As we look towards a world without medical error, we often consider activities which can improve patient safety but there is one area, often overlooked, that has time and again been proven to nearly double the risk of patient safety incidents (OR, 1.96 95% CI, 1.59-2.4) and reduce quality of care (OR, 2.31; 95% CI 1.87-2.85)^[1]; an epidemic that currently appears to have no amelioration that of Clinician Burnout.

So what is Clinician Burnout? Dissatisfaction is a feeling a clinician might have, the sentiment that they don’t enjoy their job. Disengagement goes a step further. If dissatisfaction is “I don’t like this,” disengagement is “I don’t want to do this”—they simply aren’t invested in the organization. Burnout is the next level: it’s the feeling that “I can’t do this anymore.”

Clinician and in particular, Physician burnout profoundly affects clinicians, their patients and the entire Healthcare system.

• Dissatisfied physicians and nurses are associated with lower patient satisfaction.^{[2] [3] [4]}
• Physician and care team burnout may contribute to overuse of resources and thereby increased costs of care.^{[5] [6] [7]}
• Dissatisfied physicians are more likely to prescribe inappropriate medications which can result in expensive complications.^[8]
• Physician burnout is associated with reduced adherence to treatment plans, resulting in negatively affected clinical outcomes.^[9]

Unfortunately, this pervasive ‘disease’, has profound effects on the clinicians themselves, what other ‘disease’ has such an impact on those who are supposed to be caring for the most sick, that they themselves end up needing care or worse.

With physicians exhibiting burnout showing decreased job satisfaction, job withdrawal, absenteeism, sick leave, and job turnover as the main results of burnout.^[10] In addition, burnout is linked with physical health impediments such as muscle pain, headache, insomnia, respiratory illnesses and gastrointestinal disorders.^[11]

However, more disturbingly is that there is a:

• 130% higher rate of suicide among female doctors than among women in general
• 40% higher rate of suicide among male Doctors than among men in general^[12]

It is a Global Phenomenon

Although much research has been carried out in the US, this is in no way a uniquely US phenomenon or a purely physician phenomenon with a recent study in the UK, amongst NHS Consultants, observing over a third showing emotional exhaustion, anxiety and depressive symptoms (38.7%, 43.1% and 36.1% respectively).^[13]  70% of Nurses in a recent survey reported feeling burnout, and this has been replicated across many countries including Australia and Philippines.^{[14] [15] [16]}

So, what has this got to do with Electronic Health Records?

The causes of Clinician Burnout are varied and broad but in a recent study of the causes of burnout, EHR usage was cited in the top 5 causes.^[17]

But as usual it is a little more complicated than that, in an interesting study of 4197 Rhode Island physicians, any one of 3 EHR-related stress measures as defined by them: 1) Whether the EHR adds to the frustration of one’s day, 2) sufficiency of time for documentation, or 3) the amount of time spent on the EHR at home, independently predicted burnout symptoms amongst respondents but the second, insufficiency of time for documentation, was the most strongly associated (OR 2.8. 95% CI: 2.0-4.1; P <.0001). However, this did vary by speciality.^[18] But, that is not the end of the story by any means after all, why are clinicians feeling they have insufficient time for documentation.

Another clever study looked at practices with No, Limited and High functional EHRs and although there was an increase in burnout between No EHR and both the Limited and High functioning EHRs, there was a modest decrease between the Limited and the High functioning EHRs,^[19] suggesting that a more complete workflow, that has been appropriately implemented, may mitigate some of the symptoms.

What can we do to help?

We can help organisations to recognise clinician burnout, not all organisations understand the issue or even recognise they have a problem. As alluded to above the problem is multi-factorial and whenever you get a group of clinicians together, or even on a one-to-one basis, we are privileged to hear things that may not be EHR related but nevertheless are contributing to clinician burnout. The causes are many and varied and in the words of Dr Stephen Swenson the Medical Director of Mayo Clinic’s Office of Leadership and Organisation Development “If you have seen the causes of burnout in one unit, you have seen the causes of burnout in one unit. They are unique and variable”. Encourage clinicians to talk to their peers and if possible, and with permission, talk to the clinical leaders about issues you have seen.

Specifically, though in regards the EHR, First remember that clinicians are for many reasons already dealing with stress and burnout and whatever you do when implementing an EHR it will get worse, our role is to mitigate that as much as possible.

Optimize the EHR

For those already with an EHR, it is essential to optimize the EHR to function as well as possible for the respective clinicians.  It has been shown that depending on implementation regardless of EHR there can be as much as an average of nine-fold difference in time and eight-fold difference in clicks, indicating that optimization and the actual implementation is critical to managing the frustration and time/clicks in EHR.^[20]

All optimizations should, therefore, look to standardize their approach to optimization:

“Providers often lack an organized approach to optimization and make system changes in reaction to the “squeaky wheel” of individual clinician complaints, resulting in counter-productive modifications, wasted resources, and unnecessary system complexity. Instead, IT organizations should establish specific processes and objectives for identifying usability issues, and make the optimization process as much as possible data-driven.”^[21]

After identifying the need, careful consideration should be taken into account regarding the need for change as there is clear evidence of a correlation between EHR complexity and physician satisfaction.^[22] It is often the case that appropriate Governance may not be in place within the organization, it is critical that clinicians are involved in the decisions e.g. I have seen many times where a lab or the radiology department have changed an order format, impacting the clinician’s workload, with no consultation with the clinicians.

It is always tempting, to reactively say yes to client’s requests for changes, but this is not always the best option, the really important question is why is the client asking for the change? What is the outcome they are seeking? Does the EHR really need another field to collect a piece of data that could be collected in another way without burdening the clinician?

I always like to use the Five Why’s technique when a client asks for a change? The 5 Whys typically refers to the practice of asking, five times, why the failure has occurred, or the need is requested in order to get to the root cause/causes of the problem. There can be more than one cause of a problem as well.

A great example of this occurred with a client recently..

The charge didn’t drop for some of the items used in surgery,

Why did this happen? The charges for the case were linked to a specific terminal and different terminals were used?

Why were different terminals used? Because the nurse couldn’t complete the documentation on the terminal in the theatre.

Why did the nurse need to leave the theatre?  Because the theatre needed to be prepared for the next case.

Why did the theatre need to be prepared so quickly? Because the schedule was to tight?

Why is the schedule so tight? Insufficient time in schedule for Clean-up and Prep.

The solution to the billing was therefore review the theatre schedules for appropriate clean-up and prep time.

This is an example where without 5-whys the actual underlying optimization would not have been identified and the appropriate steps introduced.

Optimization itself need not be driven directly from the clinicians, using the data to identify problems even though individuals may not have raised the issue is a fundamental process of optimization. Reviewing what screens clinicians are typically using most, or which alerts are overridden most frequently or in the greatest number (or both) then tackling the identified problem should be a routine part of optimizing the EHR.

Ensure physicians know how to use the EHR efficiently

Finally, training is fundamental and best delivered by peers in a wonderful study looking at training on how to use computer/EHR during clinical encounters during the first 10 minutes of the consultation. After the intervention the overall proportion of time using EHRs decreased significantly (53.2 vs 49.8% p < 0.0001) and more specifically during psychosocial discourse (24.5% vs 9.76% p< 0.0001).^[23]

It is critical to ensure that education is data driven as well, it is not always the person who is most vocal that is the is the most in need, Data allows the educator to understand who is most at need, and for what education. Clinician Education not only improves documentation but also reduces burnout.

Kaiser Permanente Southern California has taken a novel systems approach to ongoing EHR training for physicians, in ambulatory and inpatient care, to address retention and reinforcement of training, and also the challenges of physician burnout related to time spent on EHR documentation. Faculty members were speciality physician peers who were trained to address workflow and EHR performance issues. They used highly interactive methods of instruction including demonstration, facilitated group discussion, and individual coaching for participants who were provided with laptops linked to their clinic computer for hands-on practice and “build time” to personalize tools. Education content also addressed physician well-being, with a focus on wellness tips, time to exercise, eating healthy meals, and learning relaxation techniques.  In a recent study they showed Most physicians (85%–98% across all programs) reported improved quality, readability, and clinical accuracy of documentation; fewer medical errors; and increased efficiency in chart review and data retrieval due to the training. 78% estimated a time savings of 4 to 5 minutes or more per hour. Physician performance data from the EHR showed significant improvement in the use of order sets for several critical health conditions such as sepsis (51%), stroke (54%), and chest pain of possible cardiac cause (48%).^[24]

Summary

Healthcare is suffering an epidemic of clinician burnout which is having a negative impact on patients, clinicians and health care delivery organisations. Although EHRs are not the sole contributor to burnout, they nonetheless have an impact. That impact is felt most in relation to documentation and, in particular, in poorly implemented and poorly optimized solutions.

Ensuring appropriate optimization and appropriate education may help to tackle this tide and therefore indirectly improve patient care through improving clinician’s lives.

References

[1] Panagioti, M et Al, Association between physician burnout and patient safety, professionalism, and patient satisfaction: A systematic review and Meta-Analysis JAMA Intern Med, 2018;178(10):1317-1330

[2] Op CIt

[3] McHugh MD, Kutney-Lee A, Cimiotti JP, Sloane DM, Aiken LH. Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Aff (Millwood). 2011;30(2):202-210.

[4] Haas JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD, Brennan TA. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15(2):122-128.

[5] Kushnir T, Greenberg D, Madjar N, Hadari I, Yermiahu Y, Bachner YG. Is burnout associated with referral rates among primary care physicians in community clinics? Fam Pract. 2014;31(1):44-50.

[6] Bachman KH, Freeborn DK. HMO physicians’ use of referrals. Soc Sci Med. 1999;48(4):547-557.

[7] irovich BE, Woloshin S, Schwartz LM. Too Little? Too Much? Primary care physicians’ views on US health care

[8] Williams ES, Skinner AC. Outcomes of physician job satisfaction: Williams ES, Skinner AC. Outcomes of physician job satisfaction: a narrative review, implications, and directions for future research. Health Care Manage Rev. 2003;28(2):119-139.

[9] DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians’ characteristics influence patients’ adherence to medical treatment: results from the Medical Outcomes Study. Health Psychol. 1993;12(2):93-102.

[10] Maslach C, Schaufeli WB, Leiter MP: Job burnout. Annu rev Psychol 2001, 52: 397-422

[11] Chikani V, Reding D, Gunderson P, McCarty CA: Work characteristics predict cardiovascular disease risk factors and health functioning in rural women: the Wisconsin Rural Women’s Health Study. J Rural Health 2005, 21: 295-302

[12] Shernhammer, E and Colditz, G. Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis). Am J Psychiatry 161:12, December 2004: 2295-2302

[13] Khan A, Teoh KRH, Islam S, et al. Psychosocial work characteristics, burnout, psychological morbidity symptoms and early retirement intentions: a cross-sectional study of NHS consultants in the UK. BMJ Open 2018;8:e018720. doi:10.1136/ bmjopen-2017-018720

[14] Masterson L, “Nurses are burnt out. Here's how hospitals can help,” Healthcare Dive, May 12, 2017,

[15] Jakimowicz, Samantha; Perry, Lin; Lewis, Joanne; NLM. Australian critical care: official journal of the Confederation of Australian Critical Care Nurses31.6: 396-405. (Nov 2018)

[16] Labrague, Leodoro J; McEnroe-Petitte, Denise M; Tsaras, Konstantinos; NLM. International journal of nursing practice: e12711. (Nov 13, 2018)

[17] Peckham C, “Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout” Medscape, January 2017 https://www.medscape.com/features/slideshow/lifestyle/2017/overview#page=4

[18] Gardner, R et al, Physician stress and burnout: The impact of health information technology. Journal of the American Medical Informatics Association, 00(0), 2018, 1-9

[19] Babbott, S et al.  Electronic medical records and physician stress in primary care: results from the MEMO study, Journal of the American Medical Informatics Association 2014; 21: e100-e106

[20] Ratwani, Raj M. et al. A usability and safety analysis of electronic health records: a multi-center study Journal of the American Medical Informatics Association, 25(9), 2018, 1197–1201

[21] How to Reduce Physician Burnout During EHR Optimization – The Advisory Board  Research report. Advisory.com

[22] RAND Corporation “Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy” 2013 https://www.rand.org/pubs/research_reports/RR439.html

[23] Lanier, C., Dao, M. D., Cerutti, B., Hudelson, P., & Perron, N. J. (2015). Use of electronic health record (EHR) in the consultation: The impact of a training intervention on physician-patient interactions. Praxis, 104, 91-92.

[24] Robinson and Kersey. Novel electronic health record (EHR) education intervention in large healthcare organization improves quality, efficiency, time, and impact on burnout, Medicine (2018) 97:38