No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Pajama Time: Working After Work in the Electronic Health Record
... Pajama Time is a term attributed in academic literature to characterize physician time spent using the EHR (computer) after the end of a scheduled shift (i.e., on administrative actions such as writing clinical notes). [10][11][12] In this study, we defined pajama time as any EHR use that occurred within two days after in-person observation concluded or before the physician's next clinical shift. 10,11,13 Pajama time was measured using EHR event logs capturing EHR actions up to 48 hours after the observed shift day (two-day span), which included EHR use occurring either on-site at the medical center or elsewhere (i.e., at home). ...
... [10][11][12] In this study, we defined pajama time as any EHR use that occurred within two days after in-person observation concluded or before the physician's next clinical shift. 10,11,13 Pajama time was measured using EHR event logs capturing EHR actions up to 48 hours after the observed shift day (two-day span), which included EHR use occurring either on-site at the medical center or elsewhere (i.e., at home). See Figure 1. ...
... [21][22][23][24] This study combines data from both in-person time-motion observations and EHR event log data to demonstrate that the burden of computer use is not limited to time onshift but also commonly extends hours beyond the end of clinical shifts. 10,12,16 While EHRs facilitate improved patient care by providing physicians access to patients' prior medical histories and test results, for example, they also complicate the clinical work environment and may lead to unintended consequences such as limiting physician time at patients' bedsides. 25,26 Emergency physicians are required to adhere to documentation requirements, including written medical histories, physical examinations, interpretations of diagnostic test results, and medical decision-making notes. ...
Background: Emergency physicians face considerable workflow challenges due to unpredictable work environments, frequent interruptions, and mounting documentation requirements. Excessive time away from direct patient care is increasingly viewed as detrimental to care quality, communication, and patient safety. This study aimed to quantify and visualize the time emergency physicians spend on specific activities during their clinical shifts, particularly computer usage.
Methods: This observational time-motion study was conducted in a high-volume, urban emergency department (ED). An observer used a web-based application to track physician activities including computer use, direct patient care, and all other major tasks carried out on shift. Electronic health record (EHR) event log data was queried to measure computer use after each physician′s scheduled shift. The primary outcome was total minutes of computer time (during and after shift) per scheduled hour of clinical work.
Results: The observer tracked 20 emergency physicians for one 8-9h clinical shift each, which generated 150.0 hours of real-time observation data quantifying physicians′ ED workflow. In total, emergency physicians spent a median 29.8 minutes (IQR 25.6-38.5) on the computer per scheduled hour of their ED shift. Physicians spent a median 34.1% of their shift time using the computer and 26.9% with patients. Other activities included verbal communication with staff (15.9%), phone use (9.5%), miscellaneous tasks (5.5%), personal time (3.9%), electrocardiogram review (0.7%), and procedures (0.4%). EHR log analysis showed that physicians spent an additional median 1.3h (IQR 0.5-2.6) using the computer after their scheduled shifts.
Conclusion: Emergency physicians spent more than one-third of their ED shift working on the computer, which was more time than they spent with patients. They also spent 1-2 hours using the computer after their shifts. These findings demonstrate the need for strategies aimed at reducing unnecessary computer use during and after clinical shifts to enhance efficiency and improve patient care.
... Reported time-based measures included total time in the EHR (49 articles), 3 3,4,19,[24][25][26][27]29,31,32,35,36,40,44,45,48,51,[55][56][57][58] and time outside of normal working hours (35 articles). 3,4,6,19,25,[27][28][29][30]32,34,[36][37][38][39][40][41][42][43][44][47][48][49][50][51]53,55,66,67,[69][70][71][72]77,119 Vendor-measure studies were more likely than investigator-measure studies to report each of these 6 time-based measures (P < .001 in each case). While all vendor-measure studies reported at least 1 duration of active EHR use (e.g., EHR time, inbox time), just 28% of investigator-measure studies did so, with the remainder reporting specific measures related to counts of EHR actions (e.g., number of records opened, number of searches performed), the structure of clinical teams (e.g., betweenness, centrality), or the duration of clinical events (e.g., exam length, duration of shift). ...
... Twenty-two studies reported a measure based on a set time period, of which 7 unique periods were used 4,6,19,25,27,29,32,34,36,39,40,42,48,49,51,53,55,66,[69][70][71] An overlapping set of 22 articles, including 9 that also reported time period-based measures, reported at least 1 measure based on clinician schedules. 4,6,19,27,28,30,34,37,38,40,41,43,44,[47][48][49][50]67,69,72,77,119 These included time outside scheduled hours on days with appointments, time on days without appointments, and time after the patient checked out. These schedule-based measures differed in whether they (1) measured active EHR use or all time logged into the EHR, (2) included mid-day meetings or breaks in scheduled hours, or (3) included the 30 or 60 min before and after the first and last appointment of the day in scheduled hours. ...
... The most frequent denominator was days (31 articles) including days in a reporting period, days with a scheduled appointment/shift, weekdays, or weekend days/holidays. [2][3][4]24,26,27,31,[34][35][36]38,40,41,[43][44][45][46][48][49][50]52,54,55,59,62,66,[69][70][71]79,95 The next most popular denominators were number of appointments (12 articles), 24,25,29,30,32,35,38,40,42,44,72,77 and patients (9 articles). 26,31,39,41,51,53,56,57,98 Eleven other denominators were also used including EHR time per hour of clinic, per 8 h of clinic, per clinic session, per shift, per week, per month, per quarter, per year, per procedure, per note, and per residency. ...
Objective
The aim of this article is to compare the aims, measures, methods, limitations, and scope of studies that employ vendor-derived and investigator-derived measures of electronic health record (EHR) use, and to assess measure consistency across studies.
Materials and Methods
We searched PubMed for articles published between July 2019 and December 2021 that employed measures of EHR use derived from EHR event logs. We coded the aims, measures, methods, limitations, and scope of each article and compared articles employing vendor-derived and investigator-derived measures.
Results
One hundred and two articles met inclusion criteria; 40 employed vendor-derived measures, 61 employed investigator-derived measures, and 1 employed both. Studies employing vendor-derived measures were more likely than those employing investigator-derived measures to observe EHR use only in ambulatory settings (83% vs 48%, P = .002) and only by physicians or advanced practice providers (100% vs 54% of studies, P < .001). Studies employing vendor-derived measures were also more likely to measure durations of EHR use (P < .001 for 6 different activities), but definitions of measures such as time outside scheduled hours varied widely. Eight articles reported measure validation. The reported limitations of vendor-derived measures included measure transparency and availability for certain clinical settings and roles.
Discussion
Vendor-derived measures are increasingly used to study EHR use, but only by certain clinical roles. Although poorly validated and variously defined, both vendor- and investigator-derived measures of EHR time are widely reported.
Conclusion
The number of studies using event logs to observe EHR use continues to grow, but with inconsistent measure definitions and significant differences between studies that employ vendor-derived and investigator-derived measures.
... [77][78][79] Studies included a mix of ambulatory (n ¼ 22) 14 58,77 A majority of those studies involved single sites (77.1%) and were affiliated with an academic institution/teaching hospital (80.0%). One third used Epic systems (n ¼ 13), 13,22,27,43,53,54,56,57,64,66,69,72,73 followed by multiple/other/unspecified (n ¼ 12), 14,28,29,52,63,67,68,[75][76][77][78][79] Cerner (n ¼ 6), [58][59][60]65,71,74 Allscripts (n ¼ 2), 61,62 and Eclipsys (n ¼ 2). 55,70 Articles were published between 2010 and 2020 with 2018 (n ¼ 8) 13 13,27,43,54,55,57,59,60,63,64,66,72,74,75,77 experimental/quasiexperimental (n ¼ 8), 14,22,29,53,56,58,78,79 and cross-sectional studies (n ¼ 4). ...
... One third used Epic systems (n ¼ 13), 13,22,27,43,53,54,56,57,64,66,69,72,73 followed by multiple/other/unspecified (n ¼ 12), 14,28,29,52,63,67,68,[75][76][77][78][79] Cerner (n ¼ 6), [58][59][60]65,71,74 Allscripts (n ¼ 2), 61,62 and Eclipsys (n ¼ 2). 55,70 Articles were published between 2010 and 2020 with 2018 (n ¼ 8) 13 13,27,43,54,55,57,59,60,63,64,66,72,74,75,77 experimental/quasiexperimental (n ¼ 8), 14,22,29,53,56,58,78,79 and cross-sectional studies (n ¼ 4). 69,71,73,76 Eight studies evaluated an intervention, 14,22,52,53,56,58,75,78 including scribes (n ¼ 3), 14,52,53 documentation redesign (n ¼ 3), 58,75,78 or EHR training programs (n ¼ 2) 22,56 ; the remaining were descriptive studies on EHR activities and usage (n ¼ 27)-2 of which involved the implementation of new EHR systems. ...
... 28 Few studies addressed validity or reliability of measurements in their studies (n ¼ 11) 22,52,53,59,60,63,64,67,69,73,78 ; 2 examined interobserver reliability, 28,68 2 employed TM approaches to validate novel analytical methods to examine workflow 70 and the use of EHR usage logs to estimate workload, 27 2 examined correlations between self-reported and objective EHR usage log times, 22 tasks, such as inbox management (n ¼ 2) 69,73 ; (e) cognitively cumbersome work, such as multitasking (n ¼ 3) 61,62,68 ; (f) fragmentation of EHR workflow (n ¼ 1) 70 ; and (g) patient interaction/in-person visits (n ¼ 7). 14,28,29,43,53,62,68 Several terms were employed referring to EHR usage afterhours including "work after work," 66 "pajama time," 66 and "Clinician Logged-In Outside Clinic" (CLOC) time. 22 For example, Cox et al proposed the "amount of EHR usage taking place after scheduled duty hours" specifically for surgical residents. ...
Background:
Objective:
Electronic health records (EHRs) are linked with documentation burden resulting in clinician burnout. While clear classifications and validated measures of burnout exist, documentation burden remains ill-defined and inconsistently measured. We aim to conduct a scoping review focused on identifying approaches to documentation burden measurement and their characteristics.
Materials and methods:
Based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews (ScR) guidelines, we conducted a scoping review assessing MEDLINE, Embase, Web of Science, and CINAHL from inception to April 2020 for studies investigating documentation burden among physicians and nurses in ambulatory or inpatient settings. Two reviewers evaluated each potentially relevant study for inclusion/exclusion criteria.
Results:
Of the 3482 articles retrieved, 35 studies met inclusion criteria. We identified 15 measurement characteristics, including 7 effort constructs: EHR usage and workload, clinical documentation/review, EHR work after hours and remotely, administrative tasks, cognitively cumbersome work, fragmentation of workflow, and patient interaction. We uncovered 4 time constructs: average time, proportion of time, timeliness of completion, activity rate, and 11 units of analysis. Only 45.0% of studies assessed the impact of EHRs on clinicians and/or patients and 40.0% mentioned clinician burnout.
Discussion:
Standard and validated measures of documentation burden are lacking. While time and effort were the core concepts measured, there appears to be no consensus on the best approach nor degree of rigor to study documentation burden.
Conclusion:
Further research is needed to reliably operationalize the concept of documentation burden, explore best practices for measurement, and standardize its use.
... Assistance in writing The amount of documentation in the electronic health record is a leading cause of physician burnout (55). Outside of their shifts, clinicians frequently spend significant time finishing clinical notes and communicating with patients; generative AI provides an opportunity to speed up both of these documentation processes. ...
... In another example, the past few years have seen an uptick in provider-patient messaging through the electronic health record. While this has provided a straightforward path for patients to surface concerns and questions to their providers, providers have had to similarly spend increasing amounts of time responding (55). There have already been several pilots using large language models to respond to patient queries (1,3). ...
The increased capabilities of generative AI have dramatically expanded its possible use cases in medicine. We provide a comprehensive overview of generative AI use cases for clinicians, patients, clinical trial organizers, researchers, and trainees. We then discuss the many challenges -- including maintaining privacy and security, improving transparency and interpretability, upholding equity, and rigorously evaluating models -- which must be overcome to realize this potential, and the open research directions they give rise to.
... Of the 72 providers, 1 (1%) provider was excluded due to an absence of In Basket outpatient ambulatory Signal data. Due to the diversity of specialties, the providers were grouped into a medical group and a surgical group based on previous similar studies and the fact that these categories have similar EHR workflows [41,42]. ...
... The least represented specialties were dermatology, intensive care, neurosurgery, and cardiac surgery, at about 1% (n=1) each. Due to the diversity of specialties, the providers were grouped into a medical group (n=53, 75%) and a surgical group (n=18, 25%) based on previous similar studies (Multimedia Appendix 1) [41,42]. ...
Background
Health care organizations implement electronic health record (EHR) systems with the expectation of improved patient care and enhanced provider performance. However, while these technologies hold the potential to create improved care and system efficiencies, they can also lead to unintended negative consequences, such as patient safety issues, communication problems, and provider burnout.
Objective
This study aims to document metrics related to the In Basket communication hub (time in In Basket per day, time in In Basket per appointment, In Basket messages received per day, and turnaround time) of the EHR system implemented by Alberta Health Services, the province-wide health delivery system called Connect Care (Epic Systems). The objective was to identify how a newly implemented EHR system was used, the timing of its use, and the duration of use specifically related to In Basket activities.
Methods
A descriptive study was conducted. Due to the diversity of specialties, the providers were grouped into medical and surgical based on previous similar studies. The participants were further subgrouped based on their self-reported clinical full-time equivalent (FTE ) measure. This resulted in 3 subgroups for analysis: medical FTE <0.5, medical FTE >0.5, and surgical (all of whom reported FTE >0.5). The analysis was limited to outpatient clinical interactions and explicitly excluded inpatient activities.
Results
A total of 72 participants from 19 different specialties enrolled in this study. The providers had, on average, 8.31 appointments per day during the reporting periods. The providers received, on average, 21.93 messages per day, and they spent 7.61 minutes on average in the time in In Basket per day metric and 1.84 minutes on average in the time in In Basket per appointment metric. The time for the providers to mark messages as done (turnaround time) was on average 11.45 days during the reporting period. Although the surgical group had, on average, approximately twice as many appointments per scheduled day, they spent considerably less connected time (based on almost all time metrics) than the medical group. However, the surgical group took much longer than the medical group to mark messages as done (turnaround time).
Conclusions
We observed a range of patterns with no consistent direction. There does not seem to be evidence of a “learning curve,” which would have shown a consistent reduction in time spent on the system over time due to familiarity and experience. While this study does not show how the included metrics could be used as predictors of providers’ satisfaction or feelings of burnout, the use trends could be used to start discussions about future Canadian studies needed in this area.
... Telemedicine may also have the potential to improve clinicians' well-being and reduce burnout by improving associated risk factors such as on-call burden, communication, and job satisfaction [8][9][10]. At the same time, however, the introduction of novel technologies that impact the provision and experience of health care work can also be detrimental; in particular, there is concern about the impact of electronic health records (EHRs) on clinicians' experience of work and its role in increasing both clinical and nonclinical administrative burden for physicians, including time spent on work-related tasks "outside" of clinical hours, often referred to as "work outside work" (WOW) or "pajama time" (PT) [11][12][13][14]. Shifting clinical and administrative work into personal time, particularly when physicians are at home, is a source of concern within the medical community, and it is unclear whether the proliferation of telemedicine as a form of health care work will exacerbate or ameliorate these conditions. ...
... Prior research has found clinical load to be an important predictor of WOW burden [11,14] and recommended normalizing WOW by load [11]. To account for the reduction and gradual resumption of in-person care during the pandemic, we created a measure of clinical load reflecting the total number of patient appointments for each physician each month. ...
Background:
Telemedicine as a mode of healthcare work has grown dramatically during the COVID-19 pandemic; the impact of this transition on clinicians' after-hours EHR-based clinical and administrative work is unclear.
Objective:
This study assesses the impact of the transition to telemedicine work during the COVID-19 pandemic on physicians' EHR-based after-hours workload ("work outside work") at a large academic medical center in New York City.
Methods:
We conducted an EHR-based retrospective cohort study of ambulatory care physicians providing telemedicine services during the pre-pandemic, acute pandemic, and post-acute pandemic periods, relating EHR-based work after work to telemedicine intensity (percentage of care provided via telemedicine), and clinical load (patient load per provider).
Results:
2,129 physicians were included in this study. During the acute pandemic, the volume of care provided via telemedicine significantly increased across all physicians, while patient volume decreased. When normalizing for clinical load (average appointments per day by average clinical days per week), telemedicine intensity was positively associated with work outside work across time periods. This association was strongest in the post-acute period.
Conclusions:
Taking physicians' clinical load into account, physicians who devoted a higher proportion of their clinical time to telemedicine throughout the various stages of the pandemic engaged in higher levels of EHR-based after-hours than those who used telemedicine less intensively. This suggests that telemedicine, as currently delivered, may be less efficient than in-person-based care, and may increase the after-hours work burden of physicians.
Clinicaltrial:
N/a.
... 13,14 Providers are spending an exorbitant amount of time doing computerized provider order entry and after-hours charting; this phenomena is known as "pajama time", where providers are spending time working, at the EHR, after business hours. 3,6,7,[15][16][17][18] One study noted that for a patient encounter, providers spend an average of 16 minutes and 14 seconds using the EHR; the average patient visit is 15 minutes, so providers are often spending more time documenting in the EHR than they are spending with the actual patient. 16 The majority of this time spent in the EHR is distributed, relatively equally, around three domains: orders, documentation, and chart review. ...
... It should be noted that this is currently only assessing weekend "pajama time" and we did not assess after-hours weekday work, which was likely also present, suggesting this may be an even greater effect. 15 However, the idea that, even with scribe utilization, providers are facing after-hours documentation may explain why there are conflicting results on reports of how scribe use impacts provider documentation behaviors. ...
Medical scribes have become a widely used strategy to optimize how providers document in the electronic health record. To date, literature regarding the impact of scribes on time to complete documentation is limited. We conducted a retrospective, descriptive study of chart completion time among providers using scribes at our organization. A total of 148,410 scribed encounters, across 55 different clinics, were analyzed to determine variations in chart completion time. There was a significant variance in completion time between specialty groups and clinics within each specialty. Additionally, chart completion time was highly variable between providers working in the same clinic. These patterns were observed across all specialties included in our analysis. Our results suggest a higher level of variability with respect to chart completion when utilizing scribes than previously anticipated.
... Studies have noted the burden of EHR digital work for physicians [11][12][13]. EHR-related factors that could lead to physician stress and burnout include the extra time needed, often beyond work hours, to complete EHR-related work [14][15][16][17], usability issues [18][19][20], risks associated with errors [21], and taking time out from face-to-face interactions with patients [22]. ...
... We also did not find differences based on FTE, contrary to previous findings [16] that more work relative value units generated by physicians (another measure of workload) were associated with more EHR time after work hours. Most studies use basic measures to characterize EHR usage, such as the duration of time [14,15,55]. In one study, researchers used more complex measures to characterize mobile EHR usage, such as the number of log-ins and features used and usage paths (ie, the frequency and complexity of consecutive actions) [56]. ...
Background:
Increased work through electronic health record (EHR) messaging is frequently cited as a factor of physician burnout. However, studies to date have relied on anecdotal or self-reported measures, which limit the ability to match EHR use patterns with continuous stress patterns throughout the day.
Objective:
The aim of this study is to collect EHR use and physiologic stress data through unobtrusive means that provide objective and continuous measures, cluster distinct patterns of EHR inbox work, identify physicians' daily physiologic stress patterns, and evaluate the association between EHR inbox work patterns and physician physiologic stress.
Methods:
Physicians were recruited from 5 medical centers. Participants (N=47) were given wrist-worn devices (Garmin Vivosmart 3) with heart rate sensors to wear for 7 days. The devices measured physiological stress throughout the day based on heart rate variability (HRV). Perceived stress was also measured with self-reports through experience sampling and a one-time survey. From the EHR system logs, the time attributed to different activities was quantified. By using a clustering algorithm, distinct inbox work patterns were identified and their associated stress measures were compared. The effects of EHR use on physician stress were examined using a generalized linear mixed effects model.
Results:
Physicians spent an average of 1.08 hours doing EHR inbox work out of an average total EHR time of 3.5 hours. Patient messages accounted for most of the inbox work time (mean 37%, SD 11%). A total of 3 patterns of inbox work emerged: inbox work mostly outside work hours, inbox work mostly during work hours, and inbox work extending after hours that were mostly contiguous to work hours. Across these 3 groups, physiologic stress patterns showed 3 periods in which stress increased: in the first hour of work, early in the afternoon, and in the evening. Physicians in group 1 had the longest average stress duration during work hours (80 out of 243 min of valid HRV data; P=.02), as measured by physiological sensors. Inbox work duration, the rate of EHR window switching (moving from one screen to another), the proportion of inbox work done outside of work hours, inbox work batching, and the day of the week were each independently associated with daily stress duration (marginal R2=15%). Individual-level random effects were significant and explained most of the variation in stress (conditional R2=98%).
Conclusions:
This study is among the first to demonstrate associations between electronic inbox work and physiological stress. We identified 3 potentially modifiable factors associated with stress: EHR window switching, inbox work duration, and inbox work outside work hours. Organizations seeking to reduce physician stress may consider system-based changes to reduce EHR window switching or inbox work duration or the incorporation of inbox management time into work hours.
... 21 More recently, it has been proposed that the same metrics that are already stored and used to audit the EHR can be repurposed and utilized to objectively assess the clinical experience. [21][22][23][24][25][26] Furthermore, it has been shown that analyzing the data found in these EHR usage files can be beneficial for large-scale analyses. 19,22 As a result, it has been suggested that provider-centric EHR data can, in addition to addressing provider burnout, help generate data-driven strategies for assessing staffing models, developing more efficient EHR design, and advising future regulatory decisions. ...
... Our third area of interest was provider burnout, which has been correlated with time spent in the EHR outside of work. 20,23,26 The exact methodology for measuring time outside of usual working hours has differed between studies, so we decided to include three different metrics: (1) time spent outside 7 AM-7 PM; (2) time spent on unscheduled days (average number of minutes spent in the system on days with no scheduled patients, only including unscheduled days wherein system activity was detected); and (3) pajama time (average number of minutes spent in charting activities outside of 7 AM-5:30 PM on weekdays and outside scheduled hours on weekends, not including any time spent in the system during scheduled hours). ...
Telemedicine has been widely implemented during the coronavirus disease 2019 (COVID-19) pandemic; however, its impact on those providing care remains largely understudied. Provider documentation data collected by the electronic health record (EHR) represents an underutilized tool for assessing the provider experience. Through Epic Signal, we collected data regarding the actions logged in the EHR by health care providers of the Montefiore Health System (Bronx, NY) before and after the implementation of telemedicine during the pandemic. Focusing on five metrics (appointments per day, visits closed same day, time spent outside 7 AM-7 PM, time spent on unscheduled days, and pajama time), we performed a preliminary analysis of providers across the institution, by specialty, and according to demographic characteristics such as gender and years since graduation. We observed that after telemedicine implementation, a greater proportion of providers had fewer appointments per day, closed more notes same day, and spent less time in the EHR outside of normal working hours for each of the time-related metrics. We additionally found that providers who graduated longer ago as well as female providers spent more time documenting in the EHR after hours. This brief analysis highlights the potential of using EHR data to inform decisions based on provider well-being, specifically in the setting of telemedicine implementation.
... 40 Another found differences in usability scores among the specialties, with general internal medicine physicians rating the EHR usability higher than their colleagues in family medicine, radiology, general surgery, and orthopedic surgery. 37 However, another study observed no differences among specialties in work-life balance or EHR-related burnout, 41 and another concluded that perceived EHR productivity and ease of EHR use were mixed among different specialties. 35 Assigned patient care responsibility One study reported no association with work-life balance or burnout stemming from EHR use, 41 and one noted that physicians with more patient care responsibility typically spend more time using the EHR on days that they are not scheduled to see patients. ...
... 37 However, another study observed no differences among specialties in work-life balance or EHR-related burnout, 41 and another concluded that perceived EHR productivity and ease of EHR use were mixed among different specialties. 35 Assigned patient care responsibility One study reported no association with work-life balance or burnout stemming from EHR use, 41 and one noted that physicians with more patient care responsibility typically spend more time using the EHR on days that they are not scheduled to see patients. 42 Another study reported that having more patient care responsibility was associated with fewer in-basket messages. ...
Objective
Physicians often describe the electronic health record (EHR) as a cumbersome impediment to meaningful work, which has important implications for physician well-being. This systematic review (1) assesses organizational, physician, and information technology factors associated with EHR-related impacts on physician well-being; and (2) highlights potential improvements to EHR form and function, as recommended by frontline physicians.
Materials and methods
The MEDLINE, Embase, CINAHL, PsycINFO, ProQuest, and Web of Science databases were searched for literature describing EHR use by physicians and markers of well-being.
Results
After reviewing 7388 article, 35 ultimately met the inclusion criteria. Multiple factors across all levels were associated with EHR-related well-being among physicians. Notable predictors amenable to interventions include (1) total EHR time, (2) after-hours EHR time, (3) on-site EHR support, (4) perceived EHR usability, (5) in-basket burden, and (6) documentation burden. Physician recommendations also echoed these themes.
Conclusions
There are multiple complex factors involved in EHR-related well-being among physicians. Our review shows physicians have recommendations that span from federal regulations to organizational policies to EHR modifications. Future research should assess multipronged interventions that address these factors. As primary stakeholders, physicians should be included in the planning and implementation of such modifications to ensure compatibility with physician needs and clinical workflows.
... In this study, inbox work duration was independently associated with clinician workload as measured by the number of appointments seen during the month studied. This is in accord with a previous finding that physicians with more clinical time were disproportionately burdened by after-hours EHR work, 28 and another study that found that work relative value units (ie, work volume and complexity) were positively associated with EHR time within and outside of work hours. 24 In contrast, we did not find that lower FTE was associated with reduced inbox work. ...
... Journal of the American Medical Informatics Association, 2021, Vol.28,No. 5 ...
Objectives
Electronic health record systems are increasingly used to send messages to physicians, but research on physicians’ inbox use patterns is limited. This study’s aims were to (1) quantify the time primary care physicians (PCPs) spend managing inboxes; (2) describe daily patterns of inbox use; (3) investigate which types of messages consume the most time; and (4) identify factors associated with inbox work duration.
Materials and Methods
We analyzed 1 month of electronic inbox data for 1275 PCPs in a large medical group and linked these data with physicians’ demographic data.
Results
PCPs spent an average of 52 minutes on inbox management on workdays, including 19 minutes (37%) outside work hours. Temporal patterns of electronic inbox use differed from other EHR functions such as charting. Patient-initiated messages (28%) and results (29%) accounted for the most inbox work time. PCPs with higher inbox work duration were more likely to be female (P < .001), have more patient encounters (P < .001), have older patients (P < .001), spend proportionally more time on patient messages (P < .001), and spend more time per message (P < .001). Compared with PCPs with the lowest duration of time on inbox work, PCPs with the highest duration had more message views per workday (200 vs 109; P < .001) and spent more time on the inbox outside work hours (30 minutes vs 9.7 minutes; P < .001).
Conclusions
Electronic inbox work by PCPs requires roughly an hour per workday, much of which occurs outside scheduled work hours. Interventions to assist PCPs in handling patient-initiated messages and results may help alleviate inbox workload.
... If re ll and inbox coverage were not in place, it "would de nitely add on one or two hours a day if you're covering somebody else." Not only does the prescription re ll support decrease non-face-to-face work (or Pajama Time 15 ), but also helps physicians stay up to date with evidence-based surveillance strategies and appropriate deprescribing that might otherwise be missed. Several respondents noted that they take "a ton of stress off", allowing faculty to go on vacation or attend on the inpatient wards service without having to worry about checking their inbox or asking a colleague to cover. ...
Background
Physician burnout is a pervasive challenge facing most health care organizations. The objective of this study is to document perspectives of family medicine physician faculty and administrators on institutional factors contributing to physician burnout and efforts to change organizational structure and processes to enhance physician wellness.
Methods
Twenty family medicine physicians at an academic health system completed semi-structured interviews between November 2021 and January 2022. Interview transcripts were coded thematically. Additional data came from a survey of physicians’ perceptions and experience with departmental wellness-oriented activities and two research needs assessment surveys in 2020 and 2022.
Results
Interviewees reported that faculty leaders’ advocacy regarding a collaborative physician-administration shared governance model was essential in organizational decision-making that directly affected faculty wellness. Joint accomplishment of a well-organized, successful primary care response to the pandemic proved the effectiveness of this new partnership. New programs such as prescription refill support, nurse practitioner inbox coverage, and support from the population health program were regarded as effective in reducing burnout and improving wellness. Wellness survey respondents reported improved levels of wellness. Noted areas for improvement included centralized appointment scheduling and uneven support for the tripartite mission of academic medicine due to competing clinical demands.
Conclusions
Despite the mounting challenges experienced during the COVID-19 pandemic, faculty in the Department of Family Medicine noted enhancement of their well-being. More holistic support for academic physicians, including mentorship and compensation for teaching and research, is needed. Advocacy and subsequent organizational changes provide a model for academic family medicine departments to use to turn pandemic-related adjustments into long-term, wellness-inducing changes.
... The reasons for this practice shift are complex and cannot be solved by ambulatory blocks alone. Burdened by educational loans and escalating burnout, health systems and payors must offer competitive compensation and improved work-life measures to attract PCCM graduates into ambulatory medicine over inpatient opportunities (14,15). ...
... Clinical load refers to the amount of clinical or patient care responsibilities that a healthcare provider is responsible for, and is typically measured panel size, percent of appointment slots filled 33 . Prior research has shown an association between clinical load and work-outside-work burden 7,34,35 . This study measured clinical load as the number of appointments or visits they completed during the reporting period. ...
The COVID-19 pandemic has boosted digital health utilization, raising concerns about increased physicians’ after-hours clinical work ("work-outside-work”). The surge in patients’ digital messages and additional time spent on work-outside-work by telemedicine providers underscores the need to evaluate the connection between digital health utilization and physicians’ after-hours commitments. We examined the impact on physicians’ workload from two types of digital demands - patients’ messages requesting medical advice ( PMAR s) sent to physicians’ inbox (inbasket), and telemedicine. Our study included 1716 ambulatory-care physicians in New York City regularly practicing between November 2022 and March 2023. Regression analyses assessed primary and interaction effects of ( PMAR s) and telemedicine on work-outside-work. The study revealed a significant effect of PMAR s on physicians’ work-outside-work and that this relationship is moderated by physicians’ specialties. Non-primary care physicians or specialists experienced a more pronounced effect than their primary care peers. Analysis of their telemedicine load revealed that primary care physicians received fewer PMAR s and spent less time in work-outside-work with more telemedicine. Specialists faced increased PMAR s and did more work-outside-work as telemedicine visits increased which could be due to the difference in patient panels. Reducing PMAR volumes and efficient inbasket management strategies needed to reduce physicians’ work-outside-work. Policymakers need to be cognizant of potential disruptions in physicians carefully balanced workload caused by the digital health services.
... More time spent on digital avenues of care has also been shown to improve quality of care metrics [89]. Currently, PCPs already engage in this sort of work but they do it at the expense of time with their patients or their families [75,90]. Organizations should be wary of relying too much on physician altruism to find time to use digital tools, forcing physicians to choose between their personal wellbeing and that of their patients [91][92][93]. ...
Background
Artificial intelligence (AI) is a rapidly advancing field that is beginning to enter the practice of medicine. Primary care is a cornerstone of medicine and deals with challenges such as physician shortage and burnout which impact patient care. AI and its application via digital health is increasingly presented as a possible solution. However, there is a scarcity of research focusing on primary care physician (PCP) attitudes toward AI. This study examines PCP views on AI in primary care. We explore its potential impact on topics pertinent to primary care such as the doctor-patient relationship and clinical workflow. By doing so, we aim to inform primary care stakeholders to encourage successful, equitable uptake of future AI tools. Our study is the first to our knowledge to explore PCP attitudes using specific primary care AI use cases rather than discussing AI in medicine in general terms.
Methods
From June to August 2023, we conducted a survey among 47 primary care physicians affiliated with a large academic health system in Southern California. The survey quantified attitudes toward AI in general as well as concerning two specific AI use cases. Additionally, we conducted interviews with 15 survey respondents.
Results
Our findings suggest that PCPs have largely positive views of AI. However, attitudes often hinged on the context of adoption. While some concerns reported by PCPs regarding AI in primary care focused on technology (accuracy, safety, bias), many focused on people-and-process factors (workflow, equity, reimbursement, doctor-patient relationship).
Conclusion
Our study offers nuanced insights into PCP attitudes towards AI in primary care and highlights the need for primary care stakeholder alignment on key issues raised by PCPs. AI initiatives that fail to address both the technological and people-and-process concerns raised by PCPs may struggle to make an impact.
... Importantly, telehealth implementation has been linked to less provider time spent in the electronic health records (EHR) outside of normal working hours [26]. Given that provider burnout has been correlated with time spent in the EHR outside of work, [30][31][32] this finding suggests that telehealth approaches could also help improve physician satisfaction and reduce burnout. ...
Background
Understanding perceptions of telehealth implementation from patients and providers can improve the utility and sustainability of these programs, particularly in under-resourced rural settings. The purpose of this study was to evaluate both patient and provider perceptions of telehealth visits in a large rural healthcare system during the COVID-19 pandemic. To promote sustainability of telehealth approaches, we also assessed whether the percentage of missed appointments differed between in-person and telehealth visits.
Methods
Using anonymous surveys, we evaluated patient preferences and satisfaction with telehealth visits from November 2020 -March 2021 and assessed perceptions of telehealth efficiency and value among rural providers from September–October 2020. We examined whether telehealth perceptions differed according to patients’ age, educational attainment, insurance status, and distance to clinical site and providers’ age and length of time practicing medicine using ANOVA test. We also examined whether the percentage of missed appointments differed between in-person and telehealth visits at a family practice clinic within the rural healthcare system from April to September 2020 using a Chi-square test.
Results
Over 73% of rural patients had favorable perceptions of telehealth visits, and satisfaction was generally higher among younger patients. Patients reported difficulty with scheduling follow-up appointments, lack of personal contact and technology challenges as common barriers. Over 80% of the 219 providers responding to the survey reported that telehealth added value to their practice, while 36.6% agreed that telehealth visits are more efficient than in-person visits. Perception of telehealth value and efficiency did not differ by provider age (p = 0.67 and p = 0.67, respectively) or time in practice (p = 0.53 and p = 0.44, respectively). Technology challenges for the patient (91.3%) and provider (45.1%) were commonly reported. The percentage of missed appointments was slightly higher for telehealth visits compared to in-person visits, but the difference was not statistically significant (8.7% vs. 8.0%; p = 0.39).
Conclusions
Telehealth perceptions were generally favorable among rural patients and providers, although satisfaction was lower among older patients and providers. Our findings suggest that telehealth approaches may add value and efficiency to rural clinical practice. However, technology issues for both patients and providers and gaps in care coordination need to be addressed to promote sustainability of telehealth approaches in rural practice.
... Prior research also suggests that physicians feel burdened by time constraints in their practices, even when accommodations are not involved. 29,30 As we report in the results, some of the participants reported that their practice set-tings do not provide sufficient administrative or clinical support for the care of people with disabilities. Our physician survey found that 13.6 percent and 31.1 percent of participants, respectively, felt that time constraints were a large or moderate barrier to caring for people with disabilities. ...
People with disabilities face barriers when attempting to gain access to health care settings. Using qualitative analysis of three physician focus groups, we identified physical, communication, knowledge, structural, and attitudinal barriers to care for people with disabilities. Physicians reported feeling overwhelmed by the demands of practicing medicine in general and the requirements of the Americans with Disabilities Act of 1990 specifically; in particular, they felt that they were inadequately reimbursed for accommodations. Some physicians reported that because of these concerns, they attempted to discharge people with disabilities from their practices. Increasing health care access for people with disabilities will require increasing the accessibility of space and the availability of proper equipment, improving the education of clinicians about the care of people with disabilities, and removing structural barriers in the health care delivery system. Our findings also suggest that physicians' bias and general reluctance to care for people with disabilities play a role in perpetuating the health care disparities they experience.
... Studies suggest that physicians spend a large portion of their time on electronic health records (EHR) and administrative tasks during and after work hours. [29][30][31] A study using data collected from PLACES pediatricians in 2018 found that three-fourths reported EHR documentation as a major or moderate burden, and such burden was associated with lower scores on work-life balance and career and life satisfaction measures. 3 This study also reported that 9 in 10 pediatricians strongly agreed or agreed that improving the functionality of the EHR, providing protective time for administrative work, and obtaining physician input might help reduce administrative burdens. ...
OBJECTIVES
To examine the association of changes in pediatricians’ work characteristics with their satisfaction using longitudinal data.
METHODS
Data from a cohort study, the American Academy of Pediatrics Pediatrician Life and Career Experience Study (PLACES), were used to examine self-reported work satisfaction from 2012 to 2020 among 2002–2004 and 2009–2011 residency graduates (N = 1794). Drawing from the Physician Worklife Study, work satisfaction was measured as a 4-item scale score and averaged [range, 1 (low)–5 (high)]. Mixed effects linear regression for longitudinal analysis examined work satisfaction with year as the lone explanatory variable and then with 11 variables that might change over time (time variant) to assess how changes in work might be linked to increased or decreased satisfaction.
RESULTS
In total, 85.9% of pediatricians in 2020 (September–December) thought their work was personally rewarding. Overall mean work satisfaction scale score displayed a small but significant (P < .001) decrease over time (3.80 in 2012 to 3.69 in 2020). Mixed effects modeling identified several changes associated with increasing work satisfaction over time: increased flexibility in work hours (B = 0.23; 95% confidence interval, 0.20 to 0.25) and personal support from physician colleagues (B = 0.18; 95% confidence interval, 0.15 to 0.21) had the largest associations. Pediatricians reporting increased stress balancing work and personal responsibilities and increased work hours had decreased satisfaction scores.
CONCLUSIONS
Early- to midcareer pediatricians expressed high levels of work satisfaction, though, satisfaction scale scores decreased slightly over time for the sample overall, including during 2020 (year 1 of the coronavirus disease 2019 pandemic). Pediatricians reporting increases in flexibility with work hours and colleague support showed the strongest increase in work satisfaction.
... We included other variables known to influence EHR use patterns, such as patient load (number of appointments each day, proportion of the 7-day week with appointments, proportion of new patient visits), 18,39,45,46 patient complexity (proxied by average patient age and average problem list length), 47,48 having assistance on EHR tasks from support staff, [49][50][51] and use of the EHR on mobile devices. 52,53 New patient visits were defined as those with Current Procedural Terminology codes 99201 through 99205. ...
Objective
This study aimed to understand the association between primary care physician (PCP) proficiency with the electronic health record (EHR) system and time spent interacting with the EHR.
Materials and Methods
We examined the use of EHR proficiency tools among PCPs at one large academic health system using EHR-derived measures of clinician EHR proficiency and efficiency. Our main predictors were the use of EHR proficiency tools and our outcomes focused on 4 measures assessing time spent in the EHR: (1) total time spent interacting with the EHR, (2) time spent outside scheduled clinical hours, (3) time spent documenting, and (4) time spent on inbox management. We conducted multivariable quantile regression models with fixed effects for physician-level factors and time in order to identify factors that were independently associated with time spent in the EHR.
Results
Across 441 primary care physicians, we found mixed associations between certain EHR proficiency behaviors and time spent in the EHR. Across EHR activities studied, QuickActions, SmartPhrases, and documentation length were positively associated with increased time spent in the EHR. Models also showed a greater amount of help from team members in note writing was associated with less time spent in the EHR and documenting.
Discussion
Examining the prevalence of EHR proficiency behaviors may suggest targeted areas for initial and ongoing EHR training. Although documentation behaviors are key areas for training, team-based models for documentation and inbox management require further study.
Conclusions
A nuanced association exists between physician EHR proficiency and time spent in the EHR.
... Numerous studies have suggested that work outside of normal working hours and on days without clinic responsibility leads to professional burnout. 17,45,46 In our analysis of cancer provider messaging by clinic activity and time, we found that there continued to be a large amount of messaging activity performed outside of direct clinical responsibility. We found that despite clinical activity and time of day, logistical information persists as the most common type of information. ...
Objective
A growing research literature has highlighted the work of managing and triaging clinical messages as a major contributor to professional exhaustion and burnout. The goal of this study was to discover and quantify the distribution of message content sent among care team members treating patients with breast cancer.
Materials and Methods
We analyzed nearly two years of communication data from the electronic health record (EHR) between care team members at Vanderbilt University Medical Center. We applied natural language processing to perform sentence-level annotation into one of five information types: clinical, medical logistics, nonmedical logistics, social, and other. We combined sentence-level annotations for each respective message. We evaluated message content by team member role and clinic activity.
Results
Our dataset included 81 857 messages containing 613 877 sentences. Across all roles, 63.4% and 21.8% of messages contained logistical information and clinical information, respectively. Individuals in administrative or clinical staff roles sent 81% of all messages containing logistical information. There were 33.2% of messages sent by physicians containing clinical information—the most of any role.
Discussion and Conclusion
Our results demonstrate that EHR-based asynchronous communication is integral to coordinate care for patients with breast cancer. By understanding the content of messages sent by care team members, we can devise informatics initiatives to improve physicians’ clerical burden and reduce unnecessary interruptions.
... 9 A study of primary care physicians reported that they spent 6 hours interacting with the EHR on work days, 10 and physicians in an academic faculty group spent up to 3 hours on the EHR on days without any appointments. 11 Increased self-reported physician workload was associated with increased asynchronous alerts or inbox notifications, 12,13 and high volumes of patient call messages have been linked to burnout. 14 Less research has focused on pediatricians or the association of EHR use and work-life balance and satisfaction. ...
Objectives To examine pediatricians' perspectives on administrative tasks including electronic health record (EHR) documentation burden and their effect on work–life balance and life and career satisfaction.
Methods We analyzed 2018 survey data from the American Academy of Pediatrics (AAP) Pediatrician Life and Career Experience Study (PLACES), a longitudinal cohort study of early and midcareer pediatricians. Cohorts graduated from residency between 2002 and 2004 or 2009 and 2011. Participants were randomly selected from an AAP database (included all pediatricians who completed U.S. pediatric residency programs). Four in 10 pediatricians (1,796 out of 4,677) were enrolled in PLACES in 2012 and considered participants in 2018. Data were weighted to adjust for differences between study participants and the overall population of pediatricians. Chi-square and multivariable logistic regression examined the association of EHR burden on work–life balance (three measures) and satisfaction with work, career, and life (three measures). Responses to an open-ended question on experiences with administrative tasks were reviewed.
Results A total of 66% of pediatrician participants completed the 2018 surveys (1,192 of 1,796; analytic sample = 1,069). Three-fourths reported EHR documentation as a major or moderate burden. Half reported such burden for billing and insurance and 42.7% for quality and performance measurement. Most pediatricians reported satisfaction with their jobs (86.7%), careers (84.5%), and lives (66.2%). Many reported work–life balance challenges (52.5% reported stress balancing work and personal responsibilities). In multivariable analysis, higher reported EHR burden was associated with lower scores on career and life satisfaction measures and on all three measures of work–life balance. Open-ended responses (n = 467) revealed several themes. Two predominant themes especially supported the quantitative findings—poor EHR functionality and lack of support for administrative burdens.
Conclusion Most early to midcareer pediatricians experience administrative burdens with EHRs. These experiences are associated with worse work–life balance including more stress in balancing responsibilities and less career and life satisfaction.
... 7,8 Medical trainees are particularly vulnerable as they complete this additional documentation during what is now being referred to as ''pajama time.'' 9 It is paramount that training programs employ timeefficient technological approaches to protect trainees' well-being. 10,11 Additionally, CERT minimizes the risk of exposure of personal health information that can occur in external platforms. ...
Background
Procedural experience for residents and fellows is critical for achieving competence, and documentation of procedures performed is required. Procedure logs serve as the record of this experience, but are commonly generated manually, require substantial administrative effort, and cannot be corroborated for accuracy.
Objective
We developed and implemented a structured clinical-educational report template (CERT), which automatically generates procedure logs directly from the clinical record.
Methods
Our CERT aimed to replace the post-procedure note template for our cardiac catheterization laboratory and was incorporated into the electronic health record system. Numbers of documented procedures in automated CERT-derived procedure logs over a 1-year post-intervention period (2018–2019) were compared to manual logs and corrected for clinical volume changes. The CERT's impact on fellowship experience was also assessed.
Results
Automated CERT procedure logs increased weekly procedural documentation over manual procedure logs for total procedures (24.2 ± 6.1 vs 17.1 ± 6.8, P = .007), left heart catheterizations (14.5 ± 3.6 vs 10.8 ± 4.2, P = .039), total procedural elements (40.2 ± 11.4 versus 20.9 ± 12.5, P < .001), and captured procedural details not previously documented. The CERT also reduced self-reported administrative time and improved fellowship experience.
Conclusions
A novel CERT allows procedure logs to be automatically derived from the clinical record and increased the number of documented procedures, compared to manual logging. This innovation ensures an accurate record of procedural experience and reduces self-reported non-educational administrative time for cardiology fellows.
OBJECTIVE
To examine individual variation in total and direct patient care work hours annually across a decade and identify associations of work hours with pediatrician characteristics and measures of work-life balance.
METHODS
Using data from the American Academy of Pediatrics Pediatrician Life and Career Experience Study (PLACES), a national longitudinal study, we examined total work and direct patient care hours reported by the same pediatricians each year, 2013–2022. Yearly participation ranged from 75% to 94%. We examined work-hour patterns using mixed-effects linear regression for longitudinal data. We also developed pediatrician profiles based on work hours and direct patient care time and explored associations with multiple measures of work-life balance.
RESULTS
Analyses included 12 864 observations from 1696 pediatricians. Mean hours per week across years were 42.8 for total and 33.3 for direct patient care work. A mixed-effects model examined total work hours. The largest associations showed men working more than women (B = 7.22; 95% CI, 6.04–8.39) and subspecialists from large subspecialties working more than general pediatricians (B = 7.20; 95% CI, 6.11–8.29). There was a slight decrease in total hours found across years (B = −0.12; 95% CI, −0.21 to −0.03). Pediatricians who worked more hours reported lower work-life balance. Pediatricians working a greater portion of their time in direct patient care did not report worse work-life balance.
CONCLUSIONS
Direct patient care made up three-fourths of total work hours, and pediatricians reported a slight annual decrease in hours worked. Men, subspecialists, and hospitalists were likely to work more hours, and higher work hours were negatively associated with work-life balance.
Background Documentation burden is one of the largest contributors to physician burnout. Evaluation and Management (E&M) coding changes were implemented in 2021 to alleviate documentation burden.
Objectives We used this opportunity to develop documentation best practices, implement new electronic health record (EHR) tools, and study the potential impact on provider experiences with documentation related to these 2021 E&M changes, documentation length, and time spent documenting at an academic medical center.
Methods Five actionable best practices, developed through a consensus-driven, multidisciplinary approach in November 2020, led to the creation of two new ambulatory note templates, one for E&M visits (implemented in January 2021) and another for preventative visits (implemented in May 2021). As part of a quality-improvement initiative at nine faculty primary care clinics, surveys were developed utilizing a 5-point Likert scale to assess provider perceptions and deidentified EHR metadata (Signal, Epic Systems) were analyzed to measure changes in EHR use metrics between a pre-E&M changes timeframe (August 2020–December 2020) and a post-E&M change timeframe (August 2021–December 2021). A subgroup analysis was conducted comparing EHR use metrics among note template utilizers versus nonutilizers. Any provider who used one of the note templates at least once was categorized as a utilizer.
Results Between January 2021 and December 2021, the adoption of the E&M visit template was 31,480 instances among 120 unique ambulatory providers, and adoption of the preventative visit template was 1,464 instances among 22 unique ambulatory providers. Survey response rate among faculty primary care providers was 82% (88/107): 55% (48/88) believed the 2021 E&M changes provided an opportunity to reduce documentation burden, and 28% reported favorable satisfaction with time spent documenting. Among providers who reported using one or both of the new note templates, 81% (35/43) of survey respondents reported favorable satisfaction with new note templates. EHR use metric analyses revealed a small, yet significant reduction in time in notes per appointment (p = 0.004) with no significant change in documentation length of notes (p = 0.45). Note template utilization was associated with a statistically significant reduction in documentation length (p = 0.034).
Conclusion This study shows modest progress in improving EHR use measures of documentation length and time spent documenting following the 2021 E&M changes, but without great improvement in perceived documentation burden. Additional tools are needed to reduce documentation burden and further research is needed to understand the impact of these interventions.
Background Inefficient electronic health record (EHR) usage increases the documentation burden on physicians and other providers, which increases cognitive load and contributes to provider burnout. Studies show that EHR efficiency sessions, optimization sprints, reduce burnout using a resource-intense five-person team. We implemented sprint-inspired one-on-one post-go-live efficiency training sessions (mini-sprints) as a more economical training option directed at providers.
Objectives We evaluated a post-go-live mini-sprint intervention to assess provider satisfaction and efficiency.
Methods NorthShore University HealthSystem implemented one-on-one provider-to-provider mini-sprint sessions to optimize provider workflow within the EHR platform. The physician informaticist completed a 9-point checklist of efficiency tips with physician trainees covering schedule organization, chart review, speed buttons, billing, note personalization/optimization, preference lists, quick actions, and quick tips. We collected postsession survey data assessing for net promoter score (NPS) and open-ended feedback. We conducted financial analysis of pre- and post-mini-sprint efficiency levels and financial data.
Results Seventy-six sessions were conducted with 32 primary care physicians, 28 specialty physicians, and 16 nonphysician providers within primary care and other areas. Thirty-seven physicians completed the postsession survey. The average NPS for the completed mini-sprint sessions was 97. The proficiency score had a median of 6.12 (Interquartile range (IQR): 4.71–7.64) before training, and a median of 7.10 (IQR: 6.25–8.49) after training. Financial data analysis indicates that higher level billing codes were used at a greater frequency post-mini-sprint. The revenue increase 12 months post-mini-sprint was 75,559.50 for 40 providers, or $1,888.98 per provider in a 12-month period.
Conclusion Our data show that mini-sprint sessions were effective in optimizing efficiency within the EHR platform. Financial analysis demonstrates that this type of training program is sustainable and pays for itself. There was high satisfaction with the mini-sprint training modality, and feedback indicated an interest in further mini-sprint training sessions for physicians and nonphysician staff.
Objective
To assess the impact of the use of an ambient listening/digital scribing solution (Nuance Dragon Ambient eXperience (DAX)) on caregiver engagement, time spent on Electronic Health Record (EHR) including time after hours, productivity, attributed panel size for value-based care providers, documentation timeliness, and Current Procedural Terminology (CPT) submissions.
Materials and Methods
We performed a peer-matched controlled cohort study from March to September 2022 to evaluate the impact of DAX in outpatient clinics in an integrated healthcare system. Primary outcome measurements included provider engagement survey results, reported patient safety events related to DAX use, patients’ Likelihood to Recommend score, number of patients opting out of ambient listening, change in work relative values units, attributed value-based primary care panel size, documentation completion and CPT code submission deficiency rates, and note turnaround time.
Results
A total of 99 providers representing 12 specialties enrolled in the study; 76 matched control group providers were included for analysis. Median utilization of DAX was 47% among active participants. We found positive trends in provider engagement, while non-participants saw worsening engagement and no practical change in productivity. There was a statistically significant worsening of after-hours EHR. There was no quantifiable effect on patient safety.
Discussion
Nuance DAX use showed positive trends in provider engagement at no risk to patient safety, experience, or clinical documentation. There were no significant benefits to patient experience, documentation, or measures of provider productivity.
Conclusion
Our results highlight the potential of ambient dictation as a tool for improving the provider experience. Head-to-head comparisons of EHR documentation efficiency training are needed.
Objectives: Electronic health records (EHRs) have transformed the way modern medicine is practiced, but they remain a major source of documentation burden among physicians. This study aims to use data from Signal, a tool provided by the Epic EHR, to analyze physician metadata in the Montefiore Health System via cluster analysis to assess EHR burden and efficiency. Methods: Data were obtained for a one-month period (July 2020) representing a return to normal operation post-telemedicine implementation. Six metrics from Signal were used to phenotype physicians: time on unscheduled days, pajama time, time outside of 7 AM to 7 PM, turnaround time, proficiency score, and visits closed the same day. k-Means clustering was employed to group physicians, and the clusters were assessed overall and by sex and specialty. Results: Our results demonstrate the partitioning of physicians into a higher-efficiency, lower-time outside of scheduled hours (TOSH) cluster and a lower-efficiency, higher-TOSH cluster even when stratified by sex and specialty. Intra-cluster comparisons showed general homogeneity of physician metrics with the exception of the higher-efficiency, lower-TOSH cluster when stratified by sex. Conclusions: Taken together, the clusters uniquely reflect the EHR efficiency-burden of the Montefiore Health System. Applying k-means clustering to readily available EHR data allows for a scalable, efficient, and adaptable approach of assessing physician EHR burden and efficiency, allowing health systems to examine documentation trends and target wellness interventions.
Purpose of review:
The electronic health record (EHR) has become ubiquitous among healthcare providers. It has revolutionized how we care for patients allowing for instant access to records, improved order entry, and improved patient outcomes. However, it has also been implicated as a source of stress, burnout, and workplace dissatisfaction among its users. The article provides an overview of factors associated with burnout focusing on the pediatrician and pediatric subspecialist workflows and will summarize practical tips based on clinical informatics principles for addressing these factors.
Recent findings:
Several metrics related to EHR including training, efficiency and lack of usability have been cited as factors associated with burnout. Organizational, personal, and interpersonal factors as well as work culture are more associated with burnout than EHR use.
Summary:
Organizational strategies to address burnout include first monitoring metrics including physician satisfaction and wellbeing, incorporating mindfulness and teamwork, and decreasing stress from the EHR by providing training, standardized workflows, and efficiency tools. All clinicians should feel empowered to customize workflows and seek organizational help for improving EHR use.
Objectives:
1) To determine the impact of COVID-19 and the corresponding increase in use of telemedicine on volume, efficiency, and burden of Electronic Health Record (EHR) usage by residents and fellows; and 2) To compare these metrics with those of attending physicians.
Materials and methods:
We analyzed eleven metrics from Epic's Signal Database of outpatient physician user logs for active residents/fellows at our institution across three 1-month time periods: August 2019 (pre-pandemic / pre-telehealth), May 2020 (mid-pandemic / post-telehealth implementation) and July 2020 (follow-up period) and compared these metrics between trainees and attending physicians. We also assessed how the metrics varied for medical trainees in primary care as compared to subspecialties.
Results:
Analysis of 141 residents/fellows and 495 attendings showed that after telehealth implementation, overall patient volume, Time in In Basket per day, Time Outside of 7AM-7PM, and Time in Notes decreased significantly compared to the pre-telehealth period. Female residents, fellows, and attendings had a lower same day note closure rate before and during the post-telehealth implementation period and spent greater time working outside of 7 AM-7 PM compared to male residents, fellows, and attendings (p<0.01) compared to the pre-telehealth period. Attending physicians had a greater patient volume, spent more time and were more efficient in the EHR compared to trainees (p<0.01) in both the post-telehealth and follow-up periods as compared to the pre-telehealth period.
Conclusion:
The dramatic change in clinical operations during the pandemic serves as an inflection point to study changes in physician practice patterns via the EHR. We observed that: 1) female physicians closed fewer notes the same day and spent more time in the EHR outside of normal working hours compared to male physicians; and 2) attending physicians had higher patient volumes and also higher efficiency in the EHR compared to resident physicians.
Medicine has evolved over time, shifting from disease, illness, and injury treatment to preventive health. This chapter focuses on several domains of physician health and wellness, including general health and clinical preventive care and three preventive health behaviors: nutrition, exercise, and sleep. Within each domain, published data on US physicians are summarized and when possible, data on the US population are provided for context. The associations of each domain with pediatrician well-being are discussed, along with barriers to preventive care and preventive health behaviors. Lastly, relevant 2019 data from the American Academy of Pediatrics (AAP) Pediatrician Life and Career Experience Study (PLACES) are presented. Based on the limited data available, physicians seem relatively healthy and exhibit healthy behaviors, although there is room for improvement. Modifiable systemic and organizational barriers exist. Opportunities may be available for physicians, employers, and policymakers to provide solutions to address these barriers.
OBJECTIVE
Surgeon burnout has received increasing attention due to evidence of high prevalence across specialties. We aimed to (1) systematically characterize existing definitions of burnout, (2) evaluate tools to measure burnout, and (3) determine risk factors of surgical burnout.
DESIGN
PubMed, Google Scholar, and Embase databases were searched to identify burnout rates and tools used to measure the quality of life (QoL) published from January 2000-December 2021.
PARTICIPANTS
Surgical Trainees and Practicing Surgeons.
RESULTS
We identified 39 studies that defined surgical burnout, with 9 separate tools used to measure QoL. Surgeon burnout rates were found to be highest among general surgery trainees (20%-95%). Burnout among general surgery attendings ranged from 25% to 44%. Those most likely to experience burnout were younger and female. High rates of surgeon burnout were reported among all surgical specialties; however, these rates were lower than those of general surgeons.
CONCLUSION
Definitions of burnout vary throughout the surgical literature, but are consistently characterized by emotional exhaustion, depersonalization, and lack of personal accomplishment. The most utilized tool to measure surgical burnout has been the Maslach Burnout Inventory. Across specialties, there are high rates of burnout in both surgical trainees and attendings, indicating that this is a systemic issue within the field of surgery. Given the wide-scale nature of the problem, it is recommended that institutions provide support to surgical trainees and attending surgeons and that individual surgeons take steps toward mitigating burnout.
Objective Asynchronous messaging is an integral aspect of communication in clinical settings, but imposes additional work and potentially leads to inefficiency. The goal of this study was to describe the time spent using the electronic health record (EHR) to manage asynchronous communication to support breast cancer care coordination.
Methods We analyzed 3 years of audit logs and secure messaging logs from the EHR for care team members involved in breast cancer care at Vanderbilt University Medical Center. To evaluate trends in EHR use, we combined log data into sequences of events that occurred within 15 minutes of any other event by the same employee about the same patient.
Results Our cohort of 9,761 patients were the subject of 430,857 message threads by 7,194 employees over a 3-year period. Breast cancer care team members performed messaging actions in 37.5% of all EHR sessions, averaging 29.8 (standard deviation [SD] = 23.5) messaging sessions per day. Messaging sessions lasted an average of 1.1 (95% confidence interval: 0.99–1.24) minutes longer than nonmessaging sessions. On days when the cancer providers did not otherwise have clinical responsibilities, they still performed messaging actions in an average of 15 (SD = 11.9) sessions per day.
Conclusion At our institution, clinical messaging occurred in 35% of all EHR sessions. Clinical messaging, sometimes viewed as a supporting task of clinical work, is important to delivering and coordinating care across roles. Measuring the electronic work of asynchronous communication among care team members affords the opportunity to systematically identify opportunities to improve employee workload.
Background:
Clinician burnout is a prevalent issue in healthcare, with detrimental implications in healthcare quality and medical costs due to errors. The inefficient use of health information technologies (HIT) is attributed to having a role in burnout.
Objective:
This paper seeks to review the literature with the following two goals: (1) characterize and extract HIT trends in burnout studies over time, and (2) examine the evidence and synthesize themes of HIT's roles in burnout studies.
Methods:
A scoping literature review was performed by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with two rounds of searches in PubMed, IEEE Xplore, ACM, and Google Scholar. The retrieved papers and their references were screened for eligibility by using developed inclusion and exclusion criteria. Data were extracted from included papers and summarized either statistically or qualitatively to demonstrate patterns.
Results:
After narrowing down the initial 945 papers, 36 papers were included. All papers were published between 2013 and 2020; nearly half of them focused on primary care (n = 16; 44.4%). The most commonly studied variable was electronic health record (EHR) practices (e.g., number of clicks). The most common study population was physicians. HIT played multiple roles in burnout studies: it can contribute to burnout; it can be used to measure burnout; or it can intervene and mitigate burnout levels.
Conclusion:
This scoping review presents trends in HIT-centered burnout studies and synthesizes three roles for HIT in contributing to, measuring, and mitigating burnout. Four recommendations were generated accordingly for future burnout studies: (1) validate and standardize HIT burnout measures; (2) focus on EHR-based solutions to mitigate clinician burnout; (3) expand burnout studies to other specialties and types of healthcare providers, and (4) utilize mobile and tracking technology to study time efficiency.
Purpose:
Clinical notes function as the de facto handoff between providers and assume great importance during unplanned medical encounters. An organized and thorough oncology history is essential in care coordination. We sought to understand reader preferences for oncology history organization by comparing between chronologic and narrative formats.
Methods:
A convenience sample of 562 clinicians from 19 National Comprehensive Cancer Network Member Institutions responded to a survey comparing two formats of oncology histories, narrative and chronologic, for the same patient. Both histories were consensus-derived real-world examples. Each history was evaluated using semantic differential attributes (thorough, useful, organized, comprehensible, and succinct). Respondents choose a preference between the two styles for history gathering and as the basis of a new note. Open-ended responses were also solicited.
Results:
Respondents preferred the chronologic over the narrative history to prepare for a visit with an unknown patient (66% preference) and as a basis for their own note preparation (77% preference) (P < .01). The chronologic summary was preferred in four of the five measured attributes (useful, organized, comprehensible, and succinct); the narrative summary was favored for thoroughness (P < .01). Open-ended responses reflected the attribute scoring and noted the utility of content describing social determinants of health in the narrative history.
Conclusion:
Respondents of this convenience sample preferred a chronologic oncology history to a concise narrative history. Further studies are needed to determine the optimal structure and content of chronologic documentation for oncology patients and the provider effort to use this format.
Background:
Medical training programs across the country are bound to a set of work hour regulations, generally monitored via self-report.
Objective:
We developed a computational method to automate measurement of intern and resident work hours, which we validated against self-report.
Design, setting, and participants:
We included all electronic health record (EHR) access log data between July 1, 2018, and June 30, 2019, for trainees enrolled in the internal medicine training program. We inferred the duration of continuous in-hospital work hours by linking EHR sessions that occurred within 5 hours as "on-campus" work and further accounted for "out-of-hospital" work which might be taking place at home.
Main outcomes and measures:
We compared daily work hours estimated through the computational method with self-report and calculated the mean absolute error between the two groups. We used the computational method to estimate average weekly work hours across the rotation and the percentage of rotations where average work hours exceed the 80-hour workweek.
Results:
The mean absolute error between self-reported and EHR-derived daily work hours for first- (PGY-1), second- (PGY-2), and third- (PGY-3) year trainees were 1.27, 1.51, and 1.51 hours, respectively. Using this computational method, we estimated average (SD) weekly work hours of 57.0 (21.7), 69.9 (12.2), and 64.1 (16.3) for PGY-1, PGY-2, and PGY-3 residents.
Conclusion:
EHR log data can be used to accurately approximate self-report of work hours, accounting for both in-hospital and out-of-hospital work. Automation will reduce trainees' clerical work, improve consistency and comparability of data, and provide more complete and timely data that training programs need.
BACKGROUND
Increased work through electronic health record (EHR) messaging is frequently cited as a factor of physician burnout. However, studies to date have relied on anecdotal or self-reported measures, which limit the ability to match EHR use patterns with continuous stress patterns throughout the day.
OBJECTIVE
The aim of this study is to collect EHR use and physiologic stress data through unobtrusive means that provide objective and continuous measures, cluster distinct patterns of EHR inbox work, identify physicians’ daily physiologic stress patterns, and evaluate the association between EHR inbox work patterns and physician physiologic stress.
METHODS
Physicians were recruited from 5 medical centers. Participants (N=47) were given wrist-worn devices (Garmin Vivosmart 3) with heart rate sensors to wear for 7 days. The devices measured physiological stress throughout the day based on heart rate variability (HRV). Perceived stress was also measured with self-reports through experience sampling and a one-time survey. From the EHR system logs, the time attributed to different activities was quantified. By using a clustering algorithm, distinct inbox work patterns were identified and their associated stress measures were compared. The effects of EHR use on physician stress were examined using a generalized linear mixed effects model.
RESULTS
Physicians spent an average of 1.08 hours doing EHR inbox work out of an average total EHR time of 3.5 hours. Patient messages accounted for most of the inbox work time (mean 37%, SD 11%). A total of 3 patterns of inbox work emerged: inbox work mostly outside work hours, inbox work mostly during work hours, and inbox work extending after hours that were mostly contiguous to work hours. Across these 3 groups, physiologic stress patterns showed 3 periods in which stress increased: in the first hour of work, early in the afternoon, and in the evening. Physicians in group 1 had the longest average stress duration during work hours (80 out of 243 min of valid HRV data; P =.02), as measured by physiological sensors. Inbox work duration, the rate of EHR window switching (moving from one screen to another), the proportion of inbox work done outside of work hours, inbox work batching, and the day of the week were each independently associated with daily stress duration (marginal R2 =15%). Individual-level random effects were significant and explained most of the variation in stress (conditional R2 =98%).
CONCLUSIONS
This study is among the first to demonstrate associations between electronic inbox work and physiological stress. We identified 3 potentially modifiable factors associated with stress: EHR window switching, inbox work duration, and inbox work outside work hours. Organizations seeking to reduce physician stress may consider system-based changes to reduce EHR window switching or inbox work duration or the incorporation of inbox management time into work hours.
CLINICALTRIAL
Objective:
The study sought to examine the association between clinician burnout and measures of electronic health record (EHR) workload and efficiency, using vendor-derived EHR action log data.
Materials and methods:
We combined data from a statewide clinician survey on burnout with Epic EHR data from the ambulatory sites of 2 large health systems; the combined dataset included 422 clinicians. We examined whether specific EHR workload and efficiency measures were independently associated with burnout symptoms, using multivariable logistic regression and controlling for clinician characteristics.
Results:
Clinicians with the highest volume of patient call messages had almost 4 times the odds of burnout compared with clinicians with the fewest (adjusted odds ratio, 3.81; 95% confidence interval, 1.44-10.14; P = .007). No other workload measures were significantly associated with burnout. No efficiency variables were significantly associated with burnout in the main analysis; however, in a subset of clinicians for whom note entry data were available, clinicians in the top quartile of copy and paste use were significantly less likely to report burnout, with an adjusted odds ratio of 0.22 (95% confidence interval, 0.05-0.93; P = .039).
Discussion:
High volumes of patient call messages were significantly associated with clinician burnout, even when accounting for other measures of workload and efficiency. In the EHR, "patient calls" encompass many of the inbox tasks occurring outside of face-to-face visits and likely represent an important target for improving clinician well-being.
Conclusions:
Our results suggest that increased workload is associated with burnout and that EHR efficiency tools are not likely to reduce burnout symptoms, with the exception of copy and paste.
A career in medicine is rife with work-life conflict for both women and men. Women in particular must make choices along their medical journey, the very characteristics of which might be considered drivers of work-life imbalance and burnout (specialty, work hours, income). Societal norms, albeit changing, often result in women being more heavily involved and invested in home and childcare responsibilities. Many physicians feel stigmatized if they take advantage of flexible policies. Personal characteristics such as commitment to self-care, the ability to self-promote and to set limits, as well as the lack of effective role models and mentors for women can further impede successful work-life integration. This chapter explores key drivers of work-life conflicts in medicine, differences among the specialties and between male and female physicians, reasons for greater distress among women, and potential solutions across the career lifespan.
Wisconsin physicians are experiencing burnout at levels that surpass national benchmarks. The Wisconsin Medical Society (Society), in conjunction with the American Medical Association (AMA), conducted a survey of 1,165 Wisconsin physicians to assess burnout and its contributing factors. The results indicate that primary causes of physician burnout include utilization and interactions with electronic health records (EHR), lack of a supportive practice environment, the loss of autonomy, and poor work/life balance. Addressing physician burnout in Wisconsin calls for significant efforts by all relevant stakeholders, including insurers, government entities, health care systems and their executive leadership, and physicians themselves, and will require improving physician interactions with the EHR, increasing the physician role in administrative decision-making, and maintaining the focus of health care on the patient. To lessen the impact of the key factors that lead to physician burnout, the Society plans to convene stakeholders to improve EHR functionality, develop and encourage physician leadership opportunities, create a Center for Physician Empowerment to unite stakeholders to lead systemic change through collective education and action, and pursue legislation to establish a Physician Health Program through the state government structure.
Objective:
To quantify how stress related to use of health information technology (HIT) predicts burnout among physicians.
Methods:
All 4197 practicing physicians in Rhode Island were surveyed in 2017 on their HIT use. Our main outcome was self-reported burnout. The presence of HIT-related stress was defined by report of at least 1 of the following: poor/marginal time for documentation, moderately high/excessive time spent on the electronic health record (EHR) at home, and agreement that using an EHR adds to daily frustration. We used logistic regression to assess the association between each HIT-related stress measure and burnout, adjusting for respondent demographics, practice characteristics, and the other stress measures.
Results:
Of the 1792 physician respondents (43% response rate), 26% reported burnout. Among EHR users (91%), 70% reported HIT-related stress, with the highest prevalence in primary care-oriented specialties. After adjustment, physicians reporting poor/marginal time for documentation had 2.8 times the odds of burnout (95% CI: 2.0-4.1; P < .0001), compared to those reporting sufficient time. Physicians reporting moderately high/excessive time on EHRs at home had 1.9 times the odds of burnout (95% CI: 1.4-2.8; P < .0001), compared to those with minimal/no EHR use at home. Those who agreed that EHRs add to their daily frustration had 2.4 times the odds of burnout (95% CI: 1.6-3.7; P < .0001), compared to those who disagreed.
Conclusion:
HIT-related stress is measurable, common (about 70% among respondents), specialty-related, and independently predictive of burnout symptoms. Identifying HIT-specific factors associated with burnout may guide healthcare organizations seeking to measure and remediate burnout among their physicians and staff.
Importance:
Burnout is a self-reported job-related syndrome increasingly recognized as a critical factor affecting physicians and their patients. An accurate estimate of burnout prevalence among physicians would have important health policy implications, but the overall prevalence is unknown.
Objective:
To characterize the methods used to assess burnout and provide an estimate of the prevalence of physician burnout.
Data sources and study selection:
Systematic search of EMBASE, ERIC, MEDLINE/PubMed, psycARTICLES, and psycINFO for studies on the prevalence of burnout in practicing physicians (ie, excluding physicians in training) published before June 1, 2018.
Data extraction and synthesis:
Burnout prevalence and study characteristics were extracted independently by 3 investigators. Although meta-analytic pooling was planned, variation in study designs and burnout ascertainment methods, as well as statistical heterogeneity, made quantitative pooling inappropriate. Therefore, studies were summarized descriptively and assessed qualitatively.
Main outcomes and measures:
Point or period prevalence of burnout assessed by questionnaire.
Results:
Burnout prevalence data were extracted from 182 studies involving 109 628 individuals in 45 countries published between 1991 and 2018. In all, 85.7% (156/182) of studies used a version of the Maslach Burnout Inventory (MBI) to assess burnout. Studies variably reported prevalence estimates of overall burnout or burnout subcomponents: 67.0% (122/182) on overall burnout, 72.0% (131/182) on emotional exhaustion, 68.1% (124/182) on depersonalization, and 63.2% (115/182) on low personal accomplishment. Studies used at least 142 unique definitions for meeting overall burnout or burnout subscale criteria, indicating substantial disagreement in the literature on what constituted burnout. Studies variably defined burnout based on predefined cutoff scores or sample quantiles and used markedly different cutoff definitions. Among studies using instruments based on the MBI, there were at least 47 distinct definitions of overall burnout prevalence and 29, 26, and 26 definitions of emotional exhaustion, depersonalization, and low personal accomplishment prevalence, respectively. Overall burnout prevalence ranged from 0% to 80.5%. Emotional exhaustion, depersonalization, and low personal accomplishment prevalence ranged from 0% to 86.2%, 0% to 89.9%, and 0% to 87.1%, respectively. Because of inconsistencies in definitions of and assessment methods for burnout across studies, associations between burnout and sex, age, geography, time, specialty, and depressive symptoms could not be reliably determined.
Conclusions and relevance:
In this systematic review, there was substantial variability in prevalence estimates of burnout among practicing physicians and marked variation in burnout definitions, assessment methods, and study quality. These findings preclude definitive conclusions about the prevalence of burnout and highlight the importance of developing a consensus definition of burnout and of standardizing measurement tools to assess the effects of chronic occupational stress on physicians.
Purpose:
Primary care physicians spend nearly 2 hours on electronic health record (EHR) tasks per hour of direct patient care. Demand for non-face-to-face care, such as communication through a patient portal and administrative tasks, is increasing and contributing to burnout. The goal of this study was to assess time allocated by primary care physicians within the EHR as indicated by EHR user-event log data, both during clinic hours (defined as 8:00 am to 6:00 pm Monday through Friday) and outside clinic hours.
Methods:
We conducted a retrospective cohort study of 142 family medicine physicians in a single system in southern Wisconsin. All Epic (Epic Systems Corporation) EHR interactions were captured from "event logging" records over a 3-year period for both direct patient care and non-face-to-face activities, and were validated by direct observation. EHR events were assigned to 1 of 15 EHR task categories and allocated to either during or after clinic hours.
Results:
Clinicians spent 355 minutes (5.9 hours) of an 11.4-hour workday in the EHR per weekday per 1.0 clinical full-time equivalent: 269 minutes (4.5 hours) during clinic hours and 86 minutes (1.4 hours) after clinic hours. Clerical and administrative tasks including documentation, order entry, billing and coding, and system security accounted for nearly one-half of the total EHR time (157 minutes, 44.2%). Inbox management accounted for another 85 minutes (23.7%).
Conclusions:
Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. EHR event logs can identify areas of EHR-related work that could be delegated, thus reducing workload, improving professional satisfaction, and decreasing burnout. Direct time-motion observations validated EHR-event log data as a reliable source of information regarding clinician time allocation.
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.
Background:
Despite extensive data about physician burnout, to our knowledge, no national study has evaluated rates of burnout among US physicians, explored differences by specialty, or compared physicians with US workers in other fields.
Methods:
We conducted a national study of burnout in a large sample of US physicians from all specialty disciplines using the American Medical Association Physician Masterfile and surveyed a probability-based sample of the general US population for comparison. Burnout was measured using validated instruments. Satisfaction with work-life balance was explored.
Results:
Of 27 276 physicians who received an invitation to participate, 7288 (26.7%) completed surveys. When assessed using the Maslach Burnout Inventory, 45.8% of physicians reported at least 1 symptom of burnout. Substantial differences in burnout were observed by specialty, with the highest rates among physicians at the front line of care access (family medicine, general internal medicine, and emergency medicine). Compared with a probability-based sample of 3442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%) (P < .001 for both). Highest level of education completed also related to burnout in a pooled multivariate analysis adjusted for age, sex, relationship status, and hours worked per week. Compared with high school graduates, individuals with an MD or DO degree were at increased risk for burnout (odds ratio [OR], 1.36; P < .001), whereas individuals with a bachelor's degree (OR, 0.80; P = .048), master's degree (OR, 0.71; P = .01), or professional or doctoral degree other than an MD or DO degree (OR, 0.64; P = .04) were at lower risk for burnout.
Conclusions:
Burnout is more common among physicians than among other US workers. Physicians in specialties at the front line of care access seem to be at greatest risk.