Settled science: The indisputable link between EHR and burnout

The CEO of Epic, Judith Faulkner, recently made a statement questioning whether there was any evidence tying the EHR (electronic health record) to physician burnout. Here, as Gabriela Velazquez, MD, London C. Guidry, MD, and Amit Chawla, MD, detail, 60 peer-reviewed papers say otherwise.

Type the word “burnout” into PubMed, and 11,719 citations appear for just the past 10 years. Drill it down to “burnout and electronic medical record,” and 212 titles stare at you with an invitation to fall down the rabbit hole of why the abbreviation EHR—or the interchangeable EMR (electronic medical record)—elicits feelings of PTSD for so many healthcare workers. With a quick scroll, the buzzwords appear in neon lights: “effects on work-life balance,” “click fatigue” and “pajama time,” to the really bad players of “burden,” “depression” and “suicide.” These are becoming the vernacular of all physicians, regardless of the title of medical doctor, surgeon, fellow or resident-in-training.

Unfortunately, the EHR is truly an equal opportunist affecting all healthcare providers, including frontline nurses and physician extenders. After reviewing 212 titles, we narrowed down our search to 73 that associated the EHR with burnout. From there, we created the following four categories and assigned articles into the category for best fit, ultimately vetting 62 articles relating EHR to burnout. We looked at EHR usability and association with burnout; factors affecting physician professional satisfaction and their implications for patient care health systems, and health policy; specialty-specific EHR-related burnout; and, finally, solutions and innovations to EHR-related burnout. It is clear that physicians, healthcare workers, and healthcare systems know there is a problem. What is also clear is that despite the evolving merger of healthcare systems, we have yet to find an applicable and feasible solution to the ongoing stress and burden EHR is bringing to our community.

It sounds great in theory—an electronic account of a patient’s medical history able to be accessed across multiple hospital systems in multiple states, no longer held hostage by the whims of shoddy penmanship and fax machines. Although saying that the EHR was invented solely to improve patient outcomes is about as disingenuous as saying it was devised to save trees. Both things may be true to some extent, but they are secondary to making a profit—from the EHR companies selling the products, to the hospitals claiming every last cent from the insurance companies and patients. The HITECH Act of 2009 incentivized the adoption of the EHR while punishing non-adopters. Since then, more than $30 billion has been invested, resulting in 96% of hospitals utilizing an EMR.⁵⁹ 

The positives

It’s not all bad. As expected, 77.6% of physicians in one study stated that the EHR improved billing processes.¹⁰ Multiple studies have shown that physicians feel that the EHR has led to improved communication within the hospital.^10,34 Some feel that it has even increased their clinical workflow.¹³ The EHR allows for remote access for those clinicians technologically inclined. Knowing whether you have to go to the operating room after scrolling through a computed tomography angiography (CTA) at home can save precious time. Medication errors have also decreased drastically because of the EHR.⁵⁹

No matter how many times you try to convince yourself—or others try to convince you—that EHR is the best integration we have seen in decades, it is still dauntingly bad. All of those advantages can be converted into cons, unfortunately—mostly to the detriment of the physician. The physician’s note is no longer a document containing essential facts pertinent to patient care, but is now an itemized receipt with reimbursement documentation embedded within.¹⁷

The good news is that if you can’t finish all of your billing… I mean documentation… at work, you can now work from home. “Pajama-time” documenting has increased and is agnostic of training status (resident versus attending).³³ The paralyzing dread that comes with watching the number on your inbox rapidly approach four digits is at least one thing that comes free with the EHR. One study indicated that almost half of all weekly in-basket messages came from EHR algorithms.¹² Excessive inbox messages have been correlated with loss of situational awareness due to information overload.⁵⁷ Note bloat; the inability of various EHRs communicating effectively with one another, leading to gaps in information; the perceived shift from patient care to computer documentation; and the physical manifestations of this shift (i.e., posture-related pain). These have all been linked to decreasing physician satisfaction, which has been associated with increased burnout.³⁵

The issue is real

While we are not trying to depict an “all-time-low” of documentation, clearly this has been an issue for many years, and almost every single specialty has reported on its effects. Contemporary data suggest that this ongoing and growing issue has forced physicians to relocate, seek part-time opportunities and alternative employment.⁴⁴

One could say that maybe they were not cut out to do medicine after all. However, we have all witnessed the repercussions and long-term effects among our close circles of physician friends, family and colleagues. Once passionate and enthusiastic, they become slaves of EHRs and documentation demands until they have had enough. Physicians have lost their ability to control their documentation workload and focus on actual patient care. Organizational structures and cultures are now dictating how many hours you will be spending in front of a computer, which, inevitably, will decrease the high-quality time spent in personal encounters, which we know is incredibly important in job satisfaction.^1,2

Another interesting fact is that practitioners in group practices were less likely to report burnout compared to hospital-employed or academic practices. One of the theories is that the surveyed group practices found a way to become more productive by increasing the use of pre-charting by nurse navigators, scribes, or use of artificial intelligence.^2,6 This makes us wonder why are we not being heard by our leadership? Why do we continue to be punished for lack of checking boxes rather than increasing efforts to support the workforce in this pressing matter?

Although professional dissatisfaction can be attributed to many factors, paper after paper associated dissatisfaction with the EMR to physician burnout. The Mayo Clinic found that dissatisfaction with the EMR was an independent risk factor for providers to likely or definitely reduce clinical work hours in the next 12 months, or leave their current job in the following 24 months.¹⁶ As medicine is seeing burnout rates twice as high as those in other fields, there should be concern for physicians leaving medicine altogether.^16,46

The seeds are planted early

Unfortunately, lack of job satisfaction comes well before attending-level practice. Chest published survey results from pulmonary critical care fellows showing more than 40% surveyed felt the EHR impacted their joy in medicine in a negative way. This correlated to higher odds of burnout.³ Advanced practice practitioners (APPs) are not exempt from EHR-related frustration and burnout. Lack of time to document and daily frustration with the EHR was significantly associated with burnout in APPs.³⁴

So what is it about the EHR that reduces professional satisfaction and increases burnout? A chronic theme seems to be time. Face-to-face contact with patients is being eaten up with face-to-computer time instead. When an EHR reduces time with a patient, physicians report reduced personal satisfaction.⁷ The problem of time has many facets. The mandated documentation must be completed to avoid punishment from one’s institution, insurance companies and governmental agencies.

There is just not enough time in the workday to care for patients, document, and deal with all of the other mandatory inbox requirements. This leads to the necessity of doing homework nights, along with weekends and holidays.³⁵ Physicians spending a moderate, high or excessive amount of time at home completing EHR-related tasks were associated with higher odds of depressive symptoms.³ Professional satisfaction also decreased when physicians felt their inboxes were filled with tasks that could be assigned to others. The complexity of the EHR also had a negative impact on overall professional satisfaction.⁷ Processing large amounts of data has led to “cognitive overload,” exacerbated by the numerous clicks required to prove you did the work.²⁶

Many assumed that younger doctors would not experience the same deleterious effects from the EHR; however, the EHR does not discriminate by age. The Mayo Clinic surveyed more than 6,000 physicians: Those under 40 still reported a 55% dissatisfaction rate with the EHR compared to 66% in those 60 and above.¹³ Stanford was able to use EHR software provider Epic to look at the time spent in the EHR by first-year residents versus those in their second year and higher. The mean daily average was 5.6 hours of computer time. Considering a medicine resident typically works a 10- to 12-hour day, this is approximately half of the residents’ time spent looking at a computer. This percentage does not change significantly as one becomes an attending. One study showed attending physicians spend 37–49% of the workday at a computer screen with an average of one-to-two hours of screen time at home.²⁷ Improved overall professional satisfaction with regards to the EHR only happens when the EHR is perceived as improving quality of care for patients.⁷

Possible remedies 

So what can be done from a healthcare systems perspective? Physicians with burnout are twice as likely to leave an organization. Since the estimated cost of replacing a physician is between $500,000 and $1 million, the health and well-being of our current and future physicians should be paramount, with hospital systems taking an active role in protecting them from EHR-associated burnout and burnout in general.⁴⁶

A common goal reported by physicians to reduce burnout is having value-alignment with leadership.^2,15,24 Hospitals and healthcare organizations need to be able to enhance or restructure their existing EHRs to reduce burnout while still complying with Centers for Medicare & Medicaid Services (CMS) rules and regulations. One aim has been for better EHR education opportunities. Kaiser Permanente instituted a three-day intensive EHR education intervention for EHR documentation and physician well-being. Some 98% of the attendees reported they would recommend the training to their colleagues. Although they could not show a direct link to decreased burnout, the trend was toward decreasing time spent in the EHR, improved clinical accuracy of the documentation and fewer medical errors.⁵⁰ Simple management of the physician inbox by removing tasks such as prescription refills, and re-delegating to appropriate support staff, or stopping the automatic cc’ing of notes unless intentional are small steps toward reducing the clerical burden.⁴⁸

Fixing the EHR is a band-aid on a bullet hole: Regulatory reform is ultimately needed. The documentation burden is linked directly to billing and reimbursement.⁵³ Until this changes, the burden will continue to fall upon the healthcare provider. In 2017, CMS launched a “patients over paperwork” campaign in an attempt to evaluate and streamline documentation regulations. A small portion of this initiative is to decrease the amount of redundant documentation and be more focused on the interval history of the patient. The National Academy of Medicine along with the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education (ACGME) also launched a collaborative effort with regards to physician burnout.³⁰

Although there is an increasing amount of research being aimed at EHR and burnout, there still is no industry standard across EHR platforms to be able to study effectively.⁵⁴ This creates difficulty in obtaining meaningful data to create change. Temporary patches will continue to be developed in an attempt to mitigate burnout. Scribe implementation has increased and been found to decrease physician documentation hours at work as well as after hours.⁵³

Most recently, artificial intelligence (AI) has come to the forefront as a solution to the EHR documentation burden. The ability to have a computer program listen, create a usable note and bill correctly is being done by companies like Suki. Will this be a game changer and allow medicine to again become a contact sport, where the physician actually gets to look at the patient instead of a screen? And, if so, what is the cost and who will pay for it?

Most vascular surgeons are optimistic pessimists, thinking the third bypass will definitely be the one that saves the leg, while penciling in the inevitable amputation into next week’s schedule. We are also a self-reliant bunch. We will try and mitigate the onslaught of extra work by various workarounds, but all of this comes at a cost. The depersonalization of the patient encounter due to data entry is felt by the provider and the patient. The extra pajama time is felt by the provider and provider’s family.

Until the system stops using the EHR as a receipt for services and uses it as a tool to augment patient care, we will continue to burnout. We need good leadership to make that happen. We need to protect our future physicians from going down the same path.

REFERENCES

1. Burnout and Career Satisfaction in Women Neurologists in the United States. Moore L.R., Ziegler C., Hessler A., et al. J Womens Health (Larchmt). 2019 Apr;28(4):515-525. doi: 10.1089/jwh.2017.6888. Epub 2019 Jan 8.PMID: 30620238
2. Cross-sectional survey of workplace stressors associated with physician burnout measured by the Mini-Z and the Maslach Burnout Inventory. Olson K., Sinsky C., Rinne S.T., et al. Stress Health. 2019 Apr;35(2):157–175. doi: 10.1002/smi.2849. Epub 2019 Jan 21. PMID: 30467949
3. A National Survey of Burnout and Depression Among Fellows Training in Pulmonary and Critical Care Medicine: A Special Report by the Association of Pulmonary and Critical Care Medicine Program Directors. Sharp M., Burkart K.M., Adelman M.H., et al. Chest. 2020 Sep 18:S0012–3692(20)34511-6. doi: 10.1016/j.chest.2020.08.2117. Online ahead of print. PMID: 32956717
4. Job Satisfaction Among Academic Family Physicians. Agana D.F., Porter M., Hatch R., et al. Fam Med. 2017 Sep;49(8):622–625. PMID: 28953294 Free article.
5. Burnout Among United States Orthopaedic Surgery Residents. Somerson J.S., Patton A., Ahmed A.A., et al. J Surg Educ. 2020 Jul–Aug;77(4):961-968. doi: 10.1016/j.jsurg.2020.02.019. Epub 2020 Mar 11. PMID: 32171748
6. High Burden of Burnout on Rheumatology Practitioners. Tiwari V., Kavanaugh A., Martin G., et al. J Rheumatol 2020 Dec 1;47(12):1831–1834. doi: 10.3899/jrheum.191110. Epub 2020 Apr 1. PMID: 32238512
7. The Pros and Cons of Electronic Health Records: https://www.rand.org/pubs/research_reports/RR439.html
8. The electronic elephant in the room: Physicians and the electronic health record. Kroth P.J., Morioka-Douglas N., Veres S., et al. JAMIA Open. 2018 Jul;1(1):49–56. doi: 10.1093/jamiaopen/ooy016. Epub 2018 Jun 11. PMID: 31093606
9. In Pursuit of the Fourth Aim in Health Care: The Joy of Practice. Gergen Barnett K.A. Med Clin North Am. 2017 Sep;101(5):1031–1040. doi: 10.1016/j.mcna.2017.04.014. PMID: 28802466 Review.
10. Physician stress and burnout: the impact of health information technology. Gardner R.L., Cooper E., Haskell J., et al. J Am Med Inform Assoc. 2019 Feb 1;26(2):106–114. doi: 10.1093/jamia/ocy145. PMID: 30517663
11. Electronic health record associated stress: A survey study of adult congenital heart disease specialists. Marckini D.N., Samuel B.P., Parker J.L., Cook S.C. Congenit Heart Dis. 2019 May;14(3):356-361. doi: 10.1111/chd.12745. Epub 2019 Mar 1. PMID: 30825270
12. Physicians’ Well-Being Linked To In-Basket Messages Generated By Algorithms In Electronic Health Records. Tai-Seale M., Dillon E.C., Yang Y., et al. Health Aff (Millwood). 2019 Jul;38(7):1073–1078. doi: 10.1377/hlthaff.2018.05509. PMID: 31260371
13. Relationship Between Clerical Burden and Characteristics of the ElectronicEnvironment With Physician Burnout and Professional Satisfaction. Shanafelt T.D., Dyrbye L.N., Sinsky C., et al. Mayo Clin Proc. 2016 Jul;91(7):836-48. doi: 10.1016/j.mayocp.2016.05.007. Epub 2016 Jun 27. PMID: 27313121
14. Use of Health Information Technology by Rhode Island Physicians and Advanced Practice Providers, 2019. Mandeville B., Cooper E., Haskell J., et al. R I Med J (2013). 2020 Feb 3;103(1):21–24. PMID: 32013299 Free article.
15. Worklife and Wellness in Academic General Internal Medicine: Results from a National Survey. Linzer M., Poplau S., Babbott S., et al. J Gen Intern Med. 2016 Sep;31(9):1004–10. doi: 10.1007/s11606-016-3720-4. Epub 2016 May 2. PMID: 27138425 Free PMC article.
16. Professional Satisfaction and the Career Plans of US Physicians. Sinsky C.A., Dyrbye L.N., West C.P., et al. Mayo Clin Proc. 2017 Nov;92(11):1625–1635. doi: 10.1016/j.mayocp.2017.08.017. Epub 2017 Nov 1. PMID: 29101932
17. Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause? Downing N.L., Bates D.W., Longhurst C.A. Ann Intern Med. 2018 Jul 3;169(1):50–51. doi: 10.7326/M18–0139. Epub 2018 May 8. PMID: 29801050
18. The Burden and Burnout in Documenting Patient Care: An Integrative Literature Review. Gesner E., Gazarian P., Dykes P. Stud Health Technol Inform. 2019 Aug 21;264:1194–1198. doi: 10.3233/SHTI190415.PMID: 31438114
19. The complex case of EHRs: examining the factors impacting the EHR user experience. Tutty M.A., Carlasare L.E., Lloyd S., Sinsky C.A. J Am Med Inform Assoc. 2019 Jul 1;26(7):673–677. doi: 10.1093/jamia/ocz021. PMID: 30938754 Free PMC article.
20. Perceived Burden of EHRs on Physicians at Different Stages of Their Career. Khairat S., Burke G., Archambault H., et al. Appl Clin Inform. 2018 Apr;9(2):336–347. doi: 10.1055/s-0038-1648222. Epub 2018 May 16. PMID: 29768634 Free PMC article.
21. The burden of inbox-messaging systems and its effect on work-life balance in dermatology. Bittar P.G., Nicholas M.W. J Am Acad Dermatol. 2018 Aug;79(2):361–363.e1. doi: 10.1016/j.jaad.2017.12.026. Epub 2017 Dec 16. PMID: 29258864 No abstract available.
22. Electronic health records and burnout: Time spent on the electronic healthrecord after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians. Adler-Milstein J., Zhao W., Willard-Grace R., Knox M., Grumbach K. J Am Med Inform Assoc. 2020 Apr 1;27(4):531–538. doi: 10.1093/jamia/ocz220. PMID: 32016375
23. Nurses’ Stress Associated with Nursing Activities and Electronic HealthRecords: Data Triangulation from Continuous Stress Monitoring, Perceived Workload, and a Time Motion Study. Yen PY, Pearl N, Jethro C, et al. AMIA Annu Symp Proc. 2020 Mar 4;2019:952–961. eCollection 2019. PMID: 32308892 Free PMC article.
24. Electronic medicacords and physician stress in primary care: results from the MEMO Study. Babbott S., Manwell L.B., Brown R., et al. J Am Med Inform Assoc. 2014 Feb;21(e1):e100-6. doi: 10.1136/amiajnl-2013-001875. Epub 2013 Sep 4. PMID: 24005796 Free PMC article
25. Exploring the Association Between Electronic Health Record Use and BurnoutAmong Psychiatry Residents and Faculty: a Pilot Survey Study. Domaney N.M., Torous J., Greenberg W.E. Acad Psychiatry. 2018 Oct;42(5):648–652. doi: 10.1007/s40596-018-0939-x. Epub 2018 May 21. PMID: 29785625
26. Rethinking the electronic health record through the quadruple aim: time to align its value with the health system. Alami H., Lehoux P., Gagnon M., et al. BMC Med Inform Decis Mak. 2020 Feb 17;20(1):32. doi: 10.1186/s12911-020-1048-9.PMID: 3206643
27. Characterizing electronic health record usage patterns of inpatient medicine residents using event log data. Wang J.K., Ouyang D., Hom J., Chi J., Chen J.H. PLoS One. 2019 Feb 6;14(2):e0205379. doi: 10.1371/journal.pone.0205379. eCollection 2019. PMID: 30726208 Free PMC article.
28. Evolutionary Pressures on the Electronic Health Record: Caring for Complexity. Zulman D.M., Shah N.H., Verghese A. JAMA. PMID: 27532804
29. Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review. Moy A.J., Schwartz J.M., Chen R., et al. J Am Med Inform Assoc. 2021 Jan 12:ocaa325. doi: 10.1093/jamia/ocaa325. Online ahead of print. PMID: 33434273
30. A resolution for the new year: Responding to a call to organize against burnout. Prejean S.P., Buckingham S., Iskandrian A.E. J Nucl Cardiol. 2018 Dec;25(6):1887–1889. doi: 10.1007/s12350-018-01474-1. Epub 2018 Oct 24. PMID: 30357581 No abstract available.
31. The Association Between Perceived Electronic Health Record Usability and Professional BurnoutAmong US Physicians. Melnick E.R., Dyrbye L.N., Sinsky C.A., et al. Mayo Clin Proc. 2020 Mar;95(3):476–487. doi: 10.1016/j.mayocp.2019.09.024. Epub 2019 Nov 14.PMID: 31735343
32. Perceived Electronic Health Record Usability as a Predictor of Task Load and Burnout Among US Physicians: Mediation Analysis. Melnick E.R., Harry E., Sinsky C.A., et al. J Med Internet Res. 2020 Dec 22;22(12):e23382. doi: 10.2196/23382. PMID: 33289493
33. Electronic Health Record Effects on Work-Life Balance and Burnout Within the I(3) Population Collaborative. Robertson S.L., Robinson M.D., Reid A. J Grad Med Educ. 2017 Aug;9(4):479–484. doi: 10.4300/JGME-D-16-00123.1.PMID: 28824762
34. Estimating the association between burnout and electronic health record-related stress among advanced practice registered nurses.Harris D.A., Haskell J., Cooper E., Crouse N., Gardner R. Appl Nurs Res. 2018 Oct;43:36–41. doi: 10.1016/j.apnr.2018.06.014. Epub 2018 Jun 23. PMID: 30220361
35. Association of Electronic Health Record Design and Use Factors With Clinician Stress and Burnout. Kroth P.J., Morioka-Douglas N., Veres S., et al. JAMA Netw Open. 2019 Aug 2;2(8):e199609. doi: 10.1001/jamanetworkopen.2019.9609.PMID: 31418810
36. Association of Electronic Health Record Use With Physician Fatigue and Efficiency. Khairat S., Coleman C., Ottmar P., et al. JAMA Netw Open. 2020 Jun 1;3(6):e207385. doi: 10.1001/jamanetworkopen.2020.7385. PMID: 32515799
37. Resident Indentified Violations of Usability Heuristic Principles in Local Electronic Health Records. Berg G.M., Shupsky T., Morales K. Kans J Med. 2020 May 21;13:84–89. eCollection 2020. PMID: 32499860
38. “Seeing the Patient Is the Joy”: A Focus Group Analysis of Burnout in Outpatient Providers. Spinelli W.M., Fernstrom K.M., Britt H., Pratt R. Fam Med. 2016 Apr;48(4):273–8. PMID: 27057605 Free article.
39. A mixed-methods evaluation framework for electronic health records usability studies. Khairat S, Coleman C, Newlin T, et al. J Biomed Inform. 2019 Jun;94:103175. doi: 10.1016/j.jbi.2019.103175. Epub 2019 Apr 11. PMID: 30981897 Free PMC article.
40. Pajama Time: Working After Work in the Electronic Health Record. Saag H.S., Shah K., Jones S.A., et al. J Gen Intern Med. 2019 Sep;34(9):1695–1696. doi: 10.1007/s11606-019-05055-x. PMID: 31073856 Free PMC article. No abstract available.
41. Technology as friend or foe? Do electronic health records increase burnout? Ehrenfeld J.M., Wanderer J.P. Curr Opin Anaesthesiol. 2018 Jun;31(3):357–360. doi: 10.1097/ACO.0000000000000588. PMID: 29474217 Review.
42. The Influence of Electronic Health Record Use on Physician Burnout: Cross-Sectional Survey. Tajirian T., Stergiopoulos V., Strudwick G., et al. J Med Internet Res. 2020 Jul 15;22(7):e19274. doi: 10.2196/19274. PMID: 32673234 Free PMC article
43. Electronic Medical Record Documentation and Provider Burnout. Goldman D.A., Panageas K.S. JCO Oncol Pract. 2020 Dec 17:OP2000832. doi: 10.1200/OP.20.00832. Online ahead of print. PMID: 33332173—letter to the editor
44. Physician burnout: A neurologic crisis. Sigsbee B., Bernat J.L. Neurology. 2014 Dec 9;83(24):2302-6. doi: 10.1212/WNL.0000000000001077. Epub 2014 Nov 5. PMID: 25378679
45. Artificial Intelligence and Surgical Decision-making. Loftus T.J., Tighe P.J., Filiberto A.C., et al. JAMA Surg. 2020 Feb 1;155(2):148–158. doi: 10.1001/jamasurg.2019.4917.PMID: 31825465
46. Beyond Burnout – Redesigning Care to Restore Meaning and Sanity for Physicians. Wright A.A., Katz I.T. N Engl J Med. 2018 Jan 25;378(4):309–311. doi: 10.1056/NEJMp1716845. PMID: 29365301
47. Protecting healing relationships in the age of electronic health records: report from an international conference. Toll E.T., Alkureishi M.A., Lee W.W., et al. JAMIA Open. 2019 Jul 5;2(3):282–290. doi: 10.1093/jamiaopen/ooz012. eCollection 2019 Oct. PMID: 31984362
48. “D/C the CC (Carbon Copy)”—Improving the EHR Signal-to-Noise Ratio for Clinicians by Selective Feature De-Implementation. Chu L., Toomay S.M., Ginnings C.S., et al. Stud Health Technol Inform. 2019 Aug 21;264:1915–1916. doi: 10.3233/SHTI190711. PMID: 31438405
49. Electronic health record innovations: Helping physicians—One less click at a time. Guo U., Chen L., Mehta P.H. Health Inf Manag. 2017 Sep;46(3):140–144. doi: 10.1177/1833358316689481. Epub 2017 Jan 19. PMID: 28671038
50. Novel electronic health record (EHR) education intervention in large healthcare organization improves quality, efficiency, time, and impact on burnout. Robinson K.E., Kersey J.A. Medicine (Baltimore). 2018 Sep;97(38):e12319. doi: 10.1097/MD.0000000000012319.PMID: 30235684
51. Physician Order Entry Clerical Support Improves Physician Satisfaction and Productivity. Contratto E., Romp K., Estrada C.A., et al. South Med J. 2017 May;110(5):363–368. doi: 10.14423/SMJ.0000000000000645.PMID: 28464179
52. Addressing Burnout Syndrome From a Critical Care Specialty Organization Perspective. Cochran K.L., Doo K., Squires A., et al. AACN Adv Crit Care. 2020 Jun 15;31(2):158-166. doi: 10.4037/aacnacc2020579. PMID: 32525998
53. The burden of the digital environment: a systematic review on organization-directed workplace interventions to mitigate physician burnout. Thomas Craig K.J., Willis V.C., Gruen D., Rhee K., Jackson G.P. J Am Med Inform Assoc. 2021 Jan 19:ocaa301. doi: 10.1093/jamia/ocaa301. Online ahead of print. PMID: 33463680
54. Have you got the time? Challenges using vendor electronic health record metrics of provider efficiency. Hron J.D., Lourie E. J Am Med Inform Assoc. 2020 Apr 1;27(4):644–646. doi: 10.1093/jamia/ocz222. PMID: 32016394
55. Feeling and thinking: can theories of human motivation explain how EHR design impacts clinician burnout? Weir CR, Taber P, Taft T, et al. J Am Med Inform Assoc. 2020 Nov 12:ocaa270. doi: 10.1093/jamia/ocaa270. Online ahead of print. PMID: 33179026
56. Conceptual considerations for using EHR-based activity logs to measure clinician burnout and its effects. Kannampallil T., Abraham J., Lou S.S., Payne P.R.O. J Am Med Inform Assoc. 2020 Dec 22:ocaa305. doi: 10.1093/jamia/ocaa305. Online ahead of print. PMID: 33355360
57. Practicing Clinicians’ Recommendations to Reduce Burden from the ElectronicHealth Record Inbox: a Mixed-Methods Study. Murphy D.R., Satterly T., Giardina T.D., Sittig D.F., Singh H. J Gen Intern Med. 2019 Sep;34(9):1825–1832. doi: 10.1007/s11606–019–05112–5. Epub 2019 Jul 10. PMID: 31292905 Free PMC article.
58. Frontline Perspectives on Physician Burnout and Strategies to Improve Well-Being: Interviews with Physicians and Health System Leaders. Dillon E.C., Tai-Seale M., Meehan A., et al. J Gen Intern Med. 2020 Jan;35(1):261–267. doi: 10.1007/s11606-019-05381-0. Epub 2019 Oct 28. PMID: 31659668 Free PMC article.
59. Electronic health records: a critical appraisal of strengths and limitations. Kataria S., Ravindran V. J R Coll Physicians Edinb. 2020 Sep;50(3):262-268. doi: 10.4997/JRCPE.2020.309. PMID: 32936099 Review.
60. Organizational strategies to reduce physician burnout and improve professional fulfillment. Olson K., Marchalik D., Farley H., et al. Curr Probl Pediatr Adolesc Health Care. 2019 Dec;49(12):100664. doi: 10.1016/j.cppeds.2019.100664. Epub 2019 Oct 4. PMID: 3158801

Gabriela Velazquez, MD, London C. Guidry, MD, and Amit Chawla, MD, are vascular surgeons based in Winston-Salem, North Carolina; Baton Rouge, Louisiana; and New Orleans, respectively.