How healthcare data helps physician burnout

Electronic Medical Record (EMR) systems, available to health care professionals in British Columbia, are essentially digital versions of the paper charts in a physician’s office covering the medical and treatment history of a patient. These record systems can be seen as silos of patient health data. Part of what interests me and my team at the Health Data Coalition (HDC) is how we can use anonymized aggregate EMR patient data linked to geographic neighborhoods to learn about community needs in our province. When we bridge the data-silos of each of our individual EMRs, we can elect to use this more robust data set to guide improvements in the quality of patient care, physician workflows, and resource allocation.

OSCARCON

Last month I had the opportunity to speak at OSCARCON ’23 in Vancouver. This two day conference brings together OSCAR EMR users, partners, service providers, developers and academics. Through various workshops, presentations and discussions, the goal of this event was to learn, collaborate and strategize how OSCAR EMR can be optimized for a stronger health provider community at large. My presentation on QI & PCN Planning shared how data can take us closer to that goal.

Quality Improvement (QI) and PCN (Primary Care Networks) are key to optimizing the way we use EMRs. PCNs are a very promising concept for British Columbia healthcare. Working to network different patient medical homes, different clinics, run by physicians, by the health authorities, by nurse practitioners trying to see if we can improve access to care, has us thinking about healthcare collaboration like never before. Physicians are exploring how we might extend hours of access by linking in more expert team members - shifting our concept of what a “primary care team” looks like. We do this in hopes that through the collaboration and the synergy of different providers coming together in-person or through virtual linkages, we can provide better access to better longitudinal care experiences for patients.

How will we know that a change is an improvement? (hint: HDC Discover)

The HDC Discover application, accepts data from several EMR systems to generate useful data aggregates and visualizations. To safeguard data vulnerability, we use our rule of five. This means that data point aggregations representing fewer than five data contributors or fewer than five patients are not available to be viewed through the HDC Discover. We withhold small cell sizes and outliers to protect those clinics that provide unique services or support unique patient populations. HDC Discover currently aggregates data to three levels – the provider-level, clinic-level, and population-levels. At population-level aggregations, the data becomes fully anonymized and cannot be connected back to any individual or clinic.

The HDC Discover application allows physicians to answer the second question in the Model for Improvement: “How will we know that a change is an improvement?” with more than185 different metrics and growing.

Physicians can identify a general geographic area and see a really unique data set. This may offer a powerful visualization that is the best available approximation of the reality of the healthcare status of each neighborhood. In BC, we have five geographic health authorities that our health ministry has opted to sub-divided its provincial operations & governance by. From Vancouver Coastal Health, we currently have approximately 246 physicians or nurse practitioners represented in the HDC Data set who have signed up to contribute their EMR data into our system, so that they can choose to use the data visualizations to guide their own system improvement. In the Fraser region where I practice, there are approximately 265 contributors. We need more, as the data set approximates reality more and more as each data contributor signs on and opts-in to contribute to the data network. Even after a health professional is signed up as a data contributor to the HDC, they still have complete control of how their data is used (i.e. sharing, participation in groups, opt out). In British Columbia roughly 45% of the possible data contributors and enrolled so we’re almost halfway and there’s room to grow.

QI: an Antidote to Burnout

My journey in quality improvement learning came about as a result of work related to burnout, six years into my practice, or about seven years ago. I was raised as a people pleaser. When I began working as a family physician, I didn't have great boundaries, and I tried to rescue my patients. I had made some strides in my own struggles with anxiety and trauma before medical training which resulted in a strong compassion for patients with mental health challenges. However, without good energetic or emotional boundaries, I was working way too much early in my career and stuffing down the emotions that I was absorbing from my suffering patients day to day as a family doctor. I was technically adept as a clinician, but when it came to emotional management, emotional boundaries,  time for self-care and the ritual release of burdens that are not mine - I was not skilled at all. I had low somatic awareness and low awareness in somatic therapies. I was living out the medical culture that I was trained in where I was trying to be a “family doctor god” that carries the responsibility for the burdens of another instead of being a more sustainable and effective “family doctor guide”.

As I started my career in BC, I chose to take over a practice that serves a population with huge socio economic burdens. Some of my patients were so challenged that they were living in tents in the parking lot outside my clinic. As you can imagine, some days, I found myself managing the parking lot more than managing my clinical duties.

I was internalizing a lot of the stresses that I was dealing with in my practice and it led me quickly to burnout. In my burnout I experienced inflammatory enthesitis and dactylitis.  Walking was hard and I continued to work while limping around my clinic. My immune system was inflamed and waving red flags that I needed to change how I was approaching the challenges in my silo of the health system. I was humbled and realized that I needed to learn more skills.

Boundary Setting 

In order to continue the work I was doing with patients, I had to learn to set boundaries. I had to take myself out of the unnecessarily intense one-to-one visits with patients and figure out how I could, at a systems level, really improve how I was doing as a physician. I knew I needed to make an impact on the system as a whole if we were to get ahead of all the health system crises that are around us. I learned, with coaching, that when I said yes to my patients, yes to my staff, to my colleagues, covering shifts at the hospital, I had to be sure I wasn't saying no to myself. I needed to shift my perspective to ensure I wasn't working harder than my patients attempting to rescue them - learning that the capability and capacity for wellness exists in the patient's hands and the patient’s community and not mine - also, no one needs me to rescue them.

Prentis Hemphill says, “boundaries are the distance at which I can love you, and I can love me simultaneously.” That quote was really powerful for me because I was raised in a culture where we attempt to love unconditionally. This ideal of unconditional love is unattainable as limited humans but we often do our best to approximate it when we provide care in the helping professions. My personal experience showed me that the quality of care that I tried to provide while I was burning myself out was much lower than when I intentionally preserved my energy throughout the day and weeks, months, and years. Once I learned to say “no” to patients, to my colleagues, to the intense attraction to bandage a poorly designed health system with my personal sweat and tears, I gained capacity to provide better care.  As I was healing from my inflamed immune system with the help of a family doctor (I’m one of the lucky ones) and a rheumatologist, I approached the CEO of my Health Authority about my concerns about the health system’s quality gaps and this discussion resulted in me being offered the opportunity to travel and learn from innovative health systems around the world working on health and care quality improvement sponsored by the Joint Collaborative Committees of the Doctors of BC.

Quality Improvement is a Team Sport

My QI mentors like Dr Curt Smecher taught me that QI is a team sport and when we work together, learn together, we do better. Data tracking helps us know if the changes we are trying are making an improvement. 

What’s been concerning me lately has been 11 year old data from the New England Healthcare Institute that, in general, access to health care is only estimated to be a 10% contributor to a person’s health. Genetics & environment (read: epigenetics) contributes about 40%. The other half of health is determined by healthy behaviors: self care like connecting with nature, eating balanced diets, staying active, and social connections. Despite this, in British Columbia, we're on track to spend over $40 billion on medical services next year - but the New England data shows us that only 10% of what makes a population well is medical services. Earlier last month at HQBC’s Quality Forum, Cormac Russell reiterated this message (see image below). There is a serious mismatch in the needs data, the impact data, and the funding data. This drives me nuts.

Stronger Together 

When each neighborhood in BC chooses to use aggregated population data, we can make informed decisions. We can use population trends to determine what we’re adopting, adapting and abandoning for our communities. HDC Discover is designed to show us whether or not we're making a change in our improvement. The data allows us to measure ourselves against ourselves and track personal improvement or measure against our communities or the whole province. I look forward to the day when HDC can help us find the gaps in our system to better invest upstream and address the social determinants of health. Primary Care Network governance nodes can look at all the different data visualizations that interest them and build healthier communities with data informed resourcing of mental health services, income security, housing security and food security. From a bird’s eye view of our community network, clinics are like “system sensors” actively gathering data indicators of the needs in our communities. As physician data stewards, we hold in our EMRs some of the most useful information to help our communities.

To close my presentation at OSCARCON last month, I made it clear to the physicians in the room that we are in a system that is severely inflamed.  As natural system leaders, doctors must guide our health system to have better boundaries.  Our system resources need to be focused on the problems that, when improved, will have the greatest sustained impact for the generations to come. We need to speak up if we notice that we, as a community, are putting too much energy into less impactful solutions. To get to this systems-level positive impact, we must first unleash our own leadership capacity through improving the care we give to ourselves. When we treat ourselves with self-compassion and set boundaries for wellness and longevity, longitudinal family doctors with systems’ perspectives empowered with community level data are ideally positioned as collaborative stewards to usher in a more sustainable health system where community assets are appreciated, empowered, and networked in alignment with the quintuple aim.

It was a pleasure to represent the Health Data Coalition at this event. HDC is physician led, which is a really important factor of the organization. The team is led with a beautifully collaborative quality improvement culture. There are more and more stories like mine that show the impact of leveraging clinic level and neighborhood level data around the province. You can read some of these stories here on the HDC website.

For more information on the recent conference, OSCARCON ’23: Optimizing your OSCAR EMR Experience visit www.oscarbc.ca/events/oscarcon23/ . For highlights of this event and others, check out my Twitter feed @gatewaymedic  

For more information on contributing data to HDC please get in touch with me or visit https://hdcbc.ca/why-join-benefits/