Physician Fatigue in the EHR Era

Electronic health records have been blamed as a significant source of physician frustration and even burnout. Is it possible for managed care leaders to turn this technology from a burden to a boon?

When electronic health records (EHRs) first emerged, there was hope that this form of health information technology would improve the doctor and patient experience alike. EHR offered new possibilities for communication among health care professionals and access to patient data. In the years since, however, EHR has been blamed as a cause of dissatisfaction, stress, and even burnout. 

Back in 2013, research conducted by the RAND Corporation found EHR to be a source of both promise and frustration. In the practices studied, physicians approved of EHR in theory, along with its potential to improve patient care and professional satisfaction. 

For many, however, the state of EHR technology at that time significantly detracted from job satisfaction in a variety of ways. Among the notable sources of dissatisfaction were poor usability, time-consuming data entry, interference with face-to-face patient care, and the inability to exchange health information between products.

Recently, this type of frustration lingers on, at least for some. Roughly two-thirds of physicians indicated that EHR detracts from doctor-patient interaction, according to a 2018 survey conducted on behalf of The Physicians Foundation. In addition, over half of those surveyed, reported that EHR reduces efficiency, and more than a third said it reduces the quality of care.

Orthopedic surgeon Daniel Paull, MD, told First Report Managed Care that doctors consistently dislike electronic medical records (EMR)—the direct interface used to input data—regardless of the iteration or the company behind it. The reason, he said, is that they were never meant for note-taking but rather for billing and medicolegal purposes. 

“It’s just a big jumble of click boxes,” he said, adding that from a provider standpoint it can feel worthless. “It’s not because we don’t like technology. It’s because we’re being forced to spend time we want to spend with patients creating billing and playing this insurance game, and that’s why we hate it.”

There was a time when medical records served as a means of communication in addition to insurance and legal purposes, explained Matthew McAuliffe, MD, a physical medicine and rehabilitation specialist in Nevada. Over time, however, documentation has increasingly come to serve the latter two functions. 

EHR documentation, in turn, has become increasingly complex and time-consuming. Research published in the Annals of Internal Medicine in 2016 found, for example, that ambulatory physicians devote nearly 2 hours to EHR and desk work for every hour spent on direct patient care. 

“As a result,” Dr McAuliffe explained, “less face-to-face time can be spent with patients as more time is spent documenting. This results in a less rewarding experience for the patient and a less rewarding vocation for the physician, which ultimately leads to burnout.”

It is an issue of concern considering burnout can potentially jeopardize patient well-being. According to a study that published last October in JAMA Internal Medicine, it is associated with an increased risk of patient safety incidents and poorer quality of care. 

A Broader Look at Burnout 

Other health care stakeholders have argued that the link between burnout and EHR is often exaggerated or misrepresented. Physician burnout is a complex issue, some say, and health care IT—and EHR, in particular—is only one contributing factor. A whole array of issues, ranging from excessive workload and time pressures to difficult patient encounters and unrealistic performance expectations, could contribute to burnout as well.

New findings add some substance to this stance. A study published in August by the Journal of the American Medical Association examined the association between EHR and clinician stress, and the findings revealed that other issues, particularly work conditions, appear to play a bigger role.

In a survey of nearly 300 clinicians from three institutions, the researchers identified seven EHR design and use factors that are associated with high stress and burnout: information overload, slow system response times, excessive data entry, inability to navigate the system quickly, so-called “note bloat,” interference with the patient-clinician relationship, fear of missing something, and notes geared toward billing. 

Along with two others, these seven design and use factors collectively accounted for a modest amount of variance in stress (12.5%) and burnout (6.8%). Models that incorporated other work conditions, like a chaotic work atmosphere and workload control, accounted for higher levels of variance in stress (58.1%) and burnout (36.2%), however.

Because of this, the researchers indicated that other sources of stress aside from EHR, such as lack of attention to work-life balance and ineffective teamwork, should also be addressed as medical practices look for ways to reduce burnout.

Many of the identified EHR design and use factors could be addressed through a combination of improvements by EHR vendors, local improvements by IT personnel, and training of clinicians within the clinical setting, the researchers pointed out. Some of the factors, on the other hand, could require actions on the part of clinic or governmental policymakers, like allowing notes to be geared more toward clinical care than billing practices.

Efforts to Reduce Burnout 

In August, the American Medical Association released suggestions for reducing burnout by optimizing the EHR. Recommendations included establishing an EHR team with clinical and technical competencies, automating tasks when possible, and assigning tasks to a person whose role incorporates those duties. 

The information included examples of actions taken by Reliant Medical Group, a 500-provider multispecialty group practice located in Massachusetts, to alleviate physician burnout due to increased administrative requirements being placed on clinicians. 

Reliant’s EHR team, which includes five physicians, one physician assistant, and a nurse who work with members of the IT team, meets weekly to find ways to limit lower value alerts and pinpoint changes that could improve efficiency. 

One example is the creation of one-click orders, or recurring orders that already include the time frame for completion as well as a related diagnosis code. The organization has also worked to tackle documentation burden with the help of medical assistants, among other efforts.

As physicians spend more time in front of a computer, creating efficiencies in data systems has become a crucial part of solving physician burnout in addition to improving patient satisfaction and ensuring positive medical outcomes, according to David Gregg, MD, chief medical officer at StayWell—a health care IT organization that provides physician software for EHR systems.

He said managed care leaders need to evaluate the use of EHRs to ensure that applications work seamlessly and integrate directly in order to reduce the time required to capture information and enable more doctor-patient interaction. This means testing functionality, for example, and understanding how a system captures and processes information. 

“Physicians want to be physicians,” explained Will O’Connor, MD, chief medical information officer at software communications company, TigerConnect. “Nobody signed up to be data entry clerks. Unfortunately, EHRs are all about clicking and coding—that’s not what patients need, and it’s not what physicians need.”

It can be challenging for managed care organizations to gain easy access to the right care professionals and specialists, he pointed out. Managed care leaders should look for solutions that increase access to resources and information needed at the point of care, and leveraging smartphone technology is one option. 

Many physicians get dozens of EMR alerts every day, Dr O’Connor added, which is overwhelming and potentially unsafe. There are options, though, for sending only the types of alerts they want and need to receive, which can help reduce this type of alert fatigue.

Meanwhile, neither Drs Paull nor McAuliffe envision a particularly bright future for the relationship between doctors and electronic records. 

“Given the current medical system and its note-taking requirements for billing and medicolegal coverage, doctors will never like any EMR,” Dr Paull noted. “It will always be bad. It will just be a spectrum of really bad to less bad.”

“Unfortunately, I’m not sure if there are steps managed care leaders can take to reduce this burden as I only see it becoming more exacerbated in the future,” Dr McAuliffe added, especially as coding and documentation become increasingly complex on the insurance side.