The Centre for Addiction and Mental Health in Toronto is Canada’s largest mental health hospital and one of the world’s leading research centres. It was also the first Canadian centre to adopt Cerner. That was back in 2014. It’s been a bumpy ride in terms of how it has affected physician wellness but a robust strategy that includes giving physicians a voice at the leadership table has made a difference. CAMH’s Chief Health Information Officer Dr. Tania Tajirian shared the hospital’s 10-year journey with VPSA members recently.

“We’ve been on a fantastic journey of digital innovation,” said Dr. Tajirian, who has been a hospitalist at CAMH for 18 years and its CHIO/CMIO since 2018. “A lovely part of my job is that daily integration of tech and the improvement in the quality of care.”

Dr. Tajirian described the discrepancy between CAMH winning many awards for its digital health work, while, five years into Cerner implementation, CAMH’s physicians “hated” electronic health records. There was a disconnect between the integration of their daily work with the tech due to documentation burden.

“It’s not just the time you’re spending as clinicians documenting, it’s also the time you’re spending retrieving information,” she said. “Ten years into our Cerner implementation, the ability to find the right information at the right time is quite cumbersome.”

She strongly believes we need to demand better EHR products from the vendors—codesigning and limiting low-value documentation. She also recommends tracking measures on the back end to understand pain points to help tackle the issues.

Steps to identify and mitigate issues

When she was appointed CAMH’s CMIO in 2018, Dr. Tajirian undertook a literature review to understand what good organizations do to implement EHRs properly. A survey was administered in 2019 to identify the extent of burnout and the contribution of Cerner to this. Dr. Tajirian also wanted to identify the significant contributors to Cerner burnout.

This survey found that 75 per cent of those who described themselves as burned out identified Cerner as contributing to their symptoms.

“This was the radical transparency where CAMH could not ignore the fact that we were successful outside, but we have a major issue with our physicians,” said Dr. Tajirian.

She went on to describe the initiatives CAMH took including creating EHR SWAT teams, a physician think tank, physician use profiles, and education, communication and informatics strategies. The SWAT team addressed the need to handle EHR issues rapidly; the think tank allowed for more engagement that enabled the physician voice; physician use profiles were created to enable data and analytics. Dr. Tajirian’s team also developed newsletters and peer videos to address the need for more education.

“It [the SWAT team] has been successful because of it’s simplicity: give us all your pain points and we will categorize them [into different colour codes]. Blue: it’s going to be fixed. Yellow: it’s going to take us a bit longer. Red: there are things in Cerner that no matter you do, you’re not going to be able to fix it. We initially collected 131 change requests. We went through that categorization and have almost now completed it.”

Dr. Tajirian says the physician think tank has been remarkably successful because of leadership buy in from the top: Leadership understood the physician voice was critical to engage and sustain improvement. The group, which includes members from all academic divisions, has been meeting monthly for the past five years. IT brings ideas to physician members for discussion. Themes include automation and innovation, documentation reduction, system upgrades, artificial intelligence, medication management, and communication and engagement.

Dr. Tajirian pointed to one think tank initiative that has saved 396 hours of physician time over the 18 months since it was initiated.

“That’s the language that leadership understands,” she said. “When you want to make the case to leadership, understand that [demonstrating] the benefits of what you’re trying to do is critical.”

Follow-up survey

CAMH repeated its 2019 survey in 2023. In terms of the perceived impact and benefits of Cerner:

• 81 per cent of physician respondents believe Cerner can enable them to deliver high quality care.
• 81 per cent believe Cerner can help keep their patients safe.
• 78 per cent believe Cerner can improve communication within the circle of care.

In terms of Cerner contributing to burnout, 52 per cent of respondents believed it does (2019 = 70 per cent).

 “I wanted to understand the main pain points,” said Dr. Tajirian. “It was sobering. They were the same things as five years ago…. Did we move the needle? What physicians cared about came across loud and clear. That is, with the Think Tank, we have a voice. We really feel we have reached a point where we are part of everything and that by itself has been the biggest success.”

“Artificial intelligence will be a gamechanger”

 CAMH is a testing site with Cerner for its Clinical Digital Assist tool that is being used in the States and being developed for the Canadian market.

“It’s supposed to be a gamechanger for the documentation burden that we’re all experiencing,” said Dr. Tajirian. “Our physician liaisons are testing partners because that’s the concept we’re trying to reach: co-design.”

She later described how Ontario Health is investing in testing different AI ambient scribes. Its evaluation has found an 80 per cent reduction in documentation in primary care. She has also heard from American physicians that it has been a real time saver for them in terms of finding and summarizing information. Oracles’ CDA just went live in the US; it will available first in Canada in ambulatory clinics.

Feedback about the presentation

Twenty-two of the 66 physicians who attended the session completed the post-event survey. Like all VPSA presentations that deal with Cerner/CST, feedback was mixed. We heard frustration from our members that we will endeavour take that back to our CST meetings and to VCH leadership.

When asked what resonated most from the session, comments included:

• That the ‘pain points’ had not improved after 10 years of implementation.
• I think the fundamental distress around so much wasted time with CST remains.
• She understood the issues for physicians.
• “For every hour seeing a patient, you are documenting for two hours.”
• I did not find this talk at all useful as a ‘frontline clinician.’ Having a voice does not add anything when our feedback is largely ignored.
• Enthusiasm about what’s to come and acknowledgement of the stress we are dealing with.
• Potential for real sustainability if resources are put there.
• This was an excellent summary of the current problems facing physicians regarding EMRs. Was validating to hear [this] discussed and provided an excellent forum for starting important conversations within our group.
• Such a focused speaker, with excellent research and hope for us to help improve our own lot.
• Having a voice in improving EHR can help with burnout.
• Hope for a better system exists!
• The knowledge that the same frustrations exist across the country.
• Emphasis on engagement. CAMH has a very narrow focus and a small group of physicians, yet it was difficult and long to get this work done. CST needs to consider that when tackling multiple sites/specialties needs in the improvement of CST.
• The changes and challenges that come with system changes.

In response to the request for additional feedback, comments included:

• It is now clear that Cerner is not intuitive and will not improve, and the burden of documentation has permanently shifted to physicians.
• We do need much better tech support including CST SWAT teams and adequately funded working groups.
• As a frontline psychiatrist whose workload increased significantly with Cerner, I had been hoping for practical tips on reducing the burden. This talk was helpful in the sense of radical acceptance, that there are no realistic plans or means to reduce the documentation workload for doctors in CST.
• I think it would be more helpful to have a session on this topic but specifically applicable to VCH – perhaps collecting top CST tips and tricks from across the membership, then presenting it at a future meeting
• We also have a burden of additional work Cerner has created for our clerical support staff. I now have to try to do more admin tasks to lighten the load of the clerical staff who support me. They will burn out too if their pain points are not addressed.
• Very encouraging.
• I would like to see the VPSA follow up on some of the strategies that we can use from our mentors in Ontario. It would also be worthwhile to advocate for funding for Cerner champions to act as SWAT team members and actually work to solve problems with our current system.
• Thank you so much for listening to us and our concerns. This is a very key topic, and we need more input and support.
• This talk felt like it was directed to a leadership lens and not for day-to-day clinicians.

VPSA recorded Dr. Tajirian’s presentation; you can view it here.