Read our interview with the authors of a brilliant recent paper titled “Digital Minimalism — An Rx for Clinician Burnout” published in The New England Journal of Medicine – Nina Singh, Katharine Lawrence, Christine Sinsky and Devin Mann.
Why do we need a new way of thinking around digitization of healthcare?
- Thus far, healthcare’s digitization has been haphazard. In an ideal world, electronic health records (EHRs) and other digital health tools would have been designed with the goal of helping clinicians best serve their patients. In reality, digitization of healthcare was characterized by a maximalist approach that aimed to fulfill the wish lists of not only clinicians, but also billers, insurance companies, compliance departments, and other parties. Unfortunately, while many stakeholders benefit from the maximalist solutions that were created, clinicians bear the burden of ever-increasing data entry and other new digital work.
- This has led to patient EHR records that are on average half the length of Hamlet (Shakespeare’s longest play), with ~50% of the documentation being duplicated from prior notes. It has also led to note bloat with U.S. notes being 4 times longer on average than other countries. And it has contributed to skyrocketing levels of burnout among physicians who find themselves spending the majority of their time serving their computers rather than nurturing face-to-face relationships with their patients.
What is digital minimalism?
- Digital minimalism is a philosophy of technology use that argues for a more balanced approach to how we use technology. The term was originally coined by computer science professor Cal Newport, who wrote the book Digital Minimalism.
- Rather than categorically rejecting digital technology or endorsing the current maximalist approach, digital minimalism carefully considers whether and how each digital technology should be used. It has three tenets – clutter is costly, optimization is vital, and intentionality is satisfying.
How can digital minimalism help?
- Digital minimalism can help by providing an alternative guiding philosophy for healthcare’s relationship with technology. It argues that instead of accepting new technological tools because they may provide some value to some stakeholder, healthcare should consider whether this new tool supports the central goal of caring for patients. If so, this should not lead to automatic adoption, but should instead lead to a deeper discussion on how exactly the tool should be deployed.
- For example, in the case of a new clinical decision support alert, how should it be designed, when should it fire, and for whom? How can this be used so that value is maximized while provider burden is minimized? How can we ensure a “manageable cockpit” for physicians? (https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2674872)
- In the case of an entirely new technology like generative AI (e.g. ChatGPT), rather than viewing it as a hammer and looking for nails, we can use digital minimalism to guide if, when, where, and how it should be deployed.
- Holding ourselves to high standards using the guiding tenets of digital minimalism (clutter is costly, optimization is vital, and intentionality is satisfying) could help improve the experience of using digital technology for all healthcare workers.
What work is going on to adopt digital minimalism in health systems?
- Although health systems are not formally “adopting digital minimalism” (though we hope our recent NEJM article will prompt them to do so), there have been many previous efforts that capture the spirit of digital minimalism. We highlight a couple below:
- For example, Hawaii Pacific Health started a “Getting Rid of Stupid Stuff” Program, which asked clinicians what unnecessary and burdensome documentation requirements existed in the EHR and then removed them whenever possible (86% of items could be changed).
- NYU Langone Health assessed hospitalist workflows for managing common conditions (e.g. heart failure) and created dashboards that put all of the relevant information (e.g. inputs and outputs, medications, echocardiogram results) in one place to streamline the number of clicks required by clinicians.
- UCHealth in Colorado conducted 2-week work “sprints” for various clinical units, to understand their needs and tailor the EHR and EHR workflow accordingly. This effort improved clinician perceptions of quality of care, increased satisfaction with the EHR, and reduced time spent charting.
- Atrius Health in Boston has conducted a 5 year initiative to reduce the burden of the EHR inbox. A step-by-step “how to” guide is here (https://www.ama-assn.org/system/files/system-level-approach-to-ehr-inbox-reduction.pdf), along with a brief “Inbox Reduction Checklist” here (https://www.ama-assn.org/system/files/ehr-inbox-reduction-checklist.pdf).
Where can people turn to learn more – and what can people do if they want to push for digital minimalism in their context?
- To learn more, people can turn to: Cal Newport’s book Digital Minimalism, our NEJM article about digital minimalism in medicine (https://www.nejm.org/doi/full/10.1056/NEJMp2215297), AMA resources to manage digital work more effectively (e.g. https://www.ama-assn.org/practice-management/ama-steps-forward/taming-ehr-playbook), and academic work by researchers studying the impact of digital technology on health care (e.g. https://med.nyu.edu/research/healthcare-innovation-bridging-research-informatics-design-lab/)
- Pushing for digital minimalism in healthcare looks different depending on your role.
- Clinicians can rethink their workflows and set boundaries. Developing clear boundaries with their healthcare teams about appropriate use of each mode of communication (secure chat messages, inbasket messages, etc.) could lead to more periods of uninterrupted work and higher-quality patient care.
- Health system leaders should carefully consider whether each new digital tool is needed at all or whether non-technological solutions (e.g. workflow changes, team composition and role shifts, changing expectations, internal policy changes—see Deimplementation Checklist here: https://www.ama-assn.org/system/files/ama-steps-forward-de-implementation-checklist.pdf) can better solve the issues they are facing. If a digital tool is the best solution, leaders should work with clinicians to implement digital tools in ways that are not overly disruptive of clinician workflows and allow them to focus on what they do best – caring for patients.
- Policymakers can make sure that any new documentation requirements created are truly necessary, and consider whether the time and energy that would be needed for that additional documentation would actually be better utilized for direct patient care (e.g. using a metric like Time Needed to Treat (TNT)). They can also ensure appropriate reimbursement for digital work. In the US in 2021 the Center for Medicaid and Medicare Services reduced documentation requirements to justify level of service determinations (i.e. documentation can be focused more on clinical needs; less documentation is required strictly for billing purposes.) https://www.ama-assn.org/system/files/2020-04/e-m-office-visit-changes.pdf
- Technology developers can design digital tools with the goal of maximizing the utility:burden ratio. They should keep clinicians front and center throughout the design process, and continue incorporating their feedback even after deployment.
A big thanks to Nina and co-authors for this interesting and forward-thinking work!