The Electronic Medical Record and Nephrology Fellowship Education in the United States: An Opinion Survey

Measuring Documentation Burden in Healthcare

BACKGROUND

The enactment of the Health Information Technology for Economic and Clinical Health Act and the wide adoption of electronic health record (EHR) systems have ushered in increasing documentation burden, frequently cited as a key factor affecting the work experience of healthcare professionals and a contributor to burnout. This systematic review aims to identify and characterize measures of documentation burden.

METHODS

We integrated discussions with Key Informants and a comprehensive search of the literature, including MEDLINE, Embase, Scopus, and gray literature published between 2010 and 2023. Data were narratively and thematically synthesized.

RESULTS

We identified 135 articles about measuring documentation burden. We classified measures into 11 categories: overall time spent in EHR, activities related to clinical documentation, inbox management, time spent in clinical review, time spent in orders, work outside work/after hours, administrative tasks (billing and insurance related), fragmentation of workflow, measures of efficiency, EHR activity rate, and usability. The most common source of data for most measures was EHR usage logs. Direct tracking such as through time-motion analysis was fairly uncommon. Measures were developed and applied across various settings and populations, with physicians and nurses in the USA being the most frequently represented healthcare professionals. Evidence of validity of these measures was limited and incomplete. Data on the appropriateness of measures in terms of scalability, feasibility, or equity across various contexts were limited. The physician perspective was the most robustly captured and prominently focused on increased stress and burnout.

DISCUSSION

Numerous measures for documentation burden are available and have been tested in a variety of settings and contexts. However, most are one-dimensional, do not capture various domains of this construct, and lack robust validity evidence. This report serves as a call to action highlighting an urgent need for measure development that represents diverse clinical contexts and support future interventions.

Protected Time for Program Administration among Nephrology Program Leadership in the United States

BACKGROUND

In 2022, the Accreditation Council for Graduate Medical Education reduced minimum program director protected time for program administration from 10 to 8 h/wk, with no core faculty requirement. We surveyed program leaders regarding the effect of these changes.

METHODS

This is an anonymous, online survey of all US adult nephrology program directors (March 2023), who forwarded core faculty/associate program director (APD) surveys. The questions included protected time in 2022-2023 and 2021-2022, whether it was sufficient, estimated time needed, and two validated single-item burnout measures (emotional exhaustion and depersonalization). The analysis was descriptive.

RESULTS

Program directors: Their response was 62% (92/149), with geographic distribution/approved fellow positions similar to those nationally. Overall, protected time slightly increased from 2021 to 2022, largely in >6-fellow programs, but 42% (13/31) of these were still not meeting minimum requirements. Only 37% (30/81) agreed that they had sufficient protected time. Those with ≤6 fellows estimated needing 11±4 h/wk (15±4 h/wk with >6 fellows). Twenty-five percent (20/81) reported high levels of emotional exhaustion. Core faculty: 57 of 149 program directors (38%) forwarded the link to 454 faculty. Ninety-four percent of APDs (49/52) responded, reported 3±3 h/wk protected time (42% had none), and estimated needing 6±3 h/wk, regardless of program size. Sixty-seven of 402 core faculty (17%) responded, reported 2±3 h/wk (50% had none), and estimated needing 5±3 h/wk, regardless of program size. ≥85% of APDs and core faculty precepted clinical rotations, gave lectures, evaluated fellows, mentored scholarly work, and participated in recruitment. The majority assisted in fellow remediation. Thirty-four percent (15/44) of APDs and 21% (13/61) of core faculty reported high levels of emotional exhaustion.

CONCLUSIONS

Program leaders estimated minimum necessary program administration times (on the basis of program size) that exceeded the Accreditation Council for Graduate Medical Education requirements. APDs/core faculty contributed substantially to nonclinical training. Thirty-four percent of APDs and 25% of program directors had a high likelihood of burnout.

Point-of-Care Ultrasound Use in Nephrology: A Survey of Nephrology Program Directors, Fellows, and Fellowship Graduates

Rationale & Objective

Adoption of point-of-care ultrasound (POCUS) into nephrology practice has been relatively slow. We surveyed US nephrology program directors, their fellows, and graduates from a single training program regarding current/planned POCUS training, clinical use, and barriers to training and use.

Study Design

Anonymous, online survey.

Setting & Participants

All US nephrology program directors (n=151), their fellows (academic year 2021-2022), and 89/90 graduates (1980-2021) of the Walter Reed Nephrology Program.

Analytical Approach

Descriptive.

Results

46% (69/151) of program directors and 33% (118/361) of their fellows responded. Response rate was 62% (55/89) for Walter Reed graduates. 51% of program directors offered POCUS training, most commonly bedside training in non-POCUS oriented rotations (71%), didactic lectures (68%), and simulation (43%). 46% of fellows reported receiving POCUS training, but of these, many reported not being sufficiently trained/not confident in kidney (56%), bladder (50%), and inferior vena cava assessment (46%). Common barriers to training reported by program directors were not enough trained faculty (78%), themselves not being sufficiently trained (55%), and equipment expense (51%). 64% of program directors and 55% of fellows reported <10% of faculty were able to perform POCUS. 64% of fellows reported having too little POCUS training. 72% of program directors and 77% of graduates felt POCUS should be incorporated into the fellowship curriculum. 59% of fellows and 61% of graduates desired hands-on POCUS training rather than didactic lectures or simulation.

Limitations

Loss of respondents as program directors and fellows progressed through the survey.

Conclusions

Nephrology program directors, fellows, and graduates surveyed want POCUS training incorporated into the fellowship curriculum. No group felt sufficiently trained to confidently perform POCUS, and the major barrier to training was lack of sufficiently trained faculty. This highlights the need to "train the trainers" before POCUS can be fully integrated into fellowship training and regularly used in nephrology practice.

The Perfect Storm: Exam of a Medical Error and Factors Contributing to Its Possible Escalation

OBJECTIVE

After an initial medical misadventure, failure of recognition and continuing factors that could perpetuate the error are examined.

METHODS

A critical evaluation of the continuum of care after the initial error was conducted through chart review and comparison to published standards.

RESULTS

Analysis of the continuum of care after the original error demonstrated numerous system failures that should have alerted the providers to the initial error.

DISCUSSION

Technology, electronic medical records, lack of critical communications, and short cuts have the potential to not recognize patient care safety issues and potential harm.

CONCLUSIONS

Medical errors are multifactorial. Blame casting and accusations are not productive. Critical analysis of systems/processes, current technology, eliminating shortcuts, and critical communications may increase patient safety.