Table 2. Themes identified in pediatricians' open-ended responses to “What more should we know about your experiences with administrative tasks?” and illustrative quotes.

Patient documentation in the electronic health record (EHR), including the functionality of the EHR

Pediatricians often commented on documentation issues including time needed to adequately document patient visits, volume of requirements, and negative effect on patient encounters.  • “Use of an EHR has added significantly to work burden (that is not accommodated for in our documenting after work hours and on nights/weekends at home). If I try to document while in the room, it really detracts from the visit, taking away from that interpersonal experience. Scribes are a luxury that a small private practice cannot afford.”  • “I don't mind some administrative tasks, particularly the ones that benefit the patient in front of me. What I resent, is the weaponization of the EMR and the shift of required data entry to the clinician so every committee in the hospital can have data streaming in that suits their particular needs. As soon as a new CMS requirement is pronounced, committees jump to see how they can manipulate the EMR to capture new data or process information that they care about by compelling certain fields of the clinician. They all justify it as “just a few more clicks.” Importantly, no one is keeping track of these ever-expanding demands/clicks so more and more of the work day is about checking the boxes. Patients are noticing too.”  • “I would say that almost the entirety of my work outside of work hours is documentation in the EHR. This is not just writing progress notes for the patients I've seen in a day, but also updating discharge summaries for patients I'm signing out to another physician and updating a written handoff tool in the EHR. This is triple documentation and it is exhausting and a big 'dissatisfier'.”  • “Administrative tasks especially EHR are burdensome and painstaking. Just looking at past medications takes multiple clicks. Not all the physicians document the same so seeing another physician's note is even more challenging. Yes, it is legible and easer to access but that is where the positivity ends.”

Functionality of the EHR

Many pediatricians commented on the functionality of the EHR, expressing that the system is not user-friendly, customizable, or developed for pediatrics. Billing issues and constant changes in procedures and updates related to the EHR were also voiced.  • “EHRs are not user-friendly or customizable and do not decrease time spent charting, actually the opposite.”  • “The EHR has significantly reduced the number of patients I can see in a day. In addition, it removes the personal nature of the note causing it to seem very generic. At some point in the future, I can see how and EHR may become beneficial to both the patient and the provider but we are not there yet.”  • “Our EHR also needs improvement. People keep adding to it but not taking away. Now it's mostly a series of meaningless click boxes. It has some great, time saving features (vaccine decision support, for example), but there is also too much clutter.”  • “Also, no one has talked about how billing in the EMR takes up more time. We used to just circle items that we had done on the paper bill and someone else would input all that. Now, the doctor has to do it and pick all the correct diagnosis codes to attach, etc., when signing off on a note. My providers are resenting all this.” A few PLACES pediatricians commented that the EHR improves their work and responsiveness to patients:  • “I have made a lot of workarounds with EHR, (my major administrative task), so have ready-made note templates, etc. The initial time investment was definitely worth it.”  • “I actually feel the EHR has improved my work and responsiveness to patients. Before the EHR it would take days to share lab results and respond to patients.”

Supporting physicians with administrative burdens

Pediatricians frequently commented on ways that might help physicians reduce their administrative burdens, mostly related to patient documentation. Topics included designated time in physician schedules to complete documentation, dictation software and training on EHR system, financial-related issues, and support by administrators. Many commented on support staff and scribes taking on some documentation tasks, which would allow physicians to work at the top of their license. Both positive and negative comments were provided about scribes.  • “A scribe has been offered to physicians in my practice, but each physician is responsible for that cost. That is not much of an incentive! I would prefer more time to be built into my schedule for EHR documentation than having a scribe. All of us in my practice are either staying in office for several hours at end of day or finishing documentation at home. I do administrative tasks during the days off, as there is no other time to do it.”  • “Scribes are a luxury that a small private practice cannot afford.”  • “I had a scribe for 6–9 months, though adm. burden was decreased there was a lot of “down time” for the scribe. I have changed her role to more adm/medical assistant. Prepping my day, immunization needed, previous recent visit + last CPE [complete physical exam] documentation brought into visit. Post visit documentation routine + ins. [insurance] regulation such as care plans, referrals, documentation, etc. call back for normal laboratories.”  • “Scribes are the exact opposite of what we really need. I need to write/dictate my own notes. This helps me to remember the patient and review the case and my own thought process, i.e., important to decision making.”  • I personally have thought of scribes, but I actually feel that it would interfere with the intimate nature of the exam room. I think scribes would not decrease our workload as we would still need to review each chart and correct any errors that we found. I think in the long run it would actually increase our work than decrease our work.”  • “Dragon Medically Speaking” is a program with voice recognition that substantially reduces documentation time. I highly recommend this. Scribes increase labor costs.”  • “Being trained on an EHR in a way that truly matches how you prefer to work is important.”

Physician autonomy

Some pediatrician commented that their input is not considered, and decisions about issues that result in more administrative tasks for physicians are made by nonphysicians and/or those not aware of local issues. Comments again often focused on the EHR.  • “EHR is a necessity, but doctors should have a lot more autonomy in guiding how they are delivered and modified.”  • “Doctors do not have much control and/or say in the ridiculous amount of administrative/secretarial work they are required to do. Many other professions would not put up with this uncompensated time (e.g., lawyers).”  • “More physician input is critical. Administrators who don't even use the EMR make all the decisions and are mostly oblivious to the repercussions of their decisions. I see a movement to improve this but we still have a long way to go.”

Physician health and wellness

Pediatricians commented that administrative tasks require them to bring work home such as charting or stay at work late. Some specifically raised the effect on work–life balance, physical and mental health, and satisfaction with their career.  • “I am having a very difficult time balancing work and personal life. I am up until 1:30 a.m. at night to complete my documentational notes. It is a struggle. The lack of adequate sleep is so unhealthy. I worry about my health.”  • “Less than half of what I do on a daily basis requires my brain. Much of it just occupies my fingers and eyeballs. It is repetitive, contributes little to meaningful patient care, and deadening and a major contributor to burnout.”  • “It is an incredible burden to finish working a 10-hour day, 4–5 days per week, with at least 20 EHR charts to finish (about 2 hours of work). I leave the office as soon as all the tasks are done that have to be done at the office, so I can spend 30–60 minutes with my son before he goes to bed. Then, I chart for 2 hours. This is not sustainable.”

Other patient care responsibilities

Another topic raised by pediatricians included other patient care responsibilities that are time-consuming, burdensome, and interrupt their work flow including forms (e.g., school, daycare, camp) and other paper work, responding to patients (via calls, email, and patient portals), prescription renewals, and laboratory result inquiries.  • “Patient messages are a huge administrative burden. We do not get compensated for essentially doing mini visits over EHR messaging. We should either bill for this service or get RVUs or both.”  • “I have to complete a lot of forms for my patients, especially special-needs patients. Forms for school, asthma and allergy action plans, therapy prescriptions, nutrition forms, supplies, disability parking, and more. There is no reimbursement but they have to get done. I typically spend at least 1/2 day per week on forms. It is ridiculous.”

Abbreviations: EHR, electronic health record; EMR, electronic medical record.