Settled science: The indisputable link between EHR and burnout

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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.

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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.

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