EHRs: Causing burnout with the click of a button
EHRs occupy an important place in modern health care but are increasingly seen as a clerical burden for clinicians and a significant contributor to physician burnout. Experts would like the digitized records to become more user friendly to decrease burnout and improve patient care.
“Burnout is something that has a lot of bad outcomes,” Carlos del Rio, MD, professor of medicine and chair of the department of global health at the Emory University Rollins School of Public Health, told Infectious Disease News. “Burnout increases error. Burnout increases dissatisfaction with the profession. Burnout, at the end of the day, impacts patient care because people are not as engaged and excited about what they’re doing.”
A public health crisis
Experts from leading health organizations, including the National Academy of Medicine, have declared physician burnout to be a public health crisis, and EHRs are high on the list of contributing factors.
The computer-based records are better than paper charts, allowing for easy and widespread access to patient information. Clinicians can use them to place prescription orders, order tests, review test results, see a patient’s complete health history and communicate with patients electronically.
However, although EHRs seem built for convenience, physicians have reported feeling disconnected from patients. According to the results of a poll published by Stanford Medicine, physicians spend 62% of the time devoted to each patient on using the EHR, and almost half of office-based primary care physicians think using an EHR detracts from their clinical effectiveness. Overall, the lack of interaction and additional work has left physicians feeling overwhelmed and frustrated.
“We have these systems that weren’t necessarily designed to be incredibly user friendly,” said del Rio, who is also a spokesman for the Infectious Diseases Society of America. “You have a lot of clicking and lot of typing and things that you need to be doing to get a simple task done.”
He acknowledged that paper records were not a perfect system either, but that in the past, he was able to open a binder, write directions for a patient to receive medication, and the task was done. Now, even that could take up to 20 minutes to complete.
“Even when you’re at the end, the computer can say something like ‘you haven’t checked this box,’ or ‘you haven’t updated the medications list for this patient,’ so before you can even put the order in, you have to go back and do that,” del Rio said.
Time is a major factor. Clinicians are increasingly reporting having to us evening and weekend hours to do clerical work so that they can focus on patients and keep the workflow as smooth as possible in the office. However, for infectious disease doctors, the amount of “take-home” work may be greater than other subspecialties.
“Commonly, when an ID doctor sees a patient, it’s highly complex. They may be receiving outpatient infusions of antibiotics, they may have a lot of medical issues, they may be dealing with complications of the illness. This results in a lot of work for the ID provider that needs urgent action,” George Diaz, MD, an ID specialist at Providence Regional Medical Center in Everett, Washington, and also an IDSA spokesman, told Infectious Disease News.
“Something’s got to give, so the thing that tends to be put off is entering the information into the health record while the patient is actually there,” Diaz said. “Ultimately, ID physicians will start doing notes when their day is over or when the urgent things are completed.”
According to Diaz, there is a lack of reimbursement and compensation among ID physicians for the extra work that piles up. The issue of appropriate compensation is a widely noted factor in the loss of ID physicians and a dwindling field of medical students and residents entering the specialty.
“In an ideal world, ID is a very interesting field and a very interesting specialty, but residents and medical students are seeing the frustration that infectious disease doctors face and see that they are unhappy,” Diaz added. “That could stop them from entering the field.”
‘A major priority’
Physicians’ concerns have been heard. Penn Medicine in Philadelphia launched an initiative in October 2018 to make EHRs more streamlined, interactive and smart.
“Burnout has many downstream impacts, and at Penn Medicine, we feel the priority is two fold: to help our providers become better users of the electronic medical record, while also looking at ways to redesign the system to work better for them,” Philynn Hepschmidt, associate vice president of EHR transformation at Penn Medicine, told Infectious Disease News.
To start the process, teams at Penn Medicine launched a “Your Big Idea” innovation tournament that allowed clinicians to outline “pain points” and suggest improvements to EHRs. Suggestions included updating the systems to make it easier to find data with fewer clicks, making it easier to fill out the charts, making it easier to log in, and making certain data available by default so that clinicians do not have to re-enter information to get further in the chart.
Penn Medicine’s four-part plan to improve EHRs moved to a second phase in November, which included bringing in additional resources and delivering 670 one-to-one personalization sessions for physicians. According to Hepschmidt, the sessions were well-received, and teams are looking at how to offer these sessions more proactively throughout the year.
The third phase is to pilot “optimization sprints” in four departments, using a team-based approach by involving resources from multiple areas of expertise — clinicians, analysts and operational experts — to help identify opportunities for enhancements to workflows, functionality and education needs over a 12-week period of time.
Next, teams will identify where EHR workflow needs to change, how to enhance EHR functionality and where there may be educational opportunities for physicians, which will help develop a comprehensive plan to address the concerns. Another part of the plan is to look at areas that require solutions that extend the EHRs and engage other Penn Medicine teams to develop and design new tools to ease the burden.
Katherine Choi, MD, senior clinical innovation manager in Penn Medicine’s Center for Health Care Innovation, said the center has been working on tools that will tailor EHR systems in two initial areas of consultation. She explained that there is an opportunity to tailor notifications to inpatient providers to make curated, disease-based data views for outpatient providers.
“We’ve gotten to this point where the core EHR is the source of truth as a robust, reliable system, and there are still new ways of building towards the next stage of making it more modern and designed for the clinician,” Choi said. “We want to move from a system that they use by necessity to one that is more efficient and even delightful.”
Adapting EHR systems to be more user friendly and efficient is seen as an important first step to improving them and combatting burnout. Whether it be using medical scribes to ease the burden or making the EHRs themselves more user friendly, experts hope that EHRs become easier to navigate and use.
“Overall, electronic medical records are more work, they’re an external stressor and we’re catching onto that. We’re not just telling people ‘Sorry, you need to be resilient.’ We’re working to increase ease and efficiency. It’s a major priority,” del Rio said. “A lot of people are looking at burnout from electronic health records and viewing it from different aspects of what needs to and can be done differently. We need to get care back into caring.” – by Caitlyn Stulpin
- Stanford Medicine. How doctors feel about electronic health records: National physician poll by The Harris Poll. 2018. https://med.stanford.edu/content/dam/sm/ehr/documents/EHR-Poll-Presentation.pdf. Accessed January 30, 2019.
Disclosures: Choi, del Rio, Diaz and Hepschmidt report no financial disclosures.