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New software ups the stress level at Cleveland Clinic

STORY BY MICHELLE GENZ (Week of July 15, 2021)
Photo: Longtime Vero Beach neurologist Dr. Leslie Huszar.

Longtime Vero Beach neurologist Dr. Leslie Huszar believes in working past retirement age – keeping the brain stimulated is good, he says.

Living with chronic stress, though, is not good. And when he came out of retirement to go back to work with Cleveland Clinic Indian River Hospital, the stress was epic. Literally.

Cleveland Clinic has used Epic, the electronic health records software, longer than almost any other hospital system. After Cleveland Clinic’s takeover of the Vero hospital in 2019, Epic had to be installed in order for Indian River to link with the rest of the system’s 18 hospitals.

So far, only the outpatient practices and facilities have had to deal with the transition, and among those, Vero Radiology and Primary Care of the Treasure Coast practices have yet to make the change.

Even so, the outpatient go-live has been bumpy to say the least, derailing phone systems for months and provoking untenable frustration levels for staff and physicians. Since the September launch of Epic, more than a dozen physicians and advanced practitioners have resigned, including some of the hospital’s best.

“It’s a chaos,” said Huszar. “They created a chaos.”

Any changeover in corporate software is bound to cause turmoil. But Epic, considered among the best electronic health records system in some regards, is legendary for driving physicians crazy.

Despite that, Cleveland Clinic is hardly alone in its use of Epic. All of the top 20 hospitals on U.S. News Best Hospitals list have Epic EHR. And since Indian River’s partnership with Cleveland Clinic went into effect in 2019, two other top contenders for the merger – Orlando Health and Adventhealth – are switching to Epic.

Cleveland Clinic is more than aware of the software’s potential to cause physician burnout – what Kaiser Health News called “death by a thousand clicks.”

Several years ago, Cleveland Clinic’s IT team set up a response button on Epic for doctors to flag their pain points, as the lingo goes. Cleveland could then try to modify the software to make it less aggravating – “stupid” is the word the input effort used. 

Problems ranged from “alert fatigue” – so many alerts, doctors tune them out – to overflowing in-baskets and no time to clear them.

Doctors also complained of having to click through five to 10 more pages than necessary to get to where they want to go. And they took umbrage at the barrage of questions aimed at maximizing billing and reimbursement.

Leading that cleanup effort was Cleveland Clinic’s system-wide chief medical information officer, Dr. Amy Merlino. Merlino is one of two maternal fetal medicine specialists with privileges at Indian River. But she has not yet seen patients here. Instead, she has been helping with the complications of Epic’s delivery, “engaged at a high level,” the hospital said, with the software’s integration here.

In November 2018, Merlino and others at Cleveland Clinic in Ohio surveyed doctors about whether Epic was providing them the “tools and resources” they needed for their practices.

“Many physicians answered no,” wrote Merlino and another IT executive on an AMA website, explaining the program called Getting Rid of Stupid Stuff, or GROSS, that let physicians flag things they would like to get rid of or change in Epic.

“The message was clear: tell us what is ‘stupid’ in Epic,” Merlino and her co-author wrote. “Share the unnecessary tasks, duplicative documentation, and extra clicks that increase daily workload.”

Nearly 700 suggestions poured in, most within a month.

Had Dr. Huszar been asked to participate, he likely would have worn out the GROSS button.

As for Cleveland Clinic Indian River, a statement acknowledged the challenges in implementation, but added that “there are far more benefits to our patients.”

“We anticipate that issues will decrease and eventually resolve in the future as caregivers become more accustomed to the new system,” the statement went on.

Of all the physicians having to adapt to Epic, Huszar would seem among the least likely to overload. Huszar has been writing computer programs since the 1970s, and marketed his own EHR, MedArc, around 2010.

Huszar’s practice merged with Indian River Medical Center in 2017, around the time of his 70th birthday. When his contract expired in July 2019, Huszar decided to retire.

By then, Cleveland Clinic had taken over but was holding off on significant changes.

Six months later, Huszar changed his mind and rejoined the hospital to ease the burden on the neurology department.

“There’s too many patients,” the office manager told him, when she called to tell him she was at the brink of quitting.

“Don’t quit. I’ll come back and help out,” Huszar told her.

Cleveland Clinic approved his return in January 2020. Cleveland Clinic’s promised year-long grace period of minimal change was over, and, in short order, more and more patients began to appear on Huszar’s schedule, he said.

“They started pushing more and more patients on us. It was not discussed, nobody told me that I need to see more patients. It was more of a gentle progressive push. More and more patients just ended up on the schedule.”

When COVID-19 arrived that March, the fear of the unknown and the need for extreme precautions added to the stress of staff members. Huszar lauds the hospital for handling the pandemic well and keeping infections in the outpatient side largely at bay.

As bad as COVID anxiety seemed, it was nothing like the inescapable aggravation that came in September with the launch of Epic. After only two weeks of training – nearly all of it virtual due to COVID – the new software was in place, with its thousands of niggling differences and laborious new requirements.

Meanwhile, patients continued to pour in, and phones rang off the hook until the whole system went haywire. Soon, furious patients braved COVID and marched into offices demanding to know why they couldn’t get through.

“The staff was pushed beyond its limits,” said Huszar, who speaks reverentially about his key office assistants. “The pandemic was too much, and then they came out with Epic.”

As people left, they were not replaced, Huszar said. That appeared to be hospital policy. “‘We are not replacing; we are in transition. We are in COVID.’ That was just weird,” he said. “You ask for something: We’re missing people. And the response was, Yes, you’re missing people. Totally unresponsive system.”

For the neurology department, that meant functioning for months with only half the usual staff.

Stretched thin, the demands of Epic training and adjustment turned normal office functions into mayhem. “The pressure from inside was continuous on these people and it was not spun in a positive way. It was punitive,” Huszar said. “The tone was, this is what you do and no choice.”

As for physicians, their chief function – seeing patients – suddenly became incidental, Huszar said. Overnight, the new software was consuming his workday. “It took 95 percent of my time to deal with Epic and 5 percent was left for patients.”

“I am a person who is not anxious, who is not nervous,” said Huszar, who did his advanced training at McGill University’s renowned Montreal Neurological Institute, but who grew up in Bucharest, Hungary, amidst oppression and political turmoil. He was granted political asylum in Germany before moving to Canada.

“I have kept my cool for decades and decades until Epic,” he said. “With Epic, I literally had a stress level that was unbelievable.

“I was running through a visit as fast as I could with the Epic so I could spend some time with the patient. And in neurology, if you don’t understand the patient, you don’t have a relationship. You don’t have a treatment plan. You don’t have a diagnosis. I have to understand the patient a little bit more than just the symptoms. So, we had this epic failure.”

At one point, when things were “spiraling out of control,” as Huszar put it, Cleveland Clinic sent in a team of more than 20 from Ohio, one of whom shadowed Huszar to see what problems he was encountering. For Cleveland Clinic, it was one of multiple opportunities for training that were provided, specifically “at-the-elbow” training with physicians.

But some of the problems with Epic amounted to age discrimination, Huszar maintains. Older physicians are more likely to have vision problems and have trouble reading the small font. Others never learned to type. “For the older physicians, you take it slow to make it work. You don’t kill everybody in one week.”

It took Huszar three months of “literally typing double blind” before someone finally showed him the path to enlarge the lettering. “You can change it, but they don’t program that in,” he said.

“I was typing, and I would look at the screen and I couldn’t see what I was typing. It was incredibly stressful. The Russians invading Budapest in 1956 didn’t stress me as much as this software,” he said. “It’s clearly age discrimination. Why can’t you make it big and bold so elderly people can read it?”

Refilling prescriptions is also a nightmare. Huszar said it was easier to cancel the old one and write a whole new one than to go through all the steps for a refill.

And all of it was draining his allotted 15 minutes for the patient, he said. “There is no time left after all that you have to do.”

The pace of the rollout seemed relentless. Stress levels “built up over days and weeks and it was worse and worse and worse,” Huszar said. “And there was no relief. Every single week there was some new thing we had to do.”

Huszar was not shy about letting hospital brass know about the problems he encountered. The most serious, he said, had to do with sessions not timing out properly.

At one point, he called over Dr. Greg Rosencrance, Indian River’s president, to show him what Huszar regarded as a “major security gap” – when a doctor signed into the system, the session did not automatically end if the doctor left without signing out. Another person could come along and access the same session without having to sign in, Huszar told Rosencrance.

“It was very nice of him to come,” Huszar said. “He understood the problems. We had absolutely no issues.”

But when Rosencrance referred the matter to Dr. Lori Posk, a transplant from Cleveland Clinic in Cleveland who serves as Indian River’s EHR and data expert, she seemed to view Huszar’s concern as an unwillingness to adapt to the new system. “You’ve just got to learn Epic,” she told him.

Seven months into the Epic rollout, Huszar decided to leave the hospital a second time. He has not retired, though. He now practices out of a small office near Perkins Medical Supply, along with his favorite staff members who followed him.

“Basically, they forced on us an unworkable EHR system. EHR is a bad idea anyway. All the EHRs on the market are billing oriented, not patient oriented,” Huszar said.

“They check on how much time I spend with the patient, they check on how many characters I type, they check on every little step and they put more and more rules in it, so we see less and less patients.

“On the other hand, Cleveland Clinic comes in and they want to make money and they want you to see more and more patients. Somewhere this paradigm is not going to work.”

In addition to being a stress bomb, the Epic launch is also expensive; Cleveland Clinic Indian River’s switch will cost more than $15 million.

Another $2 million was spent on upgrades for the hospital to be able to handle the new system.

Patient care was the original motivation for EHR, which only became ubiquitous over the past 15 years. The systems were intended to give patients access to their charts, no matter where they went. But that notion quickly ran into a wall called interoperability.

Today, two key entities on Indian River’s outpatient side still don’t have Epic – Vero Radiology and the doctors at the recently acquired Primary Care of the Treasure Coast.

Both are scheduled to get Epic sometime next year. In the meantime, interoperability issues may have had something to do with why a patient was turned away last week after an appointment for a CT scan set up by a Cleveland Clinic doctor’s office never made it to Vero Radiology’s books.

Another patient, Barry Anshell, was referred to a Cleveland Clinic cardiologist by a Cleveland Clinic doctor, part of the former Primary Care of the Treasure Coast group. The referral was sent to the cardiologist on May 21.

“They never called, nor did they return my call and message,” said Anshell. Eight days later, on May 29, Anshell had a heart attack. Doctors found a 99 percent blockage of the right coronary artery and put in a stent.

Anshell is recovering. But his case may not be unique. Recently, as he was leaving the cardiologist’s office after a checkup, Anshell was told staff had to go through 1,000 phone messages backed up since January in order to get current.

“No one is addressing the question of how many people die during a transition (of EHR software) due to not being able to see their physician,” said Huszar. “How will the internist account for the fatigue caused by overwork? How many medical errors will she make?

“The majority of physicians hate their EHR and we are totally ignoring them and we are forcing a system on them that is clearly harmful to patient care on many levels.”