EHR Burden Weighs Heavily on Physicians, Leads to Burnout

Diana Phillips

September 06, 2016

Physicians are spending more time with patients' electronic health records (EHRs) than they are with the patients themselves, according to an observational study looking at the allocation of physician time in ambulatory practice.

For every hour of clinic time they spend with patients, physicians spend approximately 2 additional hours on EHR and desk work during office hours, Christine Sinsky, MD, vice president of professional satisfaction at the American Medical Association (AMA), and colleagues report in an article published online September 6 in the Annals of Internal Medicine. In addition to the time physicians spend at the office, they also spend another 1 to 2 hours on computer and other clerical work during their personal time each day.

This finding adds to the growing body of evidence suggesting that the current generation of EHRs adds to physicians' daily administrative burden and, as a result, may be increasing rates of professional burnout.

For example, in one recent study reported by Medscape Medical News, researchers found that primary care physicians lost more than an hour per day sorting through EHR notifications independent of all other EHR-related tasks. In another study, the prevalence of physician burnout was significantly higher among physicians who used EHRs than among those who did not, independent of their reported satisfaction with the technology itself.

One reason for this may be physicians' perception that the administrative burden of EHRs compromises the physician–patient relationship. In the Medscape EHR Report 2016, more than half of the physician respondents felt that EHRs reduce both the time available for face-to-face patient interaction and the number of patients who can be seen each day.

In the current study, Dr Sinsky and colleagues collected information on how 57 US physicians in family medicine, internal medicine, cardiology, and orthopaedics from multiple practice sites across four states used their time in the exam room with patients. They also studied how much time they spent outside of the exam room, both within and outside of office hours, on EHRs and office work. During office hours, trained observers collected information by using direct observation, and after-hours information was collected from self-reported diaries.

From July 7, 2015, to August 11, 2015, 49.2% of the physicians' total work time during office hours was spent on EHR and desk work, including documentation and review (38.5%), test results (6.3%), medication orders (2.4%), other orders (2.0%), and administrative tasks (1.1%), the authors report. In contrast, only 33.1% of the total time during office hours was allocated to direct clinical facetime, including 27.0% in the exam room with patients and 6.1% with staff when the patient was not present.

With respect to the exam room specifically, 52.9% of physician time was spent on direct clinical face time with patients, whereas 37.0% was spent on EHR and desk work. Their remaining time was spent on administrative (9.3%) and other (0.8%) tasks.

Of the 57 physicians in the study, only 26 used documentation support, including dictation (n = 21) and a documentation assistant (n = 5). Compared with physicians who did not use documentation support, physicians with documentation support had more direct clinical face time with patients. Specifically, the amount of time spent on direct clinical face time for those with dictation or a documentation assistant was 31.4% and 43.9%, respectively, compared with 23.1% for those without documentation support.

"This is consistent with studies demonstrating benefits from sharing documentation and order entry tasks with team members, including saving physician time, boosting productivity, increasing capacity and thus access for patients, improving quality of documentation, and improving patient and provider satisfaction," the authors write. "Optimization of documentation support may be achieved through models of advanced teamwork or documentation assistants."

More than one third of the physicians in the study documented their after-work activity in self-report diaries, together reporting a mean of 1.5 hours of after-hours work per day. The majority (59%) of the after-hours work time was allocated to EHR use.

Of 124 nights documented by the physicians, 30 involved night and/or weekend practice coverage. "When providing night coverage for the practice, physicians allocated a mean of 2.2 hours per day to performing work tasks and used the EHR for 69% of this time," the authors observe.

The study findings highlight the gap between EHR expectations and outcomes that has been identified in recent analyses. "For example, one might hypothesize that new EHR activities decrease the time physicians spend engaging with patients," the authors write. "Our data quantify previous survey data showing that physicians report spending substantial work time using the EHR. These previous studies have suggested that decreased time with patients and increased workload from EHR tasks are major contributors to career dissatisfaction among physicians."

The authors stress that the study findings are "only the first step in characterizing the ambulatory care work domain with regard to what is done, where, and for how long," and they caution against judging the observed activity to be good or bad. "Rather, it needs to be linked to quality, financial, and professional satisfaction outcomes for a full understanding of the activities that are critical to achieving superior clinical outcomes versus the activities that are required only for administrative and regulatory purposes or that represent a source of inefficiency or a waste of time, talent, or resources."

In an accompanying editorial, Susan Hingle, MD, from the Southern Illinois University School of Medicine in Springfield, notes that the association between the use of documentation support services and the increased time spent on face-to-face interaction points to an important improvement opportunity.

"Learning colleagues' strategies to alleviate some of the practice hassles related to EHRs is a great way to move forward and make improvements, and professional organizations have begun to facilitate such learning," she writes, referring to specific efforts by the AMA and the American College of Physicians to share best practices and reduce administrative burdens.

In particular, the American College of Physicians has developed policy recommendations for clinical documentation and EHR system design. The recommendations, reported by Medscape Medical News, "recognize the promise of EHRs while acknowledging the current challenges they present."

Overcoming these challenges requires stakeholder engagement and cooperation, as well as additional time-and-motion studies to evaluate the effectiveness of interventions, such as scribes or advanced care teams, in reducing the administrative burden of EHRs, Dr Hingle writes. "Now is the time to go beyond complaining about EHRs and other practice hassles and to make needed changes to the health care system that will redirect our focus from the computer screen to our patients and help us rediscover the joy of medicine."

The AMA provided financial support for this study. Dr Sinsky has disclosed an advisory relationship with practice automation company healthfinch. Two of the study coauthors have disclosed that they are employed by the AMA, and a third has reported receipt of a grant from the AMA during the conduct of the study. Two additional coauthors have disclosed receiving grants and/or funding from Mary Hitchcock Hospital and Dartmouth Hitchcock Clinic during the study. Dr Hingle has disclosed no relevant financial relationships.

Ann Intern Med. Published online September 5, 2016. Article abstract, Editorial extract

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