Burnout among physicians, advanced practice providers, registered nurses and other clinicians is an occupational syndrome driven by the realities of our work environment. According to data collected by the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience, over one-half of clinicians experience symptoms of burnout during their careers. In order to tackle burnout, we must recognize it is not primarily a personal resiliency issue, but instead woven into the conditions of work. Personal resilience and attention to one’s individual health are critically important to overcoming burnout, but this is only part of the well-being equation.

About Workplace Efficiency and Well-Being

In order to address the factors that contribute to burnout for our own clinicians, the Johns Hopkins Office of Well-Being is collaborating with partners across Johns Hopkins Medicine to look at systems, processes, and practices that promote the well-being of our clinical faculty and staff. And we are working to mitigate the things that get in the way of professional fulfillment and work life balance.

In addition to our work within Johns Hopkins Medicine, we have joined the Healthcare Professional Well-being Academic Consortium (PWAC), which enables us to collaborate, share interventions and benchmark data with peer institutions across the country. We are also part of the Leadership & Working Group for the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience.

Clinical Practice and Well-Being:
Impacts, Opportunities and Progress

Office of Care Transformation - Priorities to Improve Clinician Experience and Productivity:

• Facilitate evidence-based practice through point-of-care guidance
• Reduce workflow disruptions & deficiencies ("pain points")
• Partner with health plans to ease prior authorization burdens

What is the role of the Office of Care Transformation?

The Office of Care Transformation directs various initiatives that enable care delivery teams to improve clinical effectiveness and efficiency. The mission is to facilitate consistent, evidence-based practice, deliver better patient outcomes at a lower cost, enhance the patient and clinician experience, reduce barriers to care delivery and harmonize practice standards across the system.

What are one or two challenges your team has taken on so far?

Advancing evidence-based imaging across Johns Hopkins.

In 2014, the Center for Medicare and Medicaid Services (CMS) mandated that all ordering clinicians in the emergency medicine and outpatient clinics use an approved clinical decision support, or CDS, tool when ordering advanced imaging. Johns Hopkins Medicine piloted a commercial tool for several years but it added workflow burden for our providers without improving patient care. In response, the care transformation team designed an ambitious initiative to allow Johns Hopkins clinicians to control our standard of care for advanced imaging while minimizing workflow disruptions.

After obtaining the necessary designation by CMS, we engaged a large team of Johns Hopkins clinicians to create evidence-based guidelines embedded in Epic workflow for CMS’ eight priority clinical areas —headache, neck pain, low back pain, shoulder pain, hip pain, coronary artery disease, pulmonary embolism and lung cancer. Clinicians can consult guidelines to aid in management decision making. For direct imaging orders, our solution reduced interruptions during the ordering process from 100% for CT and MRI orders to under 10%. Now, when alerts do fire, they are actionable, substantive, and based on high caliber evidence curated by Johns Hopkins clinicians.

In early 2020 when we rolled out the advanced imaging CDS platform in the ambulatory setting, Johns Hopkins Employer Health Programs (EHP) decided to sunset their utilization management program for imaging and rely on our new system for CT and MRI. Doing so helped eliminate the need for prior authorization requirements for those imaging modalities. This is a big win for EHP members and their care providers. Data so far shows that allowing our clinicians to make decisions in conjunction with high quality, point-of-care guidance delivered by the CDS tool has been an effective utilization management program.

What is the next “pain point” that your team is hoping to address?

The advanced-imaging CDS tool that we described above assists with ordering regardless of a patient’s health plan; however, only EHP has allowed use of the tool to eliminate the need for traditional prior authorization. For other health insurance plans, prior authorization is still required, which can result in delays and denials of necessary care. To address this problem, we partnered with Johns Hopkins Health Plans to understand the requirements of traditional plans as pertains to prior authorization and medical necessity, and we are working to enhance the functionality of our CDS platform to meet the expectations of commercial payor processes in real time. Our goal is to create an end-to-end, real-time prior authorization tool* embedded in Epic, eliminating the inefficient prior authorization process for these imaging studies entirely, and then broaden the scope to all other resource utilization (infusions, procedures, etc.).

Who might that impact and how? When will people notice a difference?

Real-time, automated prior authorization coupled with the Johns Hopkins evidence-based guidelines would improve the care experience for patients, first and foremost. Automating this process will also decrease the burden on providers and generate more time for them to directly care for their patients. Approval denials often result from insufficient information transfer to the health plan rather than a test or treatment being unnecessary, which precipitate the request for a peer-to-peer review in the middle of a busy clinical day. Our hope is to ameliorate these barriers through collaboration with the health plans to harmonize rules, point-of-care feedback to clinicians, and more robust means of transmitting clinical data from Epic to the health plan.

For those who might want to learn more about this project or partner with your team on other efforts, where and how can they learn more?

For additional information, please see The Office of Care Transformation sharepoint site and this paper by Dr. Johnson and colleagues.

*Disclosure Statement: Under a license agreement between AgileMD and the Johns Hopkins University, Dr. Pamela Johnson and the University are entitled to royalty distributions related to the the AgileMD electronic prior authorization platform. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies