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Background Poorly functioning, time-consuming, and inadequate information systems are among the most important work-related psychosocial factors causing stress in physicians. The present study examined the trend in the perceived stress that was related to information systems (SRIS) among Finnish physicians during a nine-year follow-up. In addition, we examined the associations of gender, age, employment sector, specialization status, leadership position, on-call burden, and time pressure with SRIS change and levels. Methods A longitudinal design with three survey data collection waves (2006, 2010 and 2015) based on a random sample of Finnish physicians in 2006 was used. The study sample included 1095 physicians (62.3% women, mean age 54.4 years) who provided data on SRIS in every wave. GLM repeated measures analyses were used to examine the associations between independent variables and the SRIS trend during the years 2006, 2010, and 2015. Results SRIS increased during the study period. The estimated marginal mean of SRIS in 2006 was 2.80 (95% CI = 2.68–2.92) and the mean increase was 0.46 (95% CI = 0.30–0.61) points from 2006 to 2010 and 0.25 (95% CI = 0.11–0.39) points from 2010 to 2015. Moreover, our results show that the increase was most pronounced in primary care, whereas in hospitals SRIS did not increase between 2010 and 2015. SRIS increased more among those in a leadership position. On-call duties and high time-pressures were associated with higher SRIS levels during all waves. Conclusions Changing, difficult, and poorly functioning information systems (IS) are a prominent source of stress among Finnish physicians and this perceived stress continues to increase. Organizations should implement arrangements to ease stress stemming from IS especially for those with a high workload and on-call or leadership duties. To decrease IS-related stress, it would be important to study in more detail the main IS factors that contribute to SRIS. Earlier studies indicate that the usability and stability of information systems as well as end-user involvement in system development and work-procedure planning may be significant factors.
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R E S E A R C H A R T I C L E Open Access
Finnish physiciansstress related to
information systems keeps increasing: a
longitudinal three-wave survey study
Tarja Heponiemi
1*
, Hannele Hyppönen
1
, Tuulikki Vehko
1
, Sari Kujala
2
, Anna-Mari Aalto
1
, Jukka Vänskä
3
and Marko Elovainio
1,4
Abstract
Background: Poorly functioning, time-consuming, and inadequate information systems are among the most
important work-related psychosocial factors causing stress in physicians. The present study examined the trend in
the perceived stress that was related to information systems (SRIS) among Finnish physicians during a nine-year
follow-up. In addition, we examined the associations of gender, age, employment sector, specialization status,
leadership position, on-call burden, and time pressure with SRIS change and levels.
Methods: A longitudinal design with three survey data collection waves (2006, 2010 and 2015) based on a random
sample of Finnish physicians in 2006 was used. The study sample included 1095 physicians (62.3% women, mean
age 54.4 years) who provided data on SRIS in every wave. GLM repeated measures analyses were used to examine
the associations between independent variables and the SRIS trend during the years 2006, 2010, and 2015.
Results: SRIS increased during the study period. The estimated marginal mean of SRIS in 2006 was 2.80 (95%
CI = 2.682.92) and the mean increase was 0.46 (95% CI = 0.300.61) points from 2006 to 2010 and 0.25 (95%
CI = 0.110.39) points from 2010 to 2015. Moreover, our results show that the increase was most pronounced in
primary care, whereas in hospitals SRIS did not increase between 2010 and 2015. SRIS increased more among those in
a leadership position. On-call duties and high time-pressures were associated with higher SRIS levels during all waves.
Conclusions: Changing, difficult, and poorly functioning information systems (IS) are a prominent source of stress
among Finnish physicians and this perceived stress continues to increase. Organizations should implement
arrangements to ease stress stemming from IS especially for those with a high workload and on-call or leadership
duties. To decrease IS-related stress, it would be important to study in more detail the main IS factors that contribute
to SRIS. Earlier studies indicate that the usability and stability of information systems as well as end-user involvement in
system development and work-procedure planning may be significant factors.
Keywords: Information systems, Physicians, Stress, Electronic health records, Longitudinal research
Background
The most stressful work-related factors among physi-
cians have traditionally been time pressure, work load,
difficult patients, and problems in team work [13].
Recently, however, poorly functioning, time-consuming,
and inadequate information systems (IS) have emerged
as one of the most stressing factors in physicianswork
[4, 5]. Moreover, it has been shown that stress that is
related to information systems (SRIS) has increased in
the period 2006 to 2010 [6]. The use of IS has been
found to increase physiciansworkload [7] and cognitive
demands [8]. The resulting information chaos may have
ramifications, for example, for physician performance
and patient safety [9].
The increased number of functions in electronic health
records (EHRs) has been associated with more stress
and less job satisfaction [10]. In addition, time pressure
was more strongly related to negative outcomes such as
burnout, dissatisfaction, and intent to leave among those
* Correspondence: tarja.heponiemi@thl.fi
1
National Institute for Health and Welfare, P.O. Box 30, 00271 Helsinki, Finland
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Heponiemi et al. BMC Medical Informatics and Decision Making (2017) 17:147
DOI 10.1186/s12911-017-0545-y
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
physicians who had to manage a high number of EHR
functions compared to those managing a low number of
functions [10]. Poor EHR usability, time-consuming data
entry, interference with face-to-face patient care, inabil-
ity to exchange health information between health infor-
mation systems (HIS), and impairments in clinical
documentation have been found to be prominent
sources of physiciansprofessional dissatisfaction [11].
The traditional doctorpatient relationship has been
impacted by the use of HIS. Physicians have to turn to
the computer to complete electronic forms during the
encounter, and this can be time consuming, especially if
the physician suffers from limited computer skills. For
some physicians, aspects of EHRs represent a distraction
during visits [12]. In a US study, the average screen gaze
time of physicians ranged from 25% to 55% of the con-
sultancy session, inevitably meaning less eye-contact and
less conversation with the patient [13]. In the same
study, 92% of physicians felt that engagement with elec-
tronic medical records (EMR) disturbed communication
with their patients. Screen gaze has been found to be
particularly disruptive to psychosocial inquiry and emo-
tional responsiveness, indicating that visual attentiveness
to the monitor rather than eye contact with the patient
may inhibit sensitive or full patient disclosure [14]. It
has been found that after implementation of an EHR,
the physicians time in the clinical setting has transferred
from directly caring for patients to documenting in the
EHR [15]. Physicianshave been rated as having less ef-
fective communication when they spent more time look-
ing at the computer and when there were more periods
of silence in the consultation [16].
EHRs may be challenging to use because of the
multiplicity of screens, options, and navigational aids
[17]. However, the demands and pressures of care
may not allow physicians time to master all the com-
plex system functions [18]. Physicians may also see it
as a burden if forced to learn how to use the EHR
system effectively and efficiently. It is also possible
that a lack of appropriate skills and time to learn
them lead physicians to regard the EHR system as ex-
tremely complicated.
In addition, the ever-changing new functionalities and
systems require constant development of physicians
skills. In Finland in 2014, only 24% of physicians in
health centres and 37% in hospitals thought that HIS did
not require long orientation and only half of the physi-
cians knew where to give feedback about HIS problems
[19]. These ratings worsened after the year 2010. Many
physicians complain about poor service from the infor-
mation system vendor, including a lack of training and
support for problems [20]. However, IS changes may
also be a positive improvement, which might help to de-
crease stress levels related to IS.
The Finnish context
Finnish public health care is mainly financed through
taxation. All residents in Finland have a right to use
public health care services including primary health care
and specialized health care. Provision of health care ser-
vices is mainly in responsibility of municipalities. All
Finnish residents have a National Health Insurance
coverage partly reimbursing also the costs coming from
the use of private health services. The private sector
consists mainly on a) customers themselves paying and
purchasing their care or by using health insurances, and
b) occupational health services where employers pay ser-
vices for their employees. Private health care sector use
has increased from 2000 to 2009, though in the last few
years, the trend has been declining; in 2013, the private
sector constituted 5.9% of total health expenditure [21].
Some municipalities have outsourced parts or all of their
health centres through open tendering. However, most
of services are still provided by municipalities.
HIS have undergone notable recent reforms in
Finland, adding to the burden of dealing with novel
functionalities and systems. The public sector EHR
coverage in Finland reached 100% in 2010, while almost
every private sector provider also uses an EHR system
[21]. The EHR infrastructure is not uniform, however,
though the number of trade names has decreased and
since 2014, there have been five different trade names
operating in public secondary care and six in public pri-
mary care [21]. In a move towards integrated patient
data services, Finland has launched the national digital
repository for electronic patient data, Kanta, targeted to
health care service providers, pharmacies, and citizens,
which has been deployed in phases throughout Finland
during the period 20122017. Kanta services include
electronic prescription, My Kanta pages for citizens, a
patient data repository, and a pharmaceutical database.
Joining the Kanta services is mandatory for all public
health care providers, while private service providers
that use electronic documentation also have to join the
Kanta services. By the end of 2014, all pharmacies and
public service providers with the exception of one had
joined the national ePrescription service [21]. At that
time, a large proportion of private sector providers had
also joined, and the national ePrescription system was
almost fully implemented. From the beginning of 2017,
ePrescribing was the only and obligatory means for pre-
scribing and dispensing medications.
Aims of the study
The present study aimed to examine the 9-year longitu-
dinal development of SRIS levels among Finnish
physicians. SRIS levels were examined in three waves in
the years 2006, 2010 and 2015. Thus, the present study
adds to the previous literature by giving valuable
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Content courtesy of Springer Nature, terms of use apply. Rights reserved.
longitudinal information on how physicians experience
IS and how stressful experiences have developed both
recently and over the 9-year period.
Given that previous research has shown that age, gen-
der, employment sector, and specialty may have an effect
on EHR adoption and attitudes towards EHRs [2225],
we also examined the effects of these factors on the
levels and development of SRIS over the study period.
Moreover, the use of IS may lead to information chaos,
which is known to be influenced by mental workload
and time available to cope with this information chaos
[9]. Therefore, we also examined the effects of chal-
lenges at work, such as time pressures, on-call burden,
and leadership position, on levels and development of
SRIS over time. Thus, the present study also adds to pre-
vious research by examining possible work-related
correlates of SRIS.
Methods
Study sample
The present study is a part of the Finnish Health Care
Professionals Study that started in 2006. The data were
gathered from a random sample of 5000 physicians in
Finland (30% of the physician population) based on the
database of physicians maintained by the Finnish Med-
ical Association. The register covered all licensed physi-
cians in Finland. In wave 1 (2006), data were gathered
via postal questionnaires. Non-respondents were sent a
reminder and a copy of the questionnaire up to two
times. Responses were received from 2841 physicians
(response rate 57%). The sample was representative of
the eligible population in terms of age, gender, and em-
ployment sector [26]. Ethical approval for the study was
obtained from the Ethical Review Board of the National
Institute for Health and Welfare.
Four years later, in wave 2 (2010), data were gathered
via either a web-based or traditional postal survey. In
wave 1, respondents were asked for their consent to par-
ticipate in follow-up surveys, with 2206 agreeing to par-
ticipate in future surveys. Those who had died or had
incorrect address information were excluded (n= 37).
Thus, in wave 2, the follow-up survey was sent to 2169
physicians. First, an email invitation to participate in the
web-based survey was sent, which was followed by two
email reminders. For those who did not respond to
these, a postal questionnaire was sent once. Email and
postal addresses were obtained from the Finnish Medical
Association. The total number of respondents was 1705
(response rate 79%; 60% women).
In wave 3 (2015), data were gathered either via a web-
based or traditional postal survey. Questionnaires were
sent to those that gave consent for follow-up in the 2006
survey. Those who had died during the follow-up or
who had an unknown address in 2015 (n= 47) were
excluded, leaving 2159 physicians. Of these 1462 physi-
cians responded (response rate 68.3%). The present
study uses a subsample that includes 1095 physicians
(62.3% women, mean age 54.4, SD = 9.0, age range 34
72) who had answered the SRIS survey items in every
wave. The present sample included more women (57.4%
in eligible population), slightly older respondents (mean
age 47.3 in eligible population), and more specialists
(66.8% in our sample vs. 61.6 in eligible population)
compared to the eligible population.
Measurements
Stress related to information systems (SRIS) was mea-
sured with two items asking How often have you been
distracted, worried, or stressed about (during the past
half-year period) a) constantly changing information sys-
tems and b) difficult, poorly performing IT equipment /
software.The items were rated on a 5-point Likert-
scale ranging from 1 (never)to5(very often) with higher
scores indicating higher SRIS. A mean value for the two
items was calculated, with the reliability (Cronbachs
alpha) of this composite scale in the present sample be-
ing 0.84 in 2006, 0.84 in 2010, and 0.85 in 2015.
Employment sector was categorized into four groups in
the analyses: a) those who worked in primary care in
every wave (n= 162), b) those who worked in hospitals
in every wave (n= 343), c) those who worked in the pri-
vate sector in every wave (n= 102), and d) others
(n= 466). Specialization status was used from the first
wave in 2006 and it was categorized as a) not special-
ized, b) specialization ongoing, and c) specialists.
Leadership position was categorized into three groups:
a) those who had a leadership position in every wave
(n= 166), b) those who were not in a leadership position
in any wave (n= 559), and c) others (n= 323).
On-call burden was categorized into three groups: a)
those who had on-call duties in every wave (n= 318), b)
those who were not on-call in any wave (n= 431), and
c) others (n= 334).
Time pressure was measured with three items that
were developed based on previous research among
nurses and health care staff and which have shown ad-
equate psychometric properties [27]. The time-pressure
scale measures stress due to time shortages at work and
scheduling problems. An example item: How often have
you been distracted from, worried about, or stressed
about (during the past half-year period) not being able
to do your work properly.The items were rated on a 5-
point Likert-scale ranging from 1 (never)to5(very
often), with higher scores indicating higher time pres-
sure. A mean value of the three items was calculated
and the reliability of the composite scale in the present
sample was 0.84 in 2006, 0.87 in 2010, and 0.87 in 2015.
For the purpose of analyses, time pressure scores were
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categorized into three groups: a) those who had high
levels of time pressure in every wave (above the median
every time; n= 262), b) those who had low levels of time
pressure in every wave (below the median every time;
n= 296), and c) others (n= 534).
These above mentioned aggregated groups regarding
sector, leadership position, on-call duties and time pres-
sure were used for statistical analyses to get a measure
of cumulated exposure over time.
Statistical analysis
GLM repeated measures analysis was performed to exam-
ine the effects of independent variables (gender, age,
specialization status, employment sector, leadership pos-
ition, on-call burden, and time pressure) on the develop-
ment of SRIS over the study period. The associations of
Mauchlys Test of Sphericity indicated that the assumption
of sphericity had been violated, (p< .001), and therefore, a
Greenhouse-Geisser correction was used. All analyses
were conducted using the SPSS statistical package 23.0.
Results
The characteristics of the study sample are reported in
Table 1. The majority of respondents were specialized
already in 2006 and in 2015 the number of specialists
had further increased. The number of private physicians
had increased from 12% in 2006 to 22% in 2015, whereas
the numbers of primary care physicians and hospital
physicians had slightly decreased. The proportion of
those who had a leadership position had slightly in-
creased from 2006 to 2015. In contrast, the proportion
of those who had on-call duties had decreased from
2006 to 2015. Time pressure had decreased during the
study period (F = 54.1, p< 0.001).
The results of the GLM repeated measures analysis
showed that there was a significant effect of time on
SRIS (F =7.15,p= .001), indicating that SRIS had in-
creased during the study period. Post hoc tests using the
Bonferroni correction revealed that estimated marginal
means of SRIS starting from 2.80 (95% CI = 2.682.92)
in 2006 increased by an average of 0.46 (95% CI = 0.30
0.61) points from year 2006 to 2010 (p< 0.001) and then
increased by an additional 0.25 (95% CI = 0.110.39)
points between years 2010 and 2015 (p < 0.001).
Working/health-care sector had a significant inter-
action with time in relation to SRIS (F = 3.74,
p= 0.001). Those who had worked in primary care at all
time points had the highest increase in SRIS from 2006
to 2015 (Fig. 1). Those who had worked in hospitals had
the highest levels of SRIS in the years 2006 and 2010,
but in 2015 the SRIS levels had not increased further.
Among private sector physicians, the SRIS levels had in-
creased over the waves, but were less pronounced than
in other sectors.
Table 1 Characteristics of the study sample
2006 2010 2015 Whole period
a
n%n%n%n %
Specialization status
Not specialized 149 13.8 114 10.4 108 9.9
Specialization on-going 209 19.4 117 10.7 43 3.9
Specialists 721 66.8 862 78.9 934 85.6
Sector
Primary care 240 22.1 244 22.5 217 19.8 162 15.1
Hospital 482 44.5 479 44.2 443 40.5 343 32.0
Private 134 12.4 188 17.3 238 21.8 102 9.5
Other 228 21.0 173 16.0 196 17.9
Leadership position
Yes 305 28.5 345 31.6 343 32.0 166 15.2
No 767 71.5 746 68.4 728 68.0 559 51.1
On-call duties
Yes 586 53.7 471 43.1 389 35.7 318 29.0
No 505 46.3 622 56.9 700 64.3 431 39.4
Mean SD Mean SD Mean SD
SRIS 2.93 1.2 3.31 1.1 3.48 1.1
Time pressure 3.36 1.0 3.18 1.0 3.06 1.1
SRIS stress related to information systems
a
Aggregated frequencies showing those who were in the category in every measurement phase
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Leadership position had a significant interaction with
time in relation to SRIS (F = 2.80, p= 0.024). The high-
est increase of SRIS was among those who were in a
leadership position in every wave; in 2006 they had the
lowest levels of SRIS, but in 2015 the highest (Fig. 2).
Those who did not have a leadership position at all had
the highest levels in 2006, but their increase in SRIS was
not so pronounced as for others. The effect of on-call
burden did not vary across the different waves, but it
had a significant between-subjects effect (F = 4.86,
p= 0.008), indicating that those who had an on-call bur-
den in every wave had higher levels of SRIS in every
wave as well (Fig. 2). Similarly, the effect of time pres-
sure did not vary across the years, but it had a significant
between-subjects effect (F = 23.75, p< 0.001). Those
who had high levels of time pressure in every wave also
had high levels of SRIS in every wave (Fig. 2). Age was
not related to SRIS.
Discussion
The present 9-year longitudinal study with three waves
shows that stress that was related to ever-changing, diffi-
cult, and poorly functioning information systems has in-
creased among Finnish physicians between 2006 and
2015. Moreover, our results show that this increase was
most pronounced in primary care, whereas in hospitals
this increase had stopped between 2010 and 2015. Those
who had a leadership position in every wave had a
higher increase of SRIS than those who did not have a
leadership position at all. The effects of burden coming
from on-call duties and high time pressures did not vary
across time: Those who had on-call duties or high time
pressures in every wave also had higher levels of SRIS
than their counterparts in every wave.
Our findings are in line with previous findings related
to HIS showing that physicians suffer from strain and
stress from poorly functioning and inadequate HIS [46,
19, 28]. Our results also show that IS-related stress
keeps increasing. According to other studies, physicians
complain about HIS that work too slowly and unreliably
and that poorly support physiciansdaily work and mul-
tiprofessional co-operation [4, 28]. They also rate their
EHR systems very critically, reporting several usability
problems, system failures, and deficiencies as well as
poor support for the documentation and retrieval of pa-
tient data [25, 29]. Poor EHR usability, time-consuming
data entry, interference with face-to-face patient care,
and inability to exchange health information have been
associated with physiciansprofessional dissatisfaction
[11], while a higher number of EHR functions has been
associated with stress and job dissatisfaction [10, 11].
However, even though physicians experience stress
from problems associated with IS, previous studies have
shown that they also acknowledge their value. For
Fig. 1 The levels of stress related to information systems (SRIS)
according to employment sector
Fig. 2 The levels of stress related to information systems (SRIS) according
to leadership position, on-call burden and time pressure burden
Heponiemi et al. BMC Medical Informatics and Decision Making (2017) 17:147 Page 5 of 8
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example, primary care physicians in Scotland considered
that EHRs are an essential part of their work during a
consultation and facilitate patient care and make infor-
mation more accessible [30]. However, they pointed out
issues that needed improving, such as system failures,
information overload, difficulties in adjusting to new sys-
tems, interoperability problems, and poor usability.
Swedish physicians regarded their EHR system as easy
to use in general and for prescribing drugs, while be-
lieved ePrescriptions to be time saving and safer than
handwritten prescriptions [31].
We showed that primary care physicians had the high-
est increase of SRIS from 2006 to 2015 and their levels
of SRIS were highest in 2015. In contrast, hospital physi-
cians had the highest levels in 2006 and 2010, but in
2015 their levels had not increased further from 2010
levels. Thus, our results suggest that in hospitals, the
negative trend related to IS has levelled out. Previous
studies with another sample have shown that in 2010
and in 2014, hospital physicians were most critical of
HIS in Finland [4, 28]. Also results from the USA sug-
gest that hospital physicians have worse attitudes about
EMRs [32]. One reason for the levelling out of SRIS
among Finnish hospital physicians might be that im-
provements in usability of the systems used in the hospi-
tals may have been implemented. Moreover, the national
information services platform (ePrescription and eArc-
hive) have been implemented between 2010 and 2015,
supporting medication management and summary views
of patient data. It may also be that changes in the con-
text of other than information technology (IT) have lev-
elled out the impact of poor usability of IS in Finnish
hospitals. The actual effect of IS on the levelling of SRIS
in hospitals requires further examination and it would
be important to obtain more information about which
changes in IS are stressful and which are helpful. This
seems to be a double-edged sword: On the one hand,
changing systems are a source of stress, but on the other
hand they may offer improvements and reduce strain.
Our finding that private physicians had the lowest levels
of SRIS throughout the study period is in accordance with
previous findings. A previous Finnish study found that pri-
vate physicians are more satisfied with their electronic pa-
tient records (EPR) than public sector physicians [33].
Especially private sector physicians were more satisfied
with the stability and speed of their EPRs, as well as ex-
periencing less often endangering of patient safety related
to EPRs. Compared to responses from the public sector
(primary care and hospitals), Finnish physicians working
in the private sector have been more satisfied with their
EHR systems, specifically the user interface characteristics
and support for routine tasks [25].
We found that constantly changing, poorly function-
ing, and difficult information systems are experienced as
the most stressful when facing more other work-related
challenges, such as high job-demands and a need to
hurry. High time pressures and on-call burden were
associated with high SRIS in all the study waves and
leadership position in the last wave. Thus, the
complexity, time-pressure, and distraction aspects of
EHRs [12, 13, 15, 17] seem to be most strenuous when
the work is already challenging and the physician has
difficulties in coping with the work.
The present study was a 9-year longitudinal study with
three measurement phases with an interval of 45 years.
The doings and working places of the respondents be-
tween the study measurements is not possible to know.
Thus, respondent may have held other positions be-
tween the measurements than during the measurement
phases. Moreover, we used self-reported measures, and
this may be associated with problems in inflation of the
strengths of relationships and with common-method
variance. Therefore, well-known validated measures
showing good reliability were used. Our key limitation is
that our main variable SRIS was a mean of only two
items rather than on many elements. However, this
variable showed good reliability (0.840.85) and has pre-
viously been widely used and associated, for example,
with employeesdistress (General Health Questionnaire)
and higher levels of on-call duties [34, 35].
Moreover, although we controlled for factors such as
age, gender, and specialization, we cannot rule out the
possibility of residual confounding. In addition, our
sample is not completely representative of the present
physician population in Finland. Our sample included
more women, older physicians, and more specialists than
the eligible population in 2015. Our findings should
not be generalized to health care systems using differ-
ent kinds of IT-systems or dissimilar styles of organ-
izing health care.
Conclusions
The present study found that poorly functioning IS are a
prominent source of stress among Finnish physicians
and this stress continues to increase. This is alarming
particularly since SRIS has been associated with higher
levels of distress, lower self-rated health, and lower work
ability [35]. Thus, health organizations and software pro-
viders should take more seriously the problems with IS
in health care.
It is alarming that stress levels due to IS continue to
increase among physicians. IS have become a part of
everyday life for physicians over a period of several years
and previous studies suggest that with time and practice,
the influence of poor usability will diminish [36]. In par-
allel to learning, one would assume that stress levels
would also level out. The fact that stress levels still con-
tinue to rise implies that current information systems
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are too complicated, even after years of trying to learn,
especially in the context of high time pressures. In
Finland, several new systems have been adopted over the
study period and stress cumulates when physicians have
to get used to new systems before they have even
become accustomed to previous systems.
We found support for the suggestion that high mental
workload and lack of time to cope among physicians
may have an effect on the ramifications of information
chaos resulting from IS [9]. Thus, organizations should
pay more attention to the overall strain that physicians
experience. In addition, organizations should implement
arrangements to ease the stress and extra duties coming
from IS for those with high job strain, such as high
workload and a lot of on-call or leadership duties.
However, the present study also found promising re-
sults, given that hospitals had been able to stem the in-
crease in SRIS. Future studies should try to find IS and
work-related factors that could help to ease the stress
coming from poorly functioning IS in health care. Of
course, it would be most important to improve the us-
ability and stability of the systems, as well as to involve
end-users in the development of HIS and in the plan-
ning of work procedures.
Abbreviations
EHR: Electronic health record; EMR: Electronic medical record; EPR: Electronic
patient record; HIS: Health information systems; IS: Information systems;
IT: Information technology; SRIS: Stress related to information systems
Acknowledgements
None
Funding
This study was supported by the Finnish Work Environment Fund (project 116104),
the Strategic Research Council at the Academy of Finland (project 303607) and the
Ministry of Social Affairs and Health (project 112241). None of them had any role in
the design of the study and collection, analysis, and interpretation of data and in
writing.
Availability of data and materials
The datasets during and/or analyzed during the current study available from
the corresponding author on reasonable request.
Authorscontributions
TH performed the statistical analysis, participated in its design and drafted
the manuscript. HH, SK and TV were involved in drafting the manuscript and
in revising it critically for important intellectual content. JV and AA
participated in the design and coordination of the study and helped to draft
the manuscript. ME conceived of the study, and participated in its design
and coordination and helped to draft the manuscript. All authors read and
approved the final manuscript.
Ethics approval and consent to participate
Ethical approval for the study was obtained from National Institute for Health
and Welfare (former National Research and Development Centre for Welfare
and Health). The respondents were asked their consent in the first wave in
2006. The survey script also reminded the participants that they were under
no obligation to complete and/or submit the survey.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
PublishersNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
National Institute for Health and Welfare, P.O. Box 30, 00271 Helsinki,
Finland.
2
Aalto university, Espoo, Finland.
3
Finnish Medical Association,
Helsinki, Finland.
4
University of Helsinki, Helsinki, Finland.
Received: 20 April 2017 Accepted: 9 October 2017
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... According to previous studies, information systems respond poorly to the needs of physicians, thus accumulating masses of criticism and contributing to poor well-being [11,14,17,18]. Physicians' complaints regarding information systems often include aspects related to poor functionality and usability [11,17,19,20], and several IS-related factors have been directly associated with distress, stress, and burnout for healthcare professionals [13,20]. Moreover, coping with poorly functioning or difficult to use information systems is especially difficult if there are other stressful work factors, such as time pressure [12,19]. ...
... Physicians' complaints regarding information systems often include aspects related to poor functionality and usability [11,17,19,20], and several IS-related factors have been directly associated with distress, stress, and burnout for healthcare professionals [13,20]. Moreover, coping with poorly functioning or difficult to use information systems is especially difficult if there are other stressful work factors, such as time pressure [12,19]. Unfortunately, frequently changing systems require physicians to continuously update their knowledge on information systems, and learning to use these systems requires time and training [17,21]. ...
... SAIS was measured with the mean of the two items and the scale's reliability was good in the present sample (Spearman-Brown reliability estimate = 0.76). This measure of SAIS has been previously used in a longitudinal study where it showed good reliability [19], and it has also previously been associated with lower work ability, higher levels of distress and lower self-estimated health [32]. ...
Article
Full-text available
Background Physicians commonly suffer from workplace aggression and its negative consequences. Previous studies have shown that stressors such as job demands increase the risk of inappropriate treatment at workplace. Poorly functioning, and constantly changing information systems form a major work stressor for physicians. The current study examined the association between physicians’ stress attributed to information systems (SAIS) and their experiences of workplace aggression. Workplace aggression covered physical and non-physical aggression, perpetrated by coworkers, patients, patient’s relatives, or supervisors. Methods A cross-sectional survey study was conducted. The participants included 2786 physicians (67.4% women) who were sampled randomly from the registry of Finnish Medical Association, which covers almost all of the Finnish physician population. First, bivariate associations were studied among participant characteristics, SAIS and workplace aggression. Logistic regression analysis was then used to further determine how SAIS was associated with the likelihood of experiencing different types of aggression. Results Higher levels of SAIS were associated with higher likelihood of aggression with regard to all types of aggression, except non-physical aggression perpetrated by patients or relatives. The demographic factors (work-sector, gender, age) did not have a noticeable influence on the association between SAIS and aggression. Conclusions The present results build on previous evidence on the prevalence of SAIS and its negative effects on healthcare workers. Since SAIS may increase the risk of experiencing aggression, it is possible that SAIS also endangers the wellbeing of physicians and thereby the quality of patient care. Resourcing time and training during introduction of a new IS could alleviate time pressure and thus stress attributed to managing new information systems. The role of organizational climate and general workload in arousing SAIS and aggression should be examined in future studies.
... Poorly functioning and constantly changing information systems may elicit this kind of stress appraisal, which can be designated as stress related to information systems (SRIS). For example, information systems have emerged as one of the highest stress-inducing factors among Finnish physicians alongside time pressure and patient-related stress [19][20][21]. Previous findings show that SRIS has increased in the 21st century among physicians [19,21], and the usability of EHRs has an effect on its levels [22]. ...
... For example, information systems have emerged as one of the highest stress-inducing factors among Finnish physicians alongside time pressure and patient-related stress [19][20][21]. Previous findings show that SRIS has increased in the 21st century among physicians [19,21], and the usability of EHRs has an effect on its levels [22]. However, SRIS is less studied among nurses and more information is needed. ...
... This measure was developed in Finland when examining the health and well-being of physicians. [19][20][21]. It has previously been associated with, for example, experience in using information systems, cognitive workload, distress, and EHR usability [19,22]. ...
Article
Full-text available
Background: High expectations have been set for the implementations of health information systems (HIS) in health care. However, nurses have been dissatisfied after implementations of HIS. In particular, poorly functioning electronic health records (EHRs) have been found to induce stress and cognitive workload. Moreover, the need to learn new systems may require considerable effort from nurses. Thus, EHR implementations may have an effect on the well-being of nurses. Objective: This study aimed to examine the associations of EHR-to-EHR implementations and the sufficiency of related training with perceived stress related to information systems (SRIS), time pressure, and cognitive failures among registered nurses. Moreover, we examined the moderating effect of the employment sector (hospital, primary care, social services, and others) on these associations. Methods: This study was a cross-sectional survey study of 3610 registered Finnish nurses in 2020. EHR implementation was measured by assessing whether the work unit of each respondent had implemented or will implement a new EHR (1) within the last 6 months, (2) within the last 12 months, (3) in the next 12 months, and (4) at no point within the last 12 months or in the forthcoming 12 months. The associations were examined using analyses of covariance adjusted for age, gender, and employment sector. Results: The highest levels of SRIS (adjusted mean 4.07, SE 0.05) and time pressure (adjusted mean 4.55, SE 0.06) were observed among those who had experienced an EHR implementation within the last 6 months. The lowest levels of SRIS (adjusted mean 3.26, SE 0.04), time pressure (adjusted mean 4.41, SE 0.05), and cognitive failures (adjusted mean 1.84, SE 0.02) were observed among those who did not experience any completed or forthcoming implementations within 12 months. Nurses who perceived that they had received sufficient implementation-related training experienced less SRIS (F1=153.40, P<.001), time pressure (F1=80.95, P<.001), and cognitive failures (F1=34.96, P<.001) than those who had received insufficient training. Recent implementations and insufficient training were especially strongly associated with high levels of SRIS in hospitals. Conclusions: EHR implementations and insufficient training related to these implementations may endanger the well-being of nurses and even lead to errors. Thus, it is extremely important for organizations to offer comprehensive training before, during, and after implementations. Moreover, easy-to-use systems that allow transition periods, a re-engineering approach, and user involvement may be beneficial to nurses in the implementation process. Training and other improvements would be especially important in hospitals.
... Well-being is also often viewed through psychological distress, which refers to a state of emotional suffering associated with demands and stressors that a person finds difficult to deal with in daily life (General Health Questionnaire, GHO, being one of the most widely used and established measurements) [9,10]. Stress related to information systems (SRIS) refers to the stress caused by poorly functioning or constantly changing information systems [11]. Nurses' SRIS has so far been little studied [12] compared with, for example, physicians'. ...
... Nurses' SRIS has so far been little studied [12] compared with, for example, physicians'. Among physicians, SRIS has steadily increased in recent years [11], and using information systems with multiple functions has been associated with stress, especially if the work involves high time pressure [13][14][15]. Similarly, with nurses, information systems, such as demanding and detailed documentation in health records, have been found to take more time out of daily work than before [16,17] and to be a considerable source of stress [18]. ...
... SRIS was measured by two items (α = 0.62) that assessed how often a person has been distracted, worried, or stressed during the last six months about (1) constantly changing information systems and (2) difficult, poorly functioning IT equipment/software [11] on a five-point scale (ranging from 1 = 'very rarely or never' to 5 = 'very often or constantly'). The measure has been used in studies that have included physicians and has been associated with, for example, psychological distress (Heponiemi et al., 2018; Heponiemi et al., 2019). ...
Article
Full-text available
Abstract Background The use of information systems takes up a significant amount of nurses’ daily working time. Increased use of the systems requires nurses to have adequate competence in nursing informatics and is known to be a potential source of stress. However, little is known about the role of nursing informatics competence and stress related to information systems (SRIS) in the well-being of nurses. Moreover, the potential impact of nurses’ career stage on this matter is unknown. This study examined whether SRIS and nursing informatics competence are associated with stress and psychological distress in newly graduated nurses (NGNs) and experienced nurses. Methods A cross-sectional study was conducted in Finland between October and December 2018. The participants were NGNs (n = 712) with less than two years of work experience and experienced nurses (n = 1226) with more than two years of work experience. The associations of nursing informatics and SRIS with nurses’ stress and psychological distress were analyzed with linear regression analysis. Analyses were conducted separately for NGNs and experienced nurses. Models were adjusted for age, gender, and work environment. Results SRIS was associated with stress / psychological distress for both NGNs (β = 0.26 p
... The results of previous surveys have been published in several national and international papers and reports. The publications cover several topics, e.g: usability of the health information systems Kaipio et al. 2019;Viitanen et al. 2022), end-user participation on health information systems development (Martikainen et al. 2020), health information exchange , associations of different aspects of health information systems on well-being in work (Martikainen et al. 2011;Vainiomäki et al. 2017;Heponiemi et al. 2017;Heponiemi et al. 2019), validation of the National usability focused Health Information Systems-scale , and data description /assessment of representativeness Vänskä et al. 2014;Saastamoinen et al. 2018). In addition, the results of the previous surveys are summarized in the e-health and ewelfare of Finland check point reports . ...
Chapter
Full-text available
Monitoring the experiences of social welfare professionals with client information systems (CISs) is necessary in the digital transformation of the social service systems. Digitalization is one of the most significant developments that have changed human society, infiltrating almost all human activity. In social welfare and healthcare, digitized technology has pervaded and changed the entire service delivery system, the way professionals work and provide services for clients, and the ways of producing, sharing and archiving information (Ministry of Social Affairs and Health, 2015; Jormanainen & Reponen, 2020; Steiner, 2021; Breit et al., 2021). Successful adoption of technologies such as CISs requires thorough planning from organizations and new digital competences from professionals (Kujala et al., 2018; Zhu & Andersen, aheadof-print). In this chapter, the results of a national survey of social welfare professionals’ experiences of CISs are presented. The experiences are viewed from the perspective of CIS usability, information retrieval and exchange, participation in development and support for knowledge-based management. The results are presented by comparing the experiences of public sector employees with those working in the private or third sector. The first pilot survey among social welfare professionals was conducted in 2019 (Ylönen et al., 2020; Martikainen et al., 2021), however, this is the first time a national survey with social welfare professionals was carried out as part of the Monitoring and assessment of social welfare and healthcare information system services 3.0 project (STePS 3.0) (Salovaara et al., 2022).
... The results of previous surveys have been published in several national and international papers and reports. The publications cover several topics, e.g: usability of the health information systems Kaipio et al. 2019;Viitanen et al. 2022), end-user participation on health information systems development (Martikainen et al. 2020), health information exchange , associations of different aspects of health information systems on well-being in work (Martikainen et al. 2011;Vainiomäki et al. 2017;Heponiemi et al. 2017;Heponiemi et al. 2019), validation of the National usability focused Health Information Systems-scale , and data description /assessment of representativeness Vänskä et al. 2014;Saastamoinen et al. 2018). In addition, the results of the previous surveys are summarized in the e-health and ewelfare of Finland check point reports . ...
Chapter
Full-text available
There are different types of e-services available for citizens in Finland. Some services include a professional contact, some are designed to support self-care or information exchange. The most used electronic healthcare service is the national health data repository’s client interface for citizens, My Kanta Pages, that offers for example information of the prescriptions and healthcare records of the user and the possibility to give or deny a consent to information exchange between different care providers. Other national e-services include a mobile application for emergency situations (112 Suomi), a symptom assessment service (Omaolo), a health information site (Terveyskirjasto), a social security service (OmaKela) and a special healthcare service offering care pathways that require a referral (Terveyskylä). Besides national services, cities, regions, and municipal consortiums offer their residents local e-services for taking care of both social welfare and healthcare issues. https://urn.fi/URN:ISBN:978-952-343-891-0
... Physicians have expressed concerns about the impact of digitalization on information overload and ambiguity, interaction with patients, privacy issues, disruptions to workflows, and increasing workloads [5,34,[36][37][38][39]. The digitalization of work has also been found to be associated with the stress levels of physicians [40,41]. Dissatisfaction has been particularly associated with the implementation of new EHRs [42][43][44][45] and the subsequent transition period [46]. ...
Article
Full-text available
Background In health care, the benefits of digitalization need to outweigh the risks, but there is limited knowledge about the factors affecting this balance in the work environment of physicians. To achieve the benefits of digitalization, a more comprehensive understanding of this complex phenomenon related to the digitalization of physicians’ work is needed. Objective The aim of this study was to examine physicians’ perceptions of the effects of health care digitalization on their work and to analyze how these perceptions are associated with multiple factors related to work and digital health usage. Methods A representative sample of 4630 (response rate 24.46%) Finnish physicians (2960/4617, 64.11% women) was used. Statements measuring the perceived effects of digitalization on work included the patients’ active role, preventive work, interprofessional cooperation, decision support, access to patient information, and faster consultations. Network analysis of the perceived effects of digitalization and factors related to work and digital health usage was conducted using mixed graphical modeling. Adjusted and standardized regression coefficients are denoted by b. Centrality statistics were examined to evaluate the relative influence of each variable in terms of node strength. Results Nearly half of physicians considered that digitalization has promoted an active role for patients in their own care (2104/4537, 46.37%) and easier access to patient information (1986/4551, 43.64%), but only 1 in 10 (445/4529, 9.82%) felt that the impact has been positive on consultation times with patients. Almost half of the respondents estimated that digitalization has neither increased nor decreased the possibilities for preventive work (2036/4506, 45.18%) and supportiveness of clinical decision support systems (1941/4458, 43.54%). When all variables were integrated into the network, the most influential variables were purpose of using health information systems, employment sector, and specialization status. However, the grade given to the electronic health record (EHR) system that was primarily used had the strongest direct links to faster consultations (b=0.32) and facilitated access to patient information (b=0.28). At least 6 months of use of the main EHR was associated with facilitated access to patient information (b=0.18). Conclusions The results highlight the complex interdependence of multiple factors associated with the perceived effects of digitalization on physicians’ work. It seems that a high-quality EHR system is critical for promoting smooth clinical practice. In addition, work-related factors may influence other factors that affect digital health success. These factors should be considered when developing and implementing new digital health technologies or services for physicians’ work. The adoption of digital health is not just a technological project but a project that changes existing work practices.
... Palveluiden suunnittelun lähtökohtana tulisi käyttäjäkeskeisen suunnittelun periaatteiden mukaisesti olla ymmärrys käyttökontekstista sisältäen käyttäjien piirteet ja tavoitteet, käyttöympäristöt, tavoitellut tehtävät, sekä muut laitteet ja sovellukset [12]. Ammattilaisten näkökulmasta on tärkeää, että sähköisten terveyspalveluiden suunnittelussa huomioidaan myös heidän näkökulmansa, sillä tutkimusten perusteella uusien järjestelmien ja sovellusten on todettu aiheuttavan ammattilaisille tarpeetonta lisätyötä, vievän aikaa varsinaiselta potilastyötä ja johtavan kuormittuneisuuden lisääntymiseen työssä [13,14]. Ammattilaisten huomiointi jää helposti vähemmälle järjestelmien toteutusvaiheessa ennen käyttöönottoa, jolloin järjestelmien käytettävyys ontuu eivätkä ne aidosti sovellu potilaan ja hoitohenkilökunnan arkeen, minkä seurauksena järjestelmät voivat jäädä lopulta käyttämättä [15]. ...
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... Myös aiempi tutkimus on osoittanut koronaviruspandemian aiheuttaneen useita muu toksia, jotka ovat lisänneet terveydenhuollon työntekijöiden stressiä (11). Tietojärjestelmät ja niihin kytkeytyvät tekniset ongelmat ylipäätään lisäävät terveydenhuollon työntekijöiden koke maa stressiä, jota puolestaan helpottaa tietojär jestelmien käyttäjäystävällisyys (33). Aiemmat tut kimukset osoittavat, että Suomessa tietojärjes telmiin liittyvä stressi on lisääntynyt terveyden huollossa 2000luvulla ja siitä on muodostunut yksi keskeinen kuormitustekijä terveydenhuollon ammattilaisille (34,35). ...
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... Based on the literature, the direction of effects should be that exposure to techno-stressors leads to IT-related strain, which negatively impacts job satisfaction 11 . Again, in accordance with previous research, we found that good HIT usability is associated with lower levels of perceived technostress and IT-related strain and vice versa 10,20,26,27 . Therefore, HIT designers should focus on making their products reliable, useful for the end user, and easy to operate. ...
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Objective: To evaluate associations between the electronic environment, clerical burden, and burnout in US physicians. Participants and methods: Physicians across all specialties in the United States were surveyed between August and October 2014. Physicians provided information regarding use of electronic health records (EHRs), computerized physician order entry (CPOE), and electronic patient portals. Burnout was measured using validated metrics. Results: Of 6375 responding physicians in active practice, 5389 (84.5%) reported that they used EHRs. Of 5892 physicians who indicated that CPOE was relevant to their specialty, 4858 (82.5%) reported using CPOE. Physicians who used EHRs and CPOE had lower satisfaction with the amount of time spent on clerical tasks and higher rates of burnout on univariate analysis. On multivariable analysis, physicians who used EHRs (odds ratio [OR]=0.67; 95% CI, 0.57-0.79; P<.001) or CPOE (OR=0.72; 95% CI, 0.62-0.84; P<.001) were less likely to be satisfied with the amount of time spent on clerical tasks after adjusting for age, sex, specialty, practice setting, and hours worked per week. Use of CPOE was also associated with a higher risk of burnout after adjusting for these same factors (OR=1.29; 95% CI, 1.12-1.48; P<.001). Use of EHRs was not associated with burnout in adjusted models controlling for CPOE and other factors. Conclusion: In this large national study, physicians' satisfaction with their EHRs and CPOE was generally low. Physicians who used EHRs and CPOE were less satisfied with the amount of time spent on clerical tasks and were at higher risk for professional burnout.
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Background Work done in the emergency departments is one stressful aspect of physicians’ work. Numerous previous studies have highlighted the stressfulness of on-call work and especially of night on call. In addition, previous studies suggest that there may be individual differences in adjusting to changes in circadian rhythms and on-call work. Objective The objective of this study was to examine whether physicians’ on-call work is associated with perceived work-related stress factors and job resources and whether there are groups that are more vulnerable to on-call work according to sex, age, and specialization status. Methods This was a cross-sectional questionnaire study among 3230 Finnish physicians (61.5% women). The analyses were conducted using analyses of covariance adjusted for sex, age, specialization status, and employment sector. Results Physicians with on-call duties had more time pressure and stress related to team work and patient information systems compared with those who did not have on-call duties. In addition, they had less job control opportunities and experienced organization as less fair and team climate as worse. Older physicians and specialists seemed to be especially vulnerable to on-call work regarding stress factors, whereas younger and specialist trainees seemed vulnerable to on-call work regarding job resources. Conclusions Focusing on team issues and resources is important for younger physicians and trainees having on-call duties, whereas for older and specialists, attention should be focused on actual work load and time pressure.
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Background: As adoption and use of electronic health records (EHRs) grows in the United States, there is a growing need in the field of applied clinical informatics to evaluate physician perceptions and beliefs about the impact of EHRs. The meaningful use of EHR incentive program provides a suitable context to examine physician beliefs about the impact of EHRs. Objective: Contribute to the sparse literature on physician beliefs about the impact of EHRs in areas such as quality of care, effectiveness of care, and delivery of care. Methods: A cross-sectional online survey of physicians at two academic medical centers (AMCs) in the northeast who were preparing to qualify for the meaningful use of EHR incentive program. Results: Of the 1,797 physicians at both AMCs who were preparing to qualify for the incentive program, 967 completed the survey for an overall response rate of 54%. Only 23% and 27% of physicians agreed or strongly agreed that meaningful use of the EHR will help them improve the care they personally deliver and improve quality of care respectively. Physician specialty was significantly associated with beliefs; e.g., 35% of primary care physicians agreed or strongly agreed that meaningful use will improve quality of care compared to 26% of medical specialists and 21% of surgical specialists (p=0.009). Satisfaction with outpatient EHR was also significantly related to all belief items. Conclusions: Only about a quarter of physicians in our study responded positively that meaningful use of the EHR will improve quality of care and the care they personally provide. These findings are similar to and extend findings from qualitative studies about negative perceptions that physicians hold about the impact of EHRs. Factors outside of the regulatory context, such as physician beliefs, need to be considered in the implementation of the meaningful use of the EHR incentive program.
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Objectives/HypothesisTo evaluate the impact of electronic health records (EHRs) on the workflow of otolaryngology residents.Study DesignProspective, time-motion study.MethodsA time-motion study was conducted both in the 2009 to 2010 and 2012 to 2013 postgraduate years. Eight otolaryngology residents were directly observed on both operative and clinic days, with resident activities categorized by way of a database program. Comparisons were made to the same data collected in the same setting prior to and following integration of an EHR system.ResultsResidents spent their day on direct patient care (41.1%), indirect patient care (35.3%), didactic education (14.0%), personal activities (6.9%), and transit (3.1%). The primary activity during operative days was direct patient care, and during clinic days it was indirect patient care. Activities of marginal educational value comprised a considerable component of their time (16.5%). Compared to data collected prior to use of an EHR, time was spent similarly. However, residents using an EHR devoted significantly more time to indirect patient care on clinic days (P < .05).Conclusions This is the first study to evaluate EHR integration on otolaryngology resident workflow. Overall resident efficiency was not significantly altered by the implementation of an EHR. However, more time was shifted from directly caring for patients to documenting on the EHR in the clinic setting. These findings provide an important objective insight into EHRs, especially given the looming mandate for their use and the need to streamline resident curriculum in the duty hours era.Level of Evidence4. Laryngoscope, 2014