Can informatics innovation help mitigate clinician burnout?

In a recent Annals of Internal Medicine opinion piece, Downing et al¹ argued that while physicians may identify the electronic health record (EHR) as a source of dissatisfaction and burnout, the real culprit is the documentation burden caused by regulations related to billing and reimbursement rather than the EHR itself and that improvements in informatics platform alone are insufficient to solve the issue. They support this argument by comparing physician documentation burden and EHR satisfaction in the United States with other countries such as Australia, the Netherlands, Singapore, and Denmark, many of whom have implemented an EHR that is also widely implemented in ambulatory care in the United States. These comparisons suggest that documentation burden is lower and EHR satisfaction is higher. Of course, physicians are only 1 user of the EHR. While there is a large body of literature on nurse burnout, studies related to nursing and the EHR have focused primarily on lack of features and functions to meet nursing needs.² Burnout has been studied in advanced practice registered nurses who use the EHR similarly to physicians in the ambulatory care setting. A survey conducted by Harris et al³ in Rhode Island found that among advanced practice registered nurses using EHRs, insufficient time for documentation and the EHR adding to daily frustration were significant predictors of burnout. There is little literature on EHR-related burnout for other healthcare professionals such as dentists, pharmacists, medical social workers, and physical therapists.

Like many clinicians drawn to biomedical and health informatics, I was attracted by my belief in the power of biomedical and health informatics to improve healthcare processes and health outcomes. Through my years in the field, I’ve grown to appreciate the policy context and I’m proud to be part of the American Medical Informatics Association, an organization that is known for its acumen regarding the intersection of health policy and informatics. Thus, while I strongly support Downing et al’s call for regulatory reform, I believe that innovation from the field is also necessary to help mitigate clinician burnout. Consequently, I highlight papers in this issue that focus specifically on clinicians and EHRs.

Adding to the body of literature on EHRs and physician burnout, Gardner et al⁴ examined the relationship between physician EHR-related stress and burnout through a 2017 survey of all Rhode Island practicing physicians. Twenty-six percent of the 1792 respondents reported burnout and 70% reported health information technology–related stress. Physicians reporting poor or marginal time for documentation, reporting moderately high or excessive time spent on EHRs at home, and agreeing that EHRs add to their daily frustration had significantly higher odds of burnout as compared with those who did not.

Colicchio and Cimino⁵ qualitatively synthesized 23 qualitative and mixed-methods studies about the use of EHR systems to support creation and use of clinical documentation. Two findings of the review are particularly relevant to the topic of clinician burnout. Five studies on note purposes found that nonclinical purposes have become more common. Note-entry studies (n = 6) revealed that EHR interfaces affect what clinicians document. They called for more research to investigate approaches to capture and represent clinicians’ reasoning and improve note entry and retrieval or reading.

Two papers in this issue report on the design of innovations to improve clinician performance in common tasks that have potential to influence workload and burnout. Belden et al⁶ applied human factors and interaction design principles to iteratively create a medication timeline visualization intended to improve ease of use, speed, and accuracy in the ambulatory care of chronic disease. A pilot evaluation of the timeline visualization as compared to tabular presentation of the same information showed improved physician performance in 5 common medication-related tasks: (1) identify current prescription on a medication history, (2) identify past prescription on a medication history, (3) identify length of time medication has been prescribed, (4) identify new prescription in given time interval, and (5) identify dosage change in given time interval. Using a mixed methods design and scenario-based evaluation, Hosseini et al⁷ evaluated an information system designed to reconcile information across multiple electronic documents containing patient health records from a health information exchange network. Consolidation with as compared with without the information system resulted in higher accuracy, lower perceived workload, and shorter information reconciliation time in a small sample of physicians. The authors concluded that automating retrieval and reconciliation of information across multiple electronic documents is a promising approach for reducing healthcare providers’ task complexity and workload.

Addressing an area of clinician workload that is on the rise, Herr et al⁸ argued that a first step in determining whether pharmacogenomics (PGx) clinical decision support will be effective in improving prescribing decisions is to examine process measures such as physician uptake and response. Their multisite pilot study focused on 2 prerequisites for examining these process measures—characterization of alert design within the eMERGE Network, and establishing a method for sharing PGx alert response data for aggregate analysis. Although the 6 pilot sites successfully shared response data, the authors concluded that the variation in PGx alert design is a barrier to multisite PGx clinical decision support studies.

Many EHR innovations target the individual clinicians. While this is a necessary component, EHR innovations cannot help to mitigate clinician burnout without careful consideration of the socioecological context in which these innovations occur, including organizational culture, healthcare marketplace, technology ecosystem, and national policy.