EHRs, Clerical Tasks Contribute to Physician Burnout

Diana Phillips

June 28, 2016

The efficiency and care coordination gains attributed to the adoption of electronic technology for managing and communicating health information appear to come at a personal and professional cost for physicians.

Physician satisfaction with the clerical burden of electronic health records (EHRs), computerized physician order entry (CPOE), and communication via patient portals is low, but the risk for burnout associated with the use of some of these technologies is high, according to the results of a 2014 national survey across various medical specialties and practice settings.

Moreover, the association between technology usage and burnout persists regardless of the perceived value of the tools, Tait D. Shanafelt, MD, from the Division of Hematology at the Mayo Clinic, Rochester, Minnesota, and colleagues report in a study published online June 27 in Mayo Clinic Proceedings.

The findings come on heels of an earlier analysis of the same survey data that showed a dramatic rise in rates of physician burnout and dissatisfaction with work–life balance during a 3-year period.

"The reasons for the increased rate of physician burnout are complex and include individual and organizational factors," the authors explain. There has been speculation that the increasing use of EHRs and other electronic tools "may lead to information overload, frequent interruptions/distractions, and a change in the content of the professional work."

EHRs, for example, "have increased the clerical burden on physicians, altered the patient-physician interaction, and can distract from the more meaningful aspects of medical practice," the authors write. Together with the elimination of transcription services and the implementation of physician self-entry of notes, "[t]hese changes appear to have increased the amount of time physicians spend on documentation and other clerical tasks."

To evaluate these associations, the investigators analyzed physician responses to questions about the electronic environment in their practice, the clerical burden imposed by the technology, and symptoms of burnout

The survey, which included a national sample of physicians across all specialties in the United States, was conducted between August and October 2014. Of the 35,922 physicians invited to participated, 6880 completed surveys, 6560 of which were in active clinical practice and were included in the present analysis.

Of 6375 physicians who replied to the question about EHR use, 5358 (84.5%) said they used the technology. More than one third (36.0%) were satisfied or very satisfied with their EHRs, whereas almost half (43.7%) reported being dissatisfied or very dissatisfied.

Among physicians who reported using EHRs, the prevalence of burnout, as measured by the Maslach Burnout Inventory, was 57.2% compared with 44.6% of physicians not using the technology.

With respect to CPOE, 5892 of the physicians responded that the technology was relevant to their speciality. Of those, 4858 (82.5%) reported using it in the clinic, the hospital, or both settings. Among those using the technology, 38.1% were satisfied or very satisfied with it and 41.9% were dissatisfied or very dissatisfied.

The prevalence of burnout among CPOE users was highest among those who used it in the hospital only (59.2%), followed by those who used it in both the hospital and clinic (58.9%), and in the clinic only (55.8%).

Approximately one quarter (26.1%) of the 6360 physicians who responded to the question about patient portal use reported using the technology to communicate directly with patients. Of those who use it, 35.3% felt that it improved patient care, whereas 28.1% disagreed or strongly disagreed.

In addition, of the responding physicians who use the respective technologies:

  • 36.3% felt that EHRs improved patient care, whereas 41.0% disagreed or strongly disagreed,

  • 62.5% disagreed with the idea that EHRs improved operational efficiency,

  • 51.0% disagreed with the idea that communication via patient portals had efficiency benefits,

  • 46.5% felt that the amount of time spent on clerical tasks related to direct patient care (order entry, dictation, reviewing laboratory results, and communicating with patients via an electronic portal) was unreasonable,

  • 55.8% felt that the amount of time spent on clerical tasks indirectly related to patient care (correspondence, completion of forms, and answering telephone calls) was unreasonable.

Satisfaction with the various technologies and the clinical burden varied by age and specialty, the authors report. In general, younger physicians tended to be more satisfied than older ones, and pathologists and radiologists had the highest satisfaction rates, whereas urologists, family medicine physicians, and otolaryngologists had the lowest.

Further, physicians who used EHRs, CPOE, and patient portals expressed more dissatisfaction with the clerical burden directly and indirectly related to patient care. In addition, physicians who used EHRs and CPOE had higher rates of burnout, "regardless of whether they were or were not satisfied with their EHRs or CPOE," the authors note

In multivariate analyses adjusted for age, sex, specialty, practice setting, and hours worked per week, physicians who used EHRs or CPOE were less likely to be satisfied with the clerical burden directly related to patient care. Further, "[p]hysicians using CPOE had an approximately 30% higher risk of burnout after adjusting for all other factors," the authors report, indicating that "CPOE seemed to be the driving factor in the relationship between the electronic environment and physician burnout."

Use of a patient portal was not independently associated with burnout or satisfaction with the clerical burden, according to the authors.

Although additional studies are needed to validate the associations observed in this research, the findings suggest the increased risk for burnout and the clerical and cognitive burden of EHRs, CPOE, and patient portals "may threaten the potentially beneficial effects," the authors write. "Burnout has been shown to erode quality of care, increase risk of medical errors, and lead physicians to reduce clinical work hours, suggesting that the net effect of these electronic tools on quality of care for the US health care system is less clear."

Reaping the benefits of these technologies while mitigating the negative effects on physicians requires "finding ways to incorporate EHRs, patient portals, and CPOE in a manner that does not increase clerical burden for physicians or reduce their efficiency," the authors suggest. "Understanding which EHR functions pose the greatest challenges for physicians may help identify the areas that provide the greatest opportunity for redesign of practice-relevant operational processes."

The development of strategies "that incorporate these electronic tools into practice without adversely affecting physician efficiency and professional satisfaction are needed," the authors write, noting that assistant order entry and documentation support (scribes) represent promising approaches, as do advanced care team models, value stream mapping, and process standardization.

This study was funded by the Mayo Clinic Program on Physician Well-being. The authors have disclosed no relevant financial relationships.

Mayo Clin Proc. Published online June 27, 2016. Abstract

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