationship with perceived nursing workload: A mixed-methods study among community nurses. BMC Nurs. 2022;21(1):34. 
9. Butler R, Monsalve M, Thomas GW, et al. Estimating time physicians and other health care workers spend with patients in an intensive care unit using a sensor network. Am J Med. 2018;131(8):972.e9-972.e15. 
10. Yen PY, Kellye M, Lopetegui M, et al. Nurses’ time allocation and multitasking of nursing activities: a time motion study. AMIA Annu Symp Proc. 2018;2018:1137-1146. 
11. Saag HS, Shah K, Jones SA, Testa PA, Horwitz LI. Pajama time: Working after work in the electronic health record. J Gen Intern Med. 2019;34(9):1695-1696.
12. O’Reilly KB. 1 in 3 doctors has seen prior auth lead to serious adverse event. American Medical Association. March 29, 2023. 
13. ASCO. Nearly all oncology providers report prior authorization causing delayed care, other patient harms. The ASCO Post. December 25, 2022. 
14. CAQH. 2022 CAQH Index: A Decade of Progress. 2023. Accessed August 31, 2023. 
15. Erickson SM, Rockwern B, Koltov M, McLean RM. Putting patients first by reducing administrative tasks in health care: A position paper of the American College of Physicians. Ann Intern Med. 2017;166(9):659-661. 
16. Lindsay MR, Lytle K. Implementing best practices to redesign workflow and optimize nursing documentation in the electronic health record. Appl Clin Inform. 2022;13(3):711-719. 
17. Sutton DE, Fogel JR, Giard AS, Gulker LA, Ivory CH, Rosa AM. Defining an essential clinical dataset for admission patient history to reduce nursing documentation burden. Appl Clin Inform. 2020;11(3):464-473. 
18. Shah T, Kitts AB, Gold JA, et al. Electronic health record optimization and clinician well-being: a potential roadmap toward action. NAM Persp. August 2020. 
19. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: A report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11(3):272-278. 
20. Ziemann M, Erikson C, Krips M. The use of medical scribes in primary care settings. Med Care. 2021;59(10 Suppl 5):S449-S456. 
21. Mishra P, Kiang J, Grant R. Association of medical scribes in primary care with physician workflow and patient experience. JAMA Intern Med. 2018;178(11):1467-1472. 
22. Shultz CG, Holmstrom HL. The use of medical scribes in health care settings: a systematic review and future directions. J Am Board Fam Med. 2015;28(3):371-381. 
23. Contratto E, Romp K, Estrada CA, Agne A, Willett LL. Physician order entry clerical support improves physician satisfaction and productivity. South Med J. 2017;110(5):363-368. 
24. Robinson KE, Kersey JA. Novel electronic health record (EHR) education intervention in large healthcare organization improves quality, efficiency, time, and impact on burnout. Med. 2018;97(38):e12319. 
25. Dastagir MT, Chin HL, McNamara M, Poteraj K, Battaglini S, Alstot L. Advanced proficiency ehr training: Effect on physicians’ EHR efficiency, EHR satisfaction and job satisfaction. AMIA Annu Symp Proc. 2012;2012:136-143.

Technology can be both a source and solution for administrative burdens and inefficient workflows. In addition to optimizing EHRs (discussed in Reducing Administrative Burdens), organizations can leverage technology’s benefits by: 

• Automating low-value administrative tasks that cannot be eliminated
• Utilizing virtual scribes, ambient artificial intelligence (AI), voice assistants, and dictation software for documentation
• Offering intuitive options for virtual care and consultation

‍Evidence

Early evidence has shown use of dictation with natural language processing can reduce clinical documentation time without sacrificing documentation quality.¹ One study found that 77% of physicians believed dictation software improved the efficiency of their work.² Primary care physicians who adopted an AI assistant had a 72% decrease in documentation time per note and 3.3 hours of time savings per week per clinician.³ Participants also reported improved satisfaction with their workload post-adoption. 

Virtual care rose dramatically during the COVID-19 pandemic and has continued to be popular with both clinicians⁴ and patients,⁵ especially for prescription refills, test results, and mental health care. Videoconferencing is also useful for consultations with experts or when caring for those with communicable diseases.^6-8 Studies have shown, however, that complex digital technologies can worsen health disparities for some patients.^9,10 A study of physicians, psychologists, and advanced practice clinicians showed that virtual care was not associated with burnout. However, those who provided more virtual care also had more flexible schedules, which corresponded to lower work-related stress and greater perceived control over their workload.¹¹

‍Resources

The Government Accountability Office (GAO) and National Academy of Medicine (NAM) produced a report on the benefits and challenges of using AI in healthcare. 

The American Medical Association (AMA) offers news, reports and policy, continuing education, and practice management strategies for augmented intelligence, the use of AI to assist clinicians.  The Journal of the American Medical Association (JAMA) Network has curated a list of articles and resources about AI.

‍Health AI Partnership is a multi-stakeholder collaborative of physicians, scientists, systems engineers, academicians, lawyers, community organizers, and organizational leaders that provides, guidance, resources, standards, and peer learning and collaborations paces to empower healthcare organizations to use AI safely, effectively, and equitably.

The Health Resources and Services Administration (HRSA) Optimizing Virtual Care provides resources based on lessons learned from health center Quality Improvement Fund grants, including: briefs on innovative strategies and actionable tips from grantees, journey maps focusing on different patient populations, health center stories, and links to telehealth resources.

‍Spotlights

‍Healthcare leaders at Fisher-Titus Health and Duke Health explain the importance of incorporating workers’ input when designing changes to the organization’s processes and policies. Duke’s leader explained, “We must work on redesigning clinical care delivery with the people who do the work.”

Multiple health systems, including UNC Health, Stanford Health Care, and both UC San Diego Health and UW Health are partnering with Microsoft and Epic to utilize AI technology for drafting messages to patients in order to reduce pajama time for physicians and other clinicians. UNC’s Chief Information Officer stated that UNC is working closely with Epic to tailor the technology to suit various specialties rather than having a one-size-fits-all interface and workflow.

‍Baptist Health in Jacksonville, Florida has been utilizing Microsoft’s DAX app, an AI program that can record a patient visit and create a summary in the format of a EHR note.

‍Henry Ford Health’s 100% behavioral health integration program for their primary care practices has increased access for patients and improved well-being for providers. 

‍References

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