The passage of the HITECH Act of 2009 marked the dawn of a technological transformation in healthcare and led to widespread electronic health record (EHR) use in hospitals, physician offices, and health systems.
After almost a decade of federal incentives and regulations geared towards increasing adoption, EHR use is nearly universal across care settings.
While the digitization of the healthcare industry holds promise, it also introduces a new set of problems. Chief amongst them, for many organizations, is physician burnout.
According to the Agency for Healthcare Research and Quality (AHRQ), physician burnout is a long-term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment.
“In recent years, the rising prevalence of burnout among clinicians (over 50 percent in some studies) has led to questions on how it affects access to care, patient safety, and care quality,” states AHRQ on its website.
The negative effects of physician burnout extend beyond clinicians and may compromise patient care delivery.
“Burned-out doctors are more likely to leave practice, which reduces patients’ access to and continuity of care,” continues AHRQ. “Burnout can also threaten patient safety and care quality when depersonalization leads to poor interactions with patients and when burned-out physicians suffer from impaired attention, memory, and executive function.”
In a 2015 editorial in AAFP’s Family Practice Management, Dike Drummond, MD, describes physician burnout as “the constellation of symptoms that occur when your energy account has a negative balance over time.”
When physician burnout begins to set in, doctors may experience a degree of emotional exhaustion.
“The physician's physical and emotional energy levels are extremely low,” wrote Drummond.
Depersonalization has also been listed as a hallmark symptom of burnout.
“This is signaled by cynicism, sarcasm, and the need to vent about your patients or your job,” wrote Drummond. “This is also known as ‘compassion fatigue.’ At this stage, you are not emotionally available for your patients, or anyone else for that matter. Your emotional energy is tapped dry.”
Persistent feelings of emotional exhaustion, depersonalization, and professional dissatisfaction can have consequences on patients, providers, and the overall success of a healthcare organization.
In a 2018 JAMIA study, researchers at Lehigh University found levels of patient dissatisfaction directly correlate with levels of provider dissatisfaction.
Lehigh Valley Health Network (LVNH) patients seeking care during the organization’s EHR implementation process became more dissatisfied after interacting with dissatisfied physicians.
“The link between physician and patient dissatisfaction is consistent with research showing that provider job satisfaction influences interpersonal relationships with patients and their satisfaction with care,” noted researchers.
In order to address physician burnout and curb its negative effects, stakeholders first need to pinpoint the factors primarily fueling the problem.
Physician burnout, EHR technology, and administrative burden
While multiple factors likely give rise to physician burnout, healthcare industry leaders cite EHR technology as a key contributor.
In a 2017 Health Affairs blog post, a group of top healthcare CEOs called physician burnout a “public health crisis.”
C-suite members from AMA, Partners Healthcare, Mayo Clinic, Cleveland Clinic, Atrius Health, and other large organizations and health systems suggested EHR technology negatively affects clinical efficiency.
“While they have the potential to make a major contribution to patient safety and enhanced coordination of care, EHRs have also radically altered and disrupted established workflows and patient interactions, become a source of interruptions and distraction and are very time intensive,” maintained the healthcare industry leaders.
Recent research supports the claim that the demands of EHR use weigh on clinicians and aggravate feelings of exhaustion, frustration, and workplace dissatisfaction.
A New England Journal of Medicine (NEJM) Catalyst spring 2018 report from 2018 found 83 percent of clinicians, clinical leaders, and healthcare executives view physician burnout as a source of concern at their organizations and indicated EHR use contributes to the growing problem.
Surveyed clinicians said problems with EHR usability and administrative burden divert their attention away from patient care.
EHR use also cuts down on face-to-face time between patients and providers, the participants said. The demands of clinical documentation mandated by federal reporting requirements tether clinicians to their EHR systems for a portion of patient office visits.
“There is broad agreement on the need for more face-to-face time between clinicians and patients and less time spent on the electronic medical record and documentation,” the authors stated.
Some primary care physicians may spend more time on EHR use during visits than patient interaction.
In a Family Medicine study, Young et al. observed 982 patient visits at 10 residencies and found family physicians spend an average of 18.6 minutes on EHR clinical documentation, compared to 16.5 minutes interacting face-to-face with patients.
The demands of clinical documentation also cut into providers’ free time.
“The majority of family physicians worked through lunch, stayed late at clinic, or took their work home to complete the day’s EHR work,” wrote researchers.
A separate 2018 Annals of Internal Medicine study found outdated federal regulations that demand extensive EHR clinical documentation are a primary cause of burnout.
“To justify billing to such payers as the Centers for Medicare & Medicaid Services, physicians must specify diagnoses from long and confusing arrays of choices relating to each test or procedure and document a clinically irrelevant number of elements for the history of present illness, review of systems, and physical examination,” researchers explained.
Researchers suggested the administrative burden of documentation demands make many physicians feel like data entry clerks, particularly because so much of the information regulators want to see includes low-vale administrative data.
“Documentation requirements in the United States are a relic of fee-for-service and will make even less sense as we move to new payment mechanisms,” the team wrote.
Federal regulations, documentation requirements, and other administrative tasks will always be part of the healthcare industry.
However, there are steps healthcare organizations, health IT developers, and federal entities can take to reduce the strain of existing regulations on providers and reconfigure EHR systems to better suit the needs of clinicians.
Strategies for reversing the trend
To ensure physician burnout does not worsen as health IT further permeates the day-to-day operations of healthcare professionals, stakeholders need to take definitive action to address problems with administrative burden and EHR use.
Utilizing medical scribes in the clinic
Transferring administrative tasks from clinicians to medical scribes frees physicians from some of the pressures of clinical documentation.
According to a 2017 study by AMA and the University of Wisconsin, primary care physicians can spend up to 5.9 hours of an 11.4 hour workday on EHR data entry. Extensive clinical documentation requirements lead clinicians to devote a substantial portion of office visits to data entry rather than face-to-face interactions with patients.
Integrating medical scribes into the workflow may help providers get more face time with patients.
A September 2017 Annals of Family Medicine study found medical scribes improve all aspects of physician satisfaction — including satisfaction with patient encounters and clinical documentation accuracy.
Gidwani et al. examined the effects of using medical scribes in clinical practices on physician satisfaction, patient satisfaction, and charting efficiency.
Researchers conducted trials in which physicians in academic family medicine clinics alternately spent one week with medical scribes and one week without for 52 weeks.
Researchers found scribes improved overall physician satisfaction with clinics, face-to-face patient interactions, chart accuracy, time spent charting, and chart quality. Scribes can also help to restore the joy of practice and reduce feelings of isolation by allowing physicians to focus more attention on fostering interpersonal relationships with patients.
“Scribes appear to be a promising strategy to improve health care efficiency and reduce physician burnout,” stated researchers.
Scribes are becoming increasingly common in physicians’ offices.
“The popularity of scribes in the United States has risen sharply recently, and at least 22 companies are recruiting, training, and providing scribes to physicians,” stated researchers in a January 2018 JABFM study. “The number of scribes has been doubling annually; it is estimated that by 2020, there will be 100,000 scribes in the United States, or one scribe for every nine physicians.”
Adopting advanced workflow technologies
Natural language processing (NLP), artificial intelligence (AI), and voice or speech recognition (SR) hold promise for easing provider burden by allowing physicians to dictate notes and helping to automate the documentation process
A 2016 JMIR study by Kaufman et al. found NLP can effectively boost clinical documentation improvement (CDI) and EHR usability and cut down on physician EHR data entry.
Researchers in the study tested four different clinical documentation approaches. Approaches included purely standard clinical documentation in which providers use a keyboard and mouse to document notes, NLP-based approaches that involve dictation, and two hybrid approaches that involve both standard and NLP clinical documentation.
Cardiologists in the study took as little as 5.2 minutes to document notes using NLP, compared to 16.9 minutes using the standard note taking method.
When the team tested each clinical documentation approach against eight quality measures, they found a hybrid standard and NLP-based approach ranked highest. Researchers assigned each clinical documentation an average score based on its performance against selected measures.
The purely NLP-based approach earned a score of 24.5, while a hybrid standard and NLP approach scored 29.5.
“This suggests that the note was judged to be more to the point and with less redundancy,” Kaufman and colleagues wrote.
Many health IT companies are working to integrate NLP, AI, and other capabilities into EHR technology by way of virtual assistants.
Epic, athenahealth, and eClinicalWorks have developed virtual assistants to help clinicians with clinical documentation.
The user-friendly tools are designed to increase face time between patients and providers by responding to clinicians’ verbal commands. The virtual assistants can automatically pull up patient EHRs upon request, order medication refills, and present specific patient data to clinicians in response to questions.
The virtual assistants also simplify the EHR interface by displaying data elements from several disparate sources to providers on a single screen.
Consolidating data from different sources in this way saves clinicians from opening and clicking through several windows to find clinically relevant patient information.
Investing in EHR training and education
Thorough EHR training can help reduce physician frustrations with new technologies and improve ease of use.
IT leaders and hospital executives at healthcare organizations and health systems including Uniontown Hospital in Pennsylvania, have credited EHR training with shortening the adjustment period that accompanies a new EHR system launch.
Uniontown executives enforced mandatory EHR training sessions for all clinical and non-clinical staff when they integrated a new health IT tool — Dynamic Documentation — into the hospital’s Cerner EHR system.
The team offered three sessions per day for two weeks to ensure physicians with different schedules could attend at least one session.
The IT team monitored each training session to ensure all participants had a thorough understanding of how to navigate and utilize the new tool.
“This required attendance had a huge impact on the success and adoption of Dynamic Documentation,” Uniontown Clinical Informatics Integration Analyst Jennifer Abraham told EHRIntelligence.com. “Also, during the training session we made sure every doctor got the same message. The expectations were common at each session.”
Two Cerner representatives and several members of the Uniontown IT project team attended each three-hour training session.
IT executives kept class sizes under 15 physicians per session to ensure each attendee could receive personalized support from Cerner executives and Uniontown IT members when necessary.
To maintain consistency across sessions, all IT team members led training according to a standardized script.
Uniontown also prioritized giving each staff member hands-on experience with the new tool.
“Each person had their own computer and their own dictation microphone,” said Uniontown Health Information Management Director Karen Keniston. “You need to actually do it to be able to learn it.”
On a broader scale, AMA is working to promote EHR use training in medical schools to prepare future physicians for a digitized healthcare industry.
The association has been working with medical schools nationwide to familiarize students with new technologies. AMA is encouraging medical schools and residency programs to provide clinical documentation and EHR training to students that can be evaluated and demonstrated as useful in clinical practice.
“There is a clear need for medical students to have access to — and learn how to properly use — EHRs well before they enter practice,” said AMA Board Member and medical student Karthik V. Sarma.
AMA is also advocating for medical schools and residency programs to provide professional development resources for faculty to ensure appropriate modeling of EHR use during physician and patient interactions.
This push to include health IT use in medical education may help future clinicians more efficiently and effectively engage with EHR technology.
By starting students on EHR training early, AMA hopes to position students for a more seamless transition into the digitized healthcare industry.
Focusing on EHR optimization and customization
Prioritizing usability during EHR optimization and customization can also help to improve physician interactions with EHR technology and reduce provider burden.
Specializing clinical workflows can help to streamline health data access for clinicians and cut down on time spent in front of EHR systems.
When healthcare organization executives implement a commercial off-the-shelf EHR system without tailoring workflows to meet the specific needs of its users, they may be missing opportunities to reduce clicks for providers.
Industry analyst and Impact Advisors Physician Executive Tonya Edwards, MD, told EHRIntelligence.com default workflows often lack usability.
“When you are taking something out of the box, you have prescriptive workflows, workflows that are designed for that out-of-the-box system,” said Ivey. “So when you come in and you're able to look at streamlining a workflow, customizing a system to complement that streamlined workflow, you're able to then reduce some clicks.”
Some healthcare organizations skip EHR optimization during implementation and rely on default workflows due to time constraints.
In the flurry of activity and disruption that accompanies EHR implementation, IT teams, healthcare organization executives, and clinicians may not have time to sit down and discuss potential EHR optimization strategies.
“That’s where that optimization phase comes in and it’s so crucial,” said Ivey. “You are able to come, visit with them, and figure out what is cumbersome for them and see what we can do to fix it.”
When healthcare organizations are ready to begin an EHR optimization project, involving as many diverse members of healthcare organization staff is crucial to ensuring various team members’ EHR usability needs are met.
“It is a multidisciplinary team that needs to be operationally-led because it is the people doing the work who understand the work,” explained Ivey. “They understand why things need to be done in a certain order. They understand what the barriers are. Once those workflows are developed, then it's up to IT to come in and try to support that.”
During its physician optimization project, Uniontown executives made a point to include physicians in the design and development of specialized clinical workflows. Involving clinicians in workflow design can boost EHR usability by allowing users to offer input on their preferences for workflow features and layout.
With help from physician representatives, the IT team created four distinct specialized workflows.
“We had workflows for inpatient medicine, surgery, cardiology, and pediatrics,” explained Abraham. “We had physician champions from each of those areas help to build their workflows to that specialty.”
Customizing the EHR interface to suit different specialties, care settings, and healthcare organizations can also lead to usability improvements.
A 2017 study by researchers at the University of Illinois Chicago found developing separate and unique EHR interfaces for different care settings and specialties can reduce the number of clicks per day for providers.
These customized EHR interfaces can be designed to highlight health data most likely to be relevant to specific users.
By analyzing existing literature and reviewing use cases for EHR data visualization techniques, the University of Illinois Chicago team found different data visualizations and EHR models streamlined usability for faster, better-informed care delivery.
“The models can be specific disease state models or hospital models,” University of Illinois Chicago Assistant Professor of Biomedical and Health Information Sciences Andrew Boyd, MD, told EHRIntelligence.com.
“No two hospitals work the exact same way,” he added. “A physician or pediatric dentist would need a different interface than a cardiothoracic trauma surgeon based on the needs and the disease state that they’re dealing with.”
Specialty and care setting-specific EHR interfaces can be designed to display high-value clinical information to clinicians in the same way a web browser predicts which website a user is most likely to search based on user history.
“We’re not concealing — we’re highlighting the important information,” emphasized Boyd. “If a user wants to pursue other information, they would be able to pursue it.”
Collaboration between clinicians and health IT vendors during EHR optimization projects and EHR interface design can help to improve usability and physician satisfaction.
“Be engaged with the vendors,” Boyd recommended. “Be engaged with the decision-makers. When you have engaged clinicians who may not understand the IT but understand their domain, that’s when you see improvements.”
Taken together, these strategies can help to prevent physician burnout by boosting provider satisfaction, improving clinical efficiency, and allowing providers to spend more time on patient care delivery than administrative tasks.
Collaboration between clinicians, health IT developers, hospital and health system management is critical to addressing the root causes of physician burnout before further digitization exacerbates the problem.