How conventional EHR’s are contributing to Physician burnout and what can be done.
“Almost one third of Irish hospital doctors experienced burn-out, indicating suboptimal work conditions and environment”1
“50% of doctors reported being emotionally exhausted and overwhelmed by work”1
“The annual cost of physicians spending half of their time using EHRs is over $365 billion (a billion dollars a day) – more than the United States spends treating any major class of diseases and about equal to what the country spends on public primary and secondary education instruction.”2
“54% of physicians rate their morale as between somewhat or very negative”3
Physician burnout is real, and it is getting worse. In a 2019 Health Affairs blog, a group of top healthcare CEOs called physician burnout a “public health crisis”.4
In this blog, I do not want to dwell on the statistics, because all they do is substantiate what we already know. Where I think we need to focus our efforts now is not on the “if” burnout exists, but the “how”. It is worth noting that the first EMR was developed in 1972 by the Regenstreif Institute7 , with burnout among doctors first described just 2 years later, in 19748.
Physician’s needs are simple. Beyond those contained in Maslow’s hierarchy, physicians have the need to provide quality medical care, maintain autonomy, fulfil expectations, and build rapport with their patients. In current health systems, each one of these needs is systematically challenged on a daily basis, both by the EHR and other forces.
Outlined below, are just some of the ways the EHR contributes to physician burnout. This is my take on how change can be brought about for the better.
1. Administrative Burden
The earliest developments of EHR’s in the 1970’s were focused primarily on the administrative aspects of healthcare provision. Unfortunately, this ethos has remained engrained in many systems and is evident in the poor usability experienced by physicians. How can a system with billing, scheduling, registration etc. at its core, ever expect to provide the complex, bespoke features required by physicians? The simple truth is thus: Physicians are not administrators. Many EHR’s are built on the premise of administrative tasks. Asking a physician to mould their workflow into software fundamentally built for an entirely different professional field is preposterous, and causes a huge amount of understandable frustration.
2. Constant Connectivity
“Surprisingly, in a milieu where evidence is the key driver of patient treatment, the evidence on the relationship between workplace psychosocial environment and employee health is paid little attention by those who fund and manage healthcare organisations. It is buried under the constant refrain of ‘putting the patient first’ with little regard for those who are instrumental in providing care.” – Professor Blánaid Hayes, RCPI.
We know that physicians need to be able to switch off. “Resilience” workshops will tell physicians that their inability to do this is the major contributor to their burnout. At the same time, we are seeing conventional EHR’s evangelising the emergence of “connectivity” and the idea of “doctor in your pocket”. This constant connectivity to a physician means at some point in the day, every day, a physician needs to be contactable by, and as a result responsible for, their patients. While the vast majority of physicians continue to cite a high desire to practice medicine, a higher amount cite constant connectivity as a major contributor to their stress levels.
Protocols, guidelines, “Dr. Google”, paperwork, research… the list goes on. Medicine has moved from an age where physicians were expected to heal some illnesses, to one where they are expected to correct every possible wrong in the life of contemporary patients. In his book “Can Medicine Be Cured?”5, Seamus O’Mahony eloquently outlines this expansion of expectations from physicians. EHR’s are sold to Healthcare Executives on the promised “increased productivity”. The translation of this is a workforce forced to adapt their workflow to a cumbersome technology that doesn’t follow their thought flow, while management updates “targets” and “deliverables” to align with the outcomes promised to them by the EHR vendor.
It is ironic that systems which claim to increase time for Physician-Patient interactions are instrumental in reducing it. “There is broad agreement on the need for more face-to-face time between clinicians and patients and less time spent on the electronic health medical record and documentation”6 Through poor user experience, cumbersome workflows, and excessive data entry requirements, physicians are spending less and less time with their patients. How can a profession so strongly motivated by the desire to help patients benefit from less time with them? Physicians get their job satisfaction from interacting with humans and alleviating their suffering. Job satisfaction does not come from knowing that their hours of clinical coding will ensure accurate billing for the insurers.
Now, it is imperative to clarify that I am not implying for a second that conventional EHR’s should be treated as some sort of scapegoat for physician burnout. What we need to do is recognise that EHR’s play a major role and combat this. In an age when technology is constantly evolving to meet user needs, surely the optimisation of EHR’s is a low hanging fruit?
We need to implement systems that recognise the unique needs of physicians and their medical colleagues. We need to recognise that expecting a physician to use tools built for administrators is like asking your hairdresser to dry your hair with their appointment book! Systems that focus solely on the clinical needs of physicians, will be the ones that truly reduce administrative burden. These systems will empower, rather than oppress physicians, by providing solutions that fit their workflows and practices. Systems need to also recognise that the antiquated view of Physician = Physician = Physician no longer holds true. The IT needs of a cardiologist are going to be vastly different from those of a pathologist, and it is ignorant to suggest that they should both bend to fit a rigid system. There is also a fine line between “connectivity” and 24/7 responsibility. Recognising this, and allowing for it within the fabric of the IT system employed is key.
Taking steps to implement a clinically focused system is not going to end physician burnout. What it can do is show all members of the healthcare team that their needs are recognised, considered, and important. Beyond the needs of Maslow’s hierarchy, physicians just need to be allowed to be physicians. There is no reason healthcare IT systems cannot accommodate this.
1. Doctors don’t Do-little: a national cross-sectional study of workplace well-being of hospital doctors in Ireland BMJ Vol. 9, Issue 3; Blánaid Hayes, Lucia Prihodova, Gillian Walsh, Frank Doyle, Sally Doherty
2. 3 Ways to Make Electronic Health Records Less Time-Consuming for Physicians: Harvard Business Review January 10, 2019: Derek A. Hass, John D Halamka, Michael Suk
3. Physician burnout in 2019, charted: Advisory Board January 18, 2019
4. EHR Usability, Workflow Strategies for Reducing Physician Burnout; Kate Monica, EHR Intelligence
5. Can Medicine Be Cured, Seamus O’Mahony
6. New England Journal of Medicine (NEJM) Catalyst Spring 2018 report
7. Healthcare, Extracting Data: A Brief History of the EMR: Extract; Chantel Soumis
8. Burnout in Doctors, Irish Medical Journal, JFA Murphy