USE DATA TO UNLOCK THE POWER OF THE EHR

Program Goals Help clinicians improve their EHR experience and documentation process. Improve response and resolution timelines to ticket requests. Organizational Outcomes 82nd percentile for nursing trust in IT. Collaborative-Verified Best Practices Shared Ownership and Governance Clinician Relationships and Communication Nursing EHR Success What Ochsner Health Did

Program Goals Improve EHR optimization process so that providers will know where requests and approved projects are in the ticketing process. Optimize project management lifecycle to better manage end users’ expectations. Organizational Outcomes 91st percentile for provider agreement that they have a voice in improving the EHR 90th percentile for provider agreement that EHR fixes are made in a timely manner 87th percentile for provider agreement that they know how to request a fix for the EHR Collaborative-Verified Best Practices Shared Ownership and Governance What Southern Illinois Healthcare Did

† Each individual clinician’s responses to the Arch Collaborative EHR Experience Survey regarding core factors such as the EHR’s efficiency, functionality, impact on care, and so on are aggregated into an overall Net EHR Experience Score (NEES), which represents a snapshot of the clinician’s overall satisfaction with the EHR environment at their organization. The NEES is calculated by subtracting the percent of negative user feedback from the percent of positive user feedback. An NEES can range from -100 (all negative feedback) to 100 (all positive feedback). Trust in Organization/IT Leadership Has a Big Effect on Overall Experience Since Arch Collaborative research began in 2017, participating organizations have seen improvements in some areas and declines in others. Despite an overall increase in the average NEES (by 16 points), clinician satisfaction with organizational EHR delivery has decreased by about 4 percentage points. The difference in clinicians’ NEES is dramatic depending on how they rate their organization/IT leadership. On average, there is a difference of 124.1 points in NEES between clinicians who strongly agree their organization/IT leaders deliver well and those who strongly disagree. (The same trend appeared in the Arch Collaborative’s last report on this topic.) This is especially important because clinician burnout is on the rise—fewer clinicians (by about 9 percentage points) report no burnout compared to four years ago. Organizations that have earned high trust from their clinicians are uniquely set up to address burnout. Targeted Organizational Initiatives Drive Significant Satisfaction Improvement Some Collaborative organizations have measured clinician satisfaction both before and after implementing an initiative targeting a specific department or goal. On average, these organizations see significant improvement in NEES. Typical areas of focus for these initiatives include training (e.g., training sprints for specific areas, a full EHR training overhaul) and implementation of new software (EHRs and other supporting technology). In these measurements, the NEES of repeat respondents increases an average of 22 points. In contrast, repeat respondents whose organizations have measured multiple times but not for a specific improvement initiative see an average NEES increase of about 7 points. In addition to seeing an increased NEES, repeat respondents for organizations that conduct pre/post surveys also report higher satisfaction with all three EHR stakeholders. EHR Training, Efficiency, and Ease of Use Most Impact Trust in Organization/IT Leadership A Boruta analysis (an algorithm used to determine what variables are most important to a particular metric) shows that the factors most important to clinicians’ perception of their organization/IT leadership are initial and ongoing EHR training, followed by agreement that the EHR enables efficiency, is easy to learn, and enables quality care. Organizations that focus on making strides in these areas will see higher satisfaction and trust from clinicians. Utilizing Superusers Yields Higher Trust in Organization/IT Leadership One common effort organizations make to improve satisfaction with ongoing training is using EHR superusers. Organizations that leverage superusers deeply embedded in their various departments also see higher ratings for trust in organization/IT leadership. In Arch Collaborative case studies, organizations with standout EHR satisfaction share their keys to success, and there are currently 17 published case studies that relate to superusers. Below are some common recommendations (additional details are included in the Expanded Insights section of the report): Give every department/specialty a superuser Prior technical expertise isn’t necessarily needed Protected or paid time for superusers can be helpful Superusers are best deployed as a peer-to-peer aid resource to teach best practices, support adoption of personalization tools, and more Superusers are key to developing effective EHR education materials Superusers are extremely effective members of EHR governance boards EHR Support of Patient-Centered Care Affects Organization Satisfaction The EHR is supposed to be a tool that helps clinicians deliver high-quality care to patients. When clinicians feel the EHR doesn’t support high-quality, patient-centered care, they are much less likely to be satisfied with their EHR and their organization. A little over 44% of all Collaborative respondents disagree or are indifferent that their EHR enables patient-centered care. The Collaborative organizations that rate highest for agreement that the EHR enables patient-centered care also see much higher agreement (by 20 percentage points) that the organization and IT leadership deliver well, compared to organizations who score lower on this metric. For additional insights on how to make the EHR more patient-centric, see case studies from CentraCare Health , Royal Children’s Hospital Melbourne , and UVA Health . What Is the KLAS Arch Collaborative? The Arch Collaborative is a group of healthcare organizations committed to improving the EHR experience through standardized surveys and benchmarking. To date, over 250 healthcare organizations have surveyed their end users and over 240,000 clinicians have responded. Reports such as this one seek to synthesize the feedback from these clinicians into actionable insights that organizations can use to revolutionize patient care by unlocking the potential of the EHR. To participate in the Arch Collaborative, go to klasresearch.com/arch-collaborative .

For this research, Collaborative member organizations are categorized as one of the following organization types: Community hospital (single hospital, =500 beds) Community health system (multiple facilities, =1,000 beds) Midsize health system (multiple facilities, 1,001–1,500 beds) Large health system (multiple facilities, >1,500 beds) Children’s hospital Academic health system (affiliated with academic setting or university) This report includes data only from those Collaborative member organizations that have completed the executive survey (an in-depth survey specifically for organization leadership). Analysis is based on organization-level data (i.e., scores and responses aggregated for each organization), rather than individual respondent–level data. Non-US health systems and ambulatory care groups are excluded; insights on these types of organizations can be found here and here . Note: Each individual clinician’s responses to the Arch Collaborative EHR Experience Survey regarding core factors such as the EHR’s efficiency, functionality, impact on care, and so on are aggregated into an overall Net EHR Experience Score (NEES), which represents a snapshot of the clinician’s overall satisfaction with the EHR environment at their organization. The NEES is calculated by subtracting the percent of negative user feedback from the percent of positive user feedback. An NEES can range from -100 (all negative feedback) to 100 (all positive feedback). Community Hospitals: Focus on the Factors within Your Control Clinicians in community hospitals report the lowest overall EHR satisfaction. However, the difference in satisfaction between these clinicians and clinicians at the most highly satisfied organizations (community health systems) is not statistically significant when the analysis controls for the EHR in use. This suggests that the EHRs typically used by community hospitals—who often have fewer resources and thus tend to use less expensive, lower-functionality solutions—may account for a good portion of clinicians’ lower satisfaction. This is corroborated by the fact that these hospitals are the least likely to be satisfied with their EHR vendor’s delivery (see stakeholder chart in next section). However, strong EHR satisfaction is still possible for community hospitals, regardless of the EHR in use. Past Arch Collaborative research has shown that only about 33% of the variation in a user’s EHR experience can be attributed to the solution itself, which explains why satisfaction can vary widely across any given vendor’s customer base. Community hospitals can take heart knowing that efforts to improve user mastery (via initial and ongoing EHR training) and foster an organization-wide sense of shared ownership can lead to significant improvements for end users. † When it comes to improving shared ownership, a good place for community hospitals to start might be IT rounding—community hospitals are the least likely to be doing it, yet the 2020 Arch Collaborative Guidebook identifies it as a best practice of EHR governance. †For example, a Collaborative report detailing findings from organizations that have re-measured clinician satisfaction after implementing changes found that improvements to EHR governance and clinician training are both associated with an approximately 10-point increase in NEES. Case Study: IT Rounding at a Community Hospital Peninsula Regional Medical Center has built a nursing governance structure that represents all nursing divisions. But they believe for the structure to fully work, they need regular rounding so that pain points can be identified and resolved. Rounding is done by not only the informatics team but also the executive team and directors. This results in high engagement with the frontline nurses and high nursing EHR satisfaction (89th percentile among Arch Collaborative participants). Midsize Health Systems: Manage Complexity with Strong Training & Governance Midsize health systems have an average Net EHR Experience Score of 25.9, meaning clinicians at these organizations see room for improvement. Factors that complicate EHR satisfaction for these organizations include providing EHR support across multiple locations, maintaining multiple EHR systems, and navigating the layers of communication that may exist between EHR decision-makers and end users. Lack of optimization resources is another barrier reported by some midsize organizations. Compared to peers at other organizations, clinicians at midsize health systems report the lowest satisfaction with their own efforts to learn the EHR and some of the lowest satisfaction with their organizational and IT leadership (see stakeholder chart above). This suggests the need for midsize health systems to focus satisfaction-improvement efforts on driving better user proficiency and higher trust in organizational leadership. Case Study: Improving User Proficiency & Trust at a Midsize Health System Through their Super Thrive program, Legacy Health has increased both end-user proficiency and clinician trust in IT. The program focuses on treating providers well throughout a three-day off-site training course. Legacy Health analyzes Epic Signal and PEP data to identify the providers most in need of help to become more efficient with the EHR. The course provides training and also focuses on clinician wellness through things like yoga sessions and midday walks. Legacy Health was able to fund the program via a grant. Children’s Hospitals: EHR Training Key to Meeting Your Users’ Unique Needs Children’s hospitals are obviously unique from other organizations in their need to document things such as immunizations, well-child visits, and patient growth. However, their EHRs are typically not optimized to support pediatric care, and clinicians often have difficulty finding or documenting needed information. In fact, clinicians at children’s hospitals have the lowest levels of self-reported charting efficiency, with less than one-third of inpatient clinicians closing most of their charting immediately after rounds. This is a particular concern since low charting efficiency is also correlated with higher levels of clinician burnout (see chart in next section about academic health systems). At the same time, one-third of children’s hospitals (as reported by organization executives) see insufficient EHR training or education as their biggest obstacle to higher satisfaction with the EHR. Children’s hospitals are the least likely to focus their initial EHR training on workflows and are also the least likely to offer ongoing training in the form of in-person classes, with resource constraints such as lacking financial support and insufficient trainers and superusers being common concerns. Training best practices outlined in the 2020 Arch Collaborative Guidebook can help children’s hospitals provide the EHR education that pediatric care providers need to serve their unique population. can help children’s hospitals provide the EHR education pediatric care providers need to serve their unique population. Case Study: Improving Ongoing EHR Education at a Children’s Hospital Children’s Hospital and Medical Center ranked in the 85th percentile for provider agreement that ongoing EHR training is sufficient and in the 94th percentile for nurses’ satisfaction with ongoing EHR training. They allow nursing and physician leadership groups to train in the ways that best meet the needs of their clinicians. The organization consistently sets up a training booth every Tuesday at the same time in the same location so providers know when and where to get help. Providers can immediately get answers that help them improve their efficiency. The informaticists who support the nurses are all nurses who still do clinical shifts, so they can match nurse education materials to nurse-specific workflows in each department. Academic Health Systems: Make Clinician Wellness a Top Priority As with children’s hospitals, academic health systems have unique requirements that often result in longer charting times. Because they are being recorded in an educational setting, patient records in academic health systems often require a higher level of detail than may be necessary elsewhere. Additionally, many providers in these settings work as both healthcare providers and teaching faculty, making inefficient charting even more onerous. Particularly worrisome is that clinicians at academic health systems also report some of the highest levels of burnout compared to clinicians at other types of organizations. Case Study: Improving Clinician Wellness at an Academic Health System Clinicians at SUNY Upstate Medical University showed above-average levels of burnout. Their well-being dropped even further after the onset of the COVID-19 pandemic. The organization’s leadership pledged to use their Arch Collaborative survey results to connect with all departments and improve wellbeing. SUNY Upstate analyzed clinicians’ comments and grouped the issues based on how difficult they were to fix. Then they started to take action to fix those issues. The organization created new training paradigms by listening to clinicians’ concerns, and they developed at-the-elbow support. This improved clinicians’ trust in the organization by showing their feedback mattered and would be addressed. Large Health Systems: Increase Communication & Mitigate the Impact of Size-Related Complexity Clinicians at large health systems report the second highest satisfaction with the EHR and also report relatively high satisfaction with all three EHR stakeholders (i.e., the vendor, the provider organization leadership, and the end users themselves). According to executives at large health systems, the challenges these organizations do face with EHR satisfaction often stem from the organization’s size. These include communication challenges (e.g., difficult to efficiently communicate with and engage clinicians across the organization) as well as challenges that arise from having more complex EHR arrangements (e.g., multiple layers of EHR support, multiple EHRs, or multiple configurations of the same EHR). When asked to identify the top factors that contribute to their EHR success, 17% of large health system executives point to having a good EHR system or EHR vendor relationship (see chart in next section). Across the other organization types, only four other organizations cited this particular factor. Case Study: Using Communication to Build a Culture of Empathy & Accountability at a Large Health System Novant Health is in the 94th percentile for provider trust in IT, and this reflects the culture of empathy and personal accountability the organization has built. The leadership at Novant Health regularly asks questions to better understand what they can do to help the clinical teams improve. This inquisitive attitude is tied to their principle of empathy, which includes a focus on physician wellness. Novant Health holds providers accountable to certain metrics, such as closing encounters within three to four days. By evaluating these metrics, Novant Health can identify provider pain points and provide extra assistance or training as needed. The goal is not to punish providers but rather to ensure efficient practices and high quality. Community Health Systems: Continuous Improvement Is the Goal With an average Net EHR Experience Score of 40.3, community health systems have the highest EHR satisfaction among all organization types and lead out in many of the key metrics examined in this report, including satisfaction with EHR stakeholders, IT rounding, and charting efficiency. Interviewed executives at community health systems commonly attribute their success to having clinician-led governance structures and fast internal support for the EHR. Community health systems have the opportunity to capitalize on the successful structures already in place and continue to improve the EHR experience for their clinicians. Case Study: Continuous Improvement Is the Goal at High-Performing Community Health System Guthrie Clinic has been a consistent top performer in clinician EHR satisfaction (their Net EHR Experience Score is in the 94th percentile). However, exit interviews at the organization still showed that EHR frustration was a leading factor in physician turnover. To combat this, Guthrie Clinic has worked to improve their EHR training programs, including providing repeat trainings to allow information to sink in. The dedicated training programs have enhanced relationships with providers, who are now more comfortable and empowered to reach out for help. Over a two-year period, the organization has seen a 24–30 percentage point increase in clinician agreement that the EHR training is sufficient. What Is the KLAS Arch Collaborative? The Arch Collaborative is a group of healthcare organizations committed to improving the EHR experience through standardized surveys and benchmarking. To date, over 250 healthcare organizations have surveyed their end users and over 240,000 clinicians have responded. Impact reports such as this one seek to synthesize the feedback from these clinicians into actionable insights that organizations can use to revolutionize patient care by unlocking the potential of the EHR. To participate in the Arch Collaborative, go to klasresearch.com/arch-collaborative .

Few Organizations Excel with Reliability, None with Response Time The digitalization of healthcare has been ongoing for some time, yet some aspects foundational to success in such an environment have not been addressed sufficiently to allow healthcare’s most valuable resources—clinicians—to excel. Overall, almost half (44%) of clinicians do not agree that their EHR is fast enough, and no Collaborative organizations have over 90% of respondents who agree the EHR has the response time they expect (see chart to the right). In terms of system reliability, 23% of clinicians do not agree their EHR is available when needed. Of the over 270 organizations that have participated in the Collaborative, only 18 have more than 90% of respondents reporting few or no difficulties with system availability. Response Time & Reliability Issues Compromising Patient Safety Across the Collaborative, over half (57%) of clinicians agree their EHR enables patient safety, and satisfaction with system response time and reliability factor into these clinicians’ perceptions. Clinicians who strongly agree their system is reliable are much more likely to also agree the EHR enables patient safety. This trend is even more significant when it comes to system response time. “[Our EHR] is extremely slow. It takes 5–10 minutes to log on to a computer, and when we are providing direct care to sick people, that time really matters. There are numerous alerts that pop up all the time that are not helpful at all—not at all. These alerts are repetitive, inappropriate, immediately dismissible, and just another button to push when I am already busy, I have been waiting for 10 minutes for the EHR to load, and my patient who just had major surgery is screaming in pain.” —Nurse at a large health system Poor Response Time & Reliability Are Barriers to Overall EHR Satisfaction Organizations with stronger clinician agreement that their EHR has the expected speed or reliability have significantly higher EHR satisfaction than organizations that lack this agreement—for both metrics, the gap between the two groups’ Net EHR Experience Scores is more than 100 points. Further, response time and reliability are not a common concern for the Collaborative organizations with the highest overall EHR satisfaction—almost all organizations in the 80th percentile for Net EHR Experience Score have fewer than 40% of their clinicians identify response time as an issue and fewer than 20% of clinicians identify reliability as an issue. Note: Each individual clinician’s responses to the Arch Collaborative EHR Experience Survey regarding core factors such as the EHR’s efficiency, functionality, impact on care, and so on are aggregated into an overall Net EHR Experience Score (NEES), which represents a snapshot of the clinician’s overall satisfaction with the EHR environment at their organization. The NEES is calculated by subtracting the percent of negative user feedback from the percent of positive user feedback. An NEES can range from -100 (all negative feedback) to 100 (all positive feedback). Reliability Can Still Be a Problem for Organizations with Very Little Downtime Clinician perceptions of the EHR’s reliability don’t depend solely on how often the system is completely down. If the EHR drags, even clinicians at organizations that experience very little downtime can report poor system reliability. In fact, of the various EHR aspects rated by clinicians in the Collaborative survey (e.g., external integration, functionality, EHR training, etc.), response time is the one most closely correlated with clinician perceptions of the system’s reliability. This is especially significant given that response time is also one of the aspects with which clinicians across the Collaborative report the lowest satisfaction. If an organization is experiencing high uptime but low satisfaction with system reliability, they may need to focus on increasing the system’s speed. Challenges with Response Time & Reliability Often Tied to Broader Infrastructure Issues beyond the EHR A plurality of clinicians who report dissatisfaction with their EHR’s response time or reliability also mention issues with their computer, monitors, laptop, workstation, or other IT equipment. Compared to clinicians who strongly agree they have the response time/reliability they expect, clinicians who strongly disagree are 53% more likely to organically mention hardware issues and 67% more likely to report slow login times. For example, one nurse respondent indicated that it takes 60 seconds for the system to load after a password is entered. Given the frequency with which clinicians must log in during a shift, this nurse spends almost 10% of the workday waiting for the EHR to load. Next Steps: Response Time & Reliability Self-Examination Your organization may find the following questions to be a helpful starting point as you work to improve system response time and reliability: Do we comply with our vendor’s infrastructure recommendations? Do we adhere to a hardware inventory schedule? How does the Wi-Fi perform in our clinics and hospitals? Do our single sign-on and EHR vendors work together to improve the user experience? Do we know how long it takes a user to get into the system? Do we know how long it takes to shift between windows or tabs in the EHR? Are we on the latest version of our vendor’s EHR? What Is the KLAS Arch Collaborative? The Arch Collaborative is a group of healthcare organizations committed to improving the EHR experience through standardized surveys and benchmarking. To date, over 250 healthcare organizations have surveyed their end users and over 240,000 clinicians have responded. Impact reports such as this one seek to synthesize the feedback from these clinicians into actionable insights that organizations can use to revolutionize patient care by unlocking the potential of the EHR. To participate in the Arch Collaborative, go to klasresearch.com/arch-collaborative .

Note: Each individual clinician’s responses to the Arch Collaborative EHR Experience Survey regarding core factors such as the EHR’s efficiency, functionality, impact on care, and so on are aggregated into an overall Net EHR Experience Score (NEES), which represents a snapshot of the clinician’s overall satisfaction with the EHR environment at their organization. The NEES is calculated by subtracting the percent of negative user feedback from the percent of positive user feedback. An NEES can range from -100 (all negative feedback) to 100 (all positive feedback). Note: For simplicity, the term “global” will be used throughout the report to refer to the healthcare organizations and clinicians whose feedback is being analyzed in this study. Trust in IT & Organization Leadership Is Crucial to EHR Satisfaction Across Collaborative members and regardless of geographic location, Collaborative data has shown that a supportive IT structure is the factor most associated with strong EHR satisfaction. Specifically at global health systems, clinicians who strongly agree that their organization supports the EHR well are 132 times more likely to be satisfied with the EHR than those who strongly disagree. Those who disagree or strongly disagree that their organization provides sufficient support for the EHR account for 26% of all respondents from global health systems. Organizations that have lower levels of trust between clinicians and organization and IT leadership may wonder what they can do to improve. King Faisal Specialist Hospital & Research Centre in Saudi Arabia hosted a Collaborative webinar in which they shared how they create a high-trust environment by supporting their end users and engaging clinicians in EHR governance. Key points from the webinar include: Engage clinical participants in EHR governance Deploy superusers or clinician champions who share the same clinical background as end users and can pass challenges experienced by users and ideas for enhancement on to governance committees Include representation from all departments on the clinician informatics team Standardize new-hire education; use ongoing EHR education to focus on training specific to the end user’s specialty and needs Engage end users in creating EHR education Analyze end-user feedback and present it to leadership to gain buy-in, then act on the areas needing improvement EHR Training Represents Significant Opportunity for Global Health Systems Globally, just 11% of clinicians strongly agree that their ongoing EHR education is sufficient, and almost two-thirds would like additional training. The gap is particularly evident in Europe, where a majority of organizations report below average satisfaction with EHR training (Collaborative members in Europe are located in England, Ireland, Italy, and the Netherlands). Training represents a significant opportunity for global organizations to improve the overall EHR experience since clinicians at these organizations who strongly agree that their ongoing training is sufficient are 25 times more likely to be satisfied with their EHR than those who strongly disagree. Evidence-based practices for building successful initial and ongoing EHR training can be found in the Collaborative’s Clinician Training: 2021 Update report . Some highlights from that report are shared below: Self-directed eLearning is not as effective as other types of training Clinician satisfaction with training is higher when the training lasts at least an hour On average, clinicians who strongly agree that their initial or ongoing EHR training prepared them well to use the system have Net EHR Experience Scores significantly higher than clinicians who strongly disagree that their training was sufficient Clinician Burnout Is a Global Issue 26% of clinicians in this global research report at least some symptoms of burnout. Compared to other clinical roles, nurses and allied health professionals are the most likely to be experiencing burnout and may need extra consideration as organizations look for opportunities to address the challenges that drive burnout. What can be done to alleviate symptoms of burnout? Collaborative data provides insights into several factors that are strongly correlated with burnout. The data below is not all specific to global respondents but is still useful in identifying potential areas of focus: Ongoing training: Clinicians who strongly disagree that their ongoing training is sufficient are 3.5 times more likely to report feeling burned out. Trust in organization/IT leadership: Clinicians who report strong trust in their organization leadership and IT are 14% less likely to report feeling burned out. Charting efficiency: Burnout can be significantly impacted by the amount of time a clinician spends charting. Globally, clinicians with a highly efficient chart-closure rate (i.e., they complete >66% of charts the same day) are less likely to report burnout (see chart). Efficient charting also leads to higher EHR satisfaction in both inpatient and outpatient environments. Global organizations may benefit from reviewing the Collaborative report on Immediate Chart-Closure Rates for best practices around charting efficiency. What Is the KLAS Arch Collaborative? The Arch Collaborative is a group of healthcare organizations committed to improving the EHR experience through standardized surveys and benchmarking. To date, over 250 healthcare organizations have surveyed their end users and over 240,000 clinicians have responded. Impact reports such as this one seek to synthesize the feedback from these clinicians into actionable insights that organizations can use to revolutionize patient care by unlocking the potential of the EHR. To participate in the Arch Collaborative, go to klasresearch.com/arch-collaborative .

Program Goals Optimize EHR education for all Epic users at Baylor Scott & White Health Make educational resources readily available for quick access Help ease learning curves as quarterly Epic upgrades arise Organizational Outcomes uPerform users rate ongoing training 11 percentage points higher than nonusers uPerform users’ Net EHR Experience Score is 12.9 points higher than nonusers’ score Collaborative-Verified Best Practices Ongoing EHR Education Keys to Success Stand up a training team that creates training content Deploy content in different forms that are brief and direct so that end users can easily and quickly understand and adapt to them Use different formats for onboarding and ongoing EHR education Ensure that education is aligned with relevant clinical workflows for upgrades Allow clinician end users to learn on the job when they need information What Baylor Scott and White Health Did

Program Goals Help clinicians improve their EHR experience and efficiency by training with techniques relevant to physicians. Reduce or eliminate EHR-related burnout Organizational Outcomes 90th percentile in agreement that ongoing training is sufficient 96th percentile in provider EHR satisfaction 99th percentile in using personalization tools Successful optimization program saves providers three to five minutes per hour in charting Collaborative-Verified Best Practices Workflow-based training Ongoing EHR education Case studies and physician-led courses to enhance training quality What Kaiser Permanente Southern California Did

At the beginning of 2020, KLAS began asking clinicians in our Arch Collaborative survey how likely they are to leave their organization in the next two years. More than 59,000 clinicians have responded to date. Using this data, we hope to shed light on which clinicians are likely to leave and what related factors healthcare organizations can influence to improve clinician retention and resolve clinicians’ concerns. This report focuses on physicians, advanced practice providers (APPs), nurses, and allied health professionals; physician residents and fellows are excluded since they are generally not expected to stay at one organization long term. An Overall View: What Clinicians Are Most Likely to Leave? The percentage of clinicians reporting they are likely to leave their organization has fluctuated somewhat over the two years the question has been asked; it was highest overall in the Q3 of 2021. Compared to other clinical backgrounds, nurses are the most likely to have plans to leave in the next year. In Q1 of 2021, 26% of surveyed nurses reported plans to leave (the period with the highest reported percentage). This spike could be attributable to a number of factors, including the increase in acute COVID-19 cases at the time, more prevalent cultural and political antagonism toward healthcare, and the resulting strain on healthcare workers. Clinician burnout similarly grew in Q1 of 2021. Beyond clinical background, the Arch Collaborative also asks about other factors such as burnout, training, and various aspects of the EHR experience. By breaking clinicians into groups based on their answers to these and other survey questions, the Arch Collaborative has identified the clinician cohorts most likely to leave. The rest of this report takes a closer look at each of these cohorts, including providing resources and insights for organizations trying to improve the experience of these highly vulnerable clinicians. Some of the most actionable factors are discussed in this Executive Insights section; see the Expanded Insights section of the full report for insights on additional factors. A Deeper Dive on Actionable Factors That Contribute to a Clinician’s Likelihood of Leaving All Levels of Burnout Associated with Attrition Risk; When Completely Burned Out, Clinicians More Likely to Leave Than Stay Burnout is the indicator most strongly correlated with how likely clinicians are to leave their organization in the next two years. KLAS’ 2021 Clinician Burnout report found a link between burnout and attrition, especially among nurses. This report has identified that as burnout increases, so does likelihood to leave—suggesting that addressing the problems of burned out clinicians could help reduce turnover. Attrition could also be lowered by preventing clinicians from becoming severely burned out in the first place—while clinicians who are completely burned out are most likely to leave, attrition likelihood grows rapidly beginning with those who report definite symptoms of burnout. This, coupled with the sheer number of clinicians who report they are under stress or definitely burning out, suggests that there is real opportunity to reduce turnover by addressing burnout in early stages and preventing it from getting worse. To learn more about how other healthcare organizations are tackling burnout, see the case studies from UW Health (on their strategy for using virtual scribes to help reduce burnout) and Spectrum Health (on how they prioritize clinician wellness). (For more insights on burnout and other contributing factors, see KLAS’ reports on COVID-19 related burnout and nurse burnout .) Clinicians Likely to Leave Often Cite Organization-Level Problems as Contributors to Burnout Clinicians planning to leave are twice as likely to report a lack of shared values with organization leadership as a contributor to burnout (compared to those who are not likely to leave—35% versus 17%). Other factors with large gaps include lack of effective teamwork (38% to 23%), chaotic work environment (47% to 35%), and lack of autonomy in the job (23% to 12%). The common attribute of these contributors, along with several other leading responses, is that they can all be influenced by the organization’s governance structure. KLAS has previously reported that clinician perceptions of their organization are correlated with their level of burnout (see also the section below on trust in IT). Low Trust in Organization and IT Leadership Correlated with Likelihood to Leave Among clinicians who strongly disagree their organization has implemented, trained on, and supported the EHR well, more than one-third say they are likely to leave their organization in the next two years—a larger proportion than any other clinician cohort. In collaboration with several healthcare leaders, the Arch Collaborative published an article in the Journal of the American Medical Informatics Association (JAMIA), which shared that agreement that the organization delivers well is also correlated with lower burnout. Measures aimed at increasing clinician trust in the organization could have a positive effect on burnout and reduce clinicians’ desire to leave the organization. For instance, establishing a system of two-way communication between end users and the organization/IT leadership can help improve clinicians’ perception of their organization. More insights on how to achieve this can be found in the Clinician Trust in Organization/IT Leadership report. Some Collaborative organizations have also shared the strategies they used to improve clinician trust in the organization— demonstrating expertise , establishing a reliable support structure , and improving communication . Satisfaction with other EHR stakeholders (vendors and end users themselves) is similarly correlated with likelihood of leaving—see additional details in the Expanded Insights section of the full report. Users Who Are Satisfied with the EHR Are More Likely to Stay Overall EHR satisfaction † is also correlated with the likelihood that a clinician is planning to leave their organization. Those who are very dissatisfied with the EHR have almost three times the proportion reporting they are likely to leave compared to clinicians who are very satisfied with the EHR. When clinicians feel the EHR is a help rather than a hindrance, they are more likely to want to stay at their organization. Healthcare leaders should focus on improving the areas of EHR satisfaction with the most room to improve. At a foundational level, organizations need to ensure their EHR has solid reliability (i.e., uptime) and quick response time, as these issues can overshadow even an otherwise good EHR experience. Additional insights on EHR satisfaction can be found in a number of other Arch Collaborative reports including the 2020 Arch Collaborative Guidebook and The Science of Improving the EHR Experience . Less Afterhours Charting Can Improve the Clinician Experience One strategy to improve EHR satisfaction is to reduce providers’ and allied health professionals’ afterhours charting time. While some clinicians chart after hours by choice, those who are efficient enough in the EHR to complete most of their charting during business hours tend to be more satisfied with the EHR and less burned out. Charting efficiency can also be improved by implementing personalizations that are the most appropriate for each clinician’s workflow. More details can be found in the Immediate Chart-Closure Rates report. Unproductive or Duplicative Charting by Nurses Is Correlated with Attrition 30% of nurses who report spending five or more hours doing duplicative or unproductive charting per week also say they are likely to leave their organization in the next two years. Reducing charting burden can have a dramatic impact on nurse satisfaction. After Sutter Health, an Arch Collaborative participant, optimized their nursing workflows and drastically reduced nurse charting requirements, they saw a 44.7% increase in their Net EHR Experience Score (see their case study for more details). Tailoring Training to Specific Workflows Could Help Lower Turnover Just because a clinician has learned the EHR’s functionality does not mean they will be successful or satisfied with the EHR. One of the best practices found in Arch Collaborative research is that case-based (or workflow-specific) training—where clinicians learn to use the EHR in the context of their specific role—is highly effective. Clinicians who strongly disagree their training was specific to their workflow are more than twice as likely to report planning to leave their organization compared to those who strongly agree training matched their workflows. Additional insights can be found in the Expanded Insights section of the Clinician Training 2021 report, which dives deeper into workflow-specific training. Among clinicians who are likely to leave, 49% agree or strongly agree EHR training matched their workflows, compared to 61% of clinicians not likely to leave. Updating training programs to be more tailored to clinician workflows could help decrease attrition rates. What Is the KLAS Arch Collaborative? The Arch Collaborative is a group of healthcare organizations committed to improving the EHR experience through standardized surveys and benchmarking. To date, over 250 healthcare organizations have surveyed their end users and over 240,000 clinicians have responded. Impact reports such as this one seek to synthesize the feedback from these clinicians into actionable insights that organizations can use to revolutionize patient care by unlocking the potential of the EHR. To participate in the Arch Collaborative, go to klasresearch.com/arch-collaborative .

Program Goals Involve clinicians in informatics initiatives for a clinical lens on all project enhancements Create a culture where clinicians are taking the EHR’s success at their organization into their own hands Organizational Outcomes 97th percentile for agreement that the EHR enables patient-centered care 98th percentile for agreement that the organization delivers well 97th percentile for agreement that the vendor delivers well Collaborative-Verified Best Practices Focusing IT/informatics efforts on making changes for clinicians instead of imposing changes on them Building teamwork and alignment by encouraging clinical leaders and IT/informatics groups to share their goals with each other What Royal Children's Hospital Did

Program Goals Reduce burnout and time spent in the EHR for a group of 100 primary and specialty care physicians Organizational Outcomes 98% of surveyed participants would recommend a virtual scribe to their colleagues. 88% of surveyed participants felt their after-hours documentation was reduced. 28% increase in agreement that ongoing EHR education is helpful among AQuity users between measurements. Keys to Success Establishing primary and secondary virtual scribes allows for physicians to always have a scribe when needed during a patient visit. Building relationships is key to the long-term success of a virtual scribe program. What University of Wisconsin Health and AQuity Did Some of the top contributors to burnout are found to be related to the administrative burden inherent with the electronic health record. UW Health decided to add virtual scribes to a group of 100 primary and specialty care physicians to decrease burnout levels, improve documentation, and ultimately, improve how clinicians engage with patients during a care visit. Deployment of the scribe program focused on 100 clinicians to validate the efficacy of the program and to demonstrate the strength (or weakness) of virtual scribes over other documentation resources at UW Health. UW Health selected primary and specialty care physicians to receive the virtual scribes and initially required that they add one patient/session to fund the virtual scribe effort and other wellness initiatives at UW Health. This request was later removed, but over half of the participants indicated that it was easy for them to add the extra session with the help of a virtual scribe. Providers in the program are matched with a scribe from AQuity based on specialty, work schedule, and workflow style preferences. Providers only work with one to two different scribes per month. This consistency allows UW Health providers to develop a relationship with their scribes and optimize workflow efficiencies. While turnover is often a concern (as many scribes are pre-med students) AQuity’s virtual model allows for scribes to continue working in a variety of circumstances and the approach to have primary and secondary scribes creates a safety net so physicians never have to worry about a scribe not knowing the specialty or unique workflows of the provider. Primary scribes typically work with a provider for 90% of their encounters, with a secondary scribe covering when the primary scribe takes a day off. Scribes are used for the majority of patient encounters, leaving little to be done after a clinician is finished seeing a patient to complete and sign off documents. Virtual scribes also help with pre-charting and the in-basket messages, leading to much lower total time spent in the EHR. In addition to measuring the success of the program with the Arch Collaborative, UW Health surveyed participants regarding their symptoms of burnout and satisfaction with their virtual scribes and measured how clinicians perceived their after-hours work time change. Even with the measurements being conducted during COVID-19, a vast majority of those surveyed reported reduced burnout symptoms, 88% felt satisfied with their virtual scribe and felt their documentation burdens had been decreased during clinic hours and 88% felt their after-hours documentation was reduced. 98% of surveyed participants would recommend a virtual scribe to their colleagues. More than half of the scribe supported physicians indicated it was easy for them to add extra patients per shift due to their scribe support.

Clinicians in the Most Complex Arrangements More Likely to Experience Stress or Burnout from EHR Issues More than one-third (36%) of providers who have the most complicated work arrangements and also report symptoms of burnout cite the EHR or other IT issues as factors in their burnout. In contrast, these factors are cited by only 20% of burned out providers with simpler work arrangements. Similar patterns appear among nurses and allied health professionals. Providers in the Most Complex Arrangements Spend More Non-Business Hours Charting Nearly 80% of providers who have the simplest work arrangements spend less than 5 hours per week charting outside of normal business hours. In contrast, that number is only 57% for those with the most complex arrangements. More than one-third of this group spends 6–15 hours per week on afterhours charting. Reasons for EHR Dissatisfaction in Complex Arrangements Different EHR systems across locations “The fact that the two locations are not integrated and are still on two different systems is a huge inconvenience for providers who are seeing patients in both places. It is also dangerous because it complicates patient care.” —Nurse practitioner, academic health system (2 locations, acute care & ambulatory) Different system configurations  (when using the same EHR) “We are using one system, but the different environments do not communicate with each other, so it is hard to find the information we need, and that can lead to miscommunication.” —Physician, academic health system (4 locations, acute care & ambulatory) Workflows not streamlined for multi-setting or multi-location providers “Portability is a problem for providers who practice in multiple locations. There are no adjustments in the system to improve workflows for anyone who isn’t a PCP doing simple work in one location.” —Physician, academic health system (3 locations, acute care & ambulatory) Varied levels of EHR support across settings and locations “The boots-on-the-ground clinical engineering people and IT support vary from facility to facility. [Location A] has a good response. [Location B] is decent. [Location C] is below average.” —Physician, large health system (4 locations, acute care & ambulatory) How to Achieve Strong EHR Satisfaction in Complex Work Arrangements Providers who work in multiple settings or locations aren’t all struggling with the EHR. 30% of those in the highest-complexity group (those working in acute care and other settings across multiple locations) are considered highly satisfied with their EHR experience. How can organizations improve the EHR satisfaction for all providers in complex work arrangements? 1. Provide training that targets workflow and location differences In the Arch Collaborative survey, participants are asked to share the top three things they want addressed to improve their EHR experience. The need for better or more EHR training is cited about 27% more often by dissatisfied users in the most complex arrangements compared to those with simpler work arrangements. Vidant Health is an example of how to provide successful EHR training. They specifically target clinicians who work in multiple locations by requiring them to receive video instruction specific to their workflows before the standard classes. Clinicians also attend a three-hour, setting-specific class (inpatient, ambulatory, or ED), and those who work in multiple settings are required to go to each related class. 2. Encourage use of personalization tools Clinicians that work in multiple settings see bigger satisfaction gains from use of personalization tools than those that work in a single setting. Personalization tools are cited as a reason for high EHR satisfaction about four times as often by clinicians in complex arrangements compared to clinicians with simpler work arrangements. Kaiser Permanente Northwest has developed their own method to improve personalization use. They noticed that some EHR users find it more difficult to invest time and energy on their own into learning and using personalization tools, and these users are typically the ones who struggle with EHR efficiency. Kaiser Permanente Northwest built tools tailored to all providers in a given department, with the philosophy that similar providers will benefit from similar tools, improving efficiency and workflows across the department. 3. Ensure the voices of clinicians in complex arrangements are heard when it comes to workflow differences Different providers have different support and communication needs, and improving the EHR requires input from diverse clinical backgrounds and settings. This is especially true with providers who work in multiple settings as the effects of setting-specific issues will be compounded for them. One provider from an academic health system illustrated this concept, explaining, “Too many of the doctors that assist the IT folks don’t actually practice in locations or care settings that well represent the others. They are not good representatives of the masses. . . . Rarely do they deliver any resolution or true improvement.” MemorialCare designed their training programs to cover multiple service lines for clinicians of various backgrounds. In 1997, they established their best-practice team, which includes members from multiple hospitals, physician groups, and offices who come together to share diverse ideas for enhancing care and improving patient safety. This team obtains feedback from a variety of clinicians so every service line has a voice in the EHR changes. As an example, the critical care team recently updated over 100 order sets by removing benzodiazepine in response to the FDA’s warning about it increasing fall risks for elderly patients. Among Collaborative organizations, MemorialCare ranks in the 99th percentile for provider EHR efficiency and in the 97th percentile for the EHR’s support of quality care. What Is the KLAS Arch Collaborative? The Arch Collaborative is a group of healthcare organizations committed to improving the EHR experience through standardized surveys and benchmarking. To date, over 250 healthcare organizations have surveyed their end users and over 240,000 clinicians have responded. Impact reports such as this one seek to synthesize the feedback from these clinicians into actionable insights that organizations can use to revolutionize patient care by unlocking the potential of the EHR. To participate in the Arch Collaborative, go to klasresearch.com/arch-collaborative .