Curing Burnout Means Radically Rethinking Digital Tools, Not Just Fixing EHRs
Our Take:
As technology and digital transformation take hold in healthcare, greater focus needs to be placed on meeting provider needs and managing clinical burnout. While the digital transformation of healthcare has both positive aspects for clinician burnout, such as the potential to apply artificial intelligence to help optimize workflows, the ability to focus clinician expertise, and the use of natural language processing to automate workflows, at present the additional burdens related to the implementation of electronic health records (EHRs) and the inefficiencies in workflows introduced by additional administrative and regulatory burdens on clinical workflows have negated the positive impact.
Key Takeaways:
Replacing a physician lost to burnout costs a healthcare system anywhere from $250 000 to a million dollars.
Clinical burnout is a global health crisis with more than 60% of providers reporting at least 1 symptom of burnout.
For every hour of clinical face time, physicians spend nearly 2 additional hours on EHRs and desk work within the clinical day.
A study reported physicians spend nearly half of their time during office hours on EHR and desk work, including documentation, translation to approximately 2 hours of EHR, and work time for each hour of direct patient care.
Research carried out by HIMSS and UK med-tech firm Nuance Communications found 97% of doctors and 99% of nurses surveyed had experienced burnout at some point in their working life.
According to Journal Annals of Internal Medicine, the economic impacts of burnout are also significant, costing the U.S. approximately $4.6 billion every year.
The Problem:
Clinical burnout is a major threat to the US healthcare system. Even prior to the COVID pandemic, clinician burnout was considered a global health crisis with more than 60% of providers reporting at least 1 symptom of burnout. Factors that contribute include digital tools used among different specialties, practice settings, and requirements for compliance and reimbursement (computerized physician order entry, amount of data needed to be entered in EHRs for each clinical encounter). While EHRs can be effective tools, they require comprehensive, timely and continuous training in order to reduce the digital burden on top of physicians' routine clinical duties. In addition, the organizational structure, continued improvement and development of health information technology, and coordination and implementation of policy and regulations will play a key role.
The Backdrop:
According to Annals of Internal Medicine, for every hour of clinical facetime with patients, physicians spend nearly 2 additional hours on EHRs and desk work during the day. In addition, outside office hours, physicians spend another 1-2 hours of personal time each night (affectionately referred to as “pajama time”), doing additional computer and other clerical work. These additional demands contribute to physician burnout which has significant economic costs. For example, according to a study by HIMSS and Nuance Communications, 97% of doctors and 99% of European nurses surveyed had experienced burnout at some point in their working life and that this impact was nearly universal. According to the Annals of Internal Medicine study noted above, the economic impacts of burnout are significant, costing the U.S. some $4.6 billion every year. These impacts can range from emotional impacts such as energy depletion or exhaustion, increased mental distance from one’s job, feelings of negativism or cynicism related to one’s job to higher rates of turnover, prevalence of substance use disorders, increased malpractice claims, greater physician errors and a higher incidence of unnecessary tests and consultations. While clinical burnout has multiple underlying causes, EHRs have been demonstrated to play a significant role in burnout as they are the intersection of clinical duties and technology. EHRs as they are currently designed and deployed can be overly time-consuming, frustrating, overly complex and require multiple screens to click through to get to relevant information. Moreover, as noted in “Physician Well Being and the Future of Health Information Technology”, EHRs [and other health IT] can be loaded with alerts to “serve population health, quality assurance, risk management, customer service, billing, or research goals, yet the sum result may be an overload of alerts such that some are ignored or clicked through, perhaps without any real attention to priority.” As the article goes on to point out, “to reduce overwhelm, tools are needed to filter, prioritize, and frame information for users and their clinical questions.
Implications:
Burned-out doctors are more likely to leave their practice or worse. In fact, according to the Medscape National Physician Burnout & Suicide Report 2020: The Generational Divide, over 20% of both male and female physicians reported having thoughts contemplating suicide. At a minimum this reduces patient access to care, impairs care continuation and at worst threatens the physical safety of patients themselves. To improve and ease the burden, comprehensive quality and timely training should help partially mitigate technology-related stress. However, as noted in “Physician Well-Being and the Future of Health Information Technology” from the Mayo Clinic Proceedings, “it would be shortsighted to imagine that simply fixing the EHR will prevent technology related burnout.” In addition, expanding the care team, utilizing scribes including the use of digital scribes, and dividing the documentation with streamlined team-based documentation will ease the load, improve efficiency, productivity and provide quality care. For example, a recent study in the Journal of the American Medical Informatics Association demonstrated physician documentation time was reduced by 50% with scribe implementation, thus allowing more time for patient-facing interactions. In addition, AI based digital scribes that deploy natural language processing can help physicians in the documentation process through use of time-saving, uninterrupted chain of thought processes for documentation. While many of these are still in the early stages of development and require heavy oversight and checking by human scribes (often overseas), they hold great potential. Perhaps most importantly developers and designers of HIT need to fundamentally rethink the way they design their tools for use by clinicians. Increasingly to improve effectiveness and adoption of their products, designers will need to consider the “importance of physician involvement in the design and implementation of HIT [which] cannot be overstated.” Earlier and more frequent physician involvement in development of user experience and user interface should help decrease data entry time by limiting keystrokes and/or mouse clicks through iteratively adjusting the tool’s performance based on user experience and feedback to the design team. Moreover, by more proactively involving physicians (and other clinicians) in the process, developers will move away from a failed alert-based system to one that more appropriately recognizes physician/patient engagement as one of increasingly limited time constraints. For “a strategy of approaching encounter expectations from a perspective of constraints is essential” as it will allow new products to help prioritize and highlight clinical information that needs action and should be acted on in the moment.
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