Technology’s role in clinician burnout
Experts cite usability concerns and the immaturity of some supportive technology, but the slow-evolving nature of healthcare shares blame.
Blame for clinician burnout often circles back to pressures associated with electronic health records and other digital systems.
Some of the criticism is warranted; in other areas, EHRs are an accessory at worst, or a reflection of systemic issues for which records systems are the proverbial messenger.
Last year, a review of research published by the National Library of Medicine identified six key factors linking burnout to the use of EHRs -- documentation and related tasks; EHRs' poor design; workload; overtime work; inbox alerts; and alert fatigue.
Technology companies have recognized the need for improvement in the technology – emphasizing improvements in usability, offering shortcuts and other assists to facilitate documentation, improving initial and ongoing training, and broader use of standards to enable interoperability and easy exchange of patient data.
Charting, documentation burdens
The work is needed, says William Hayes, MD, chief medical officer for Mobile, Ala.-based CPSI and vice chair of the HIMSS Electronic Health Records Association. “From an EHR standpoint, we will have a long way to go” on improving the usability of technology and reducing clinician burnout.
Health IT companies have been able to provide improvements to aid documentation. “With technologies or processes, we have seen a lot of progress,” Hayes says. “Sometimes it’s a simple thing, like a quick list of things like dictation or smart phrases for charting.”
But the big need is to come to a consensus on what documentation is really needed. Lack of agreement on what is essential results in long patient notes, which means more time compiling and more time needed by clinicians to tease out critical information from mounds of verbiage.
“I don’t think anyone has figured out what an ideal clinical note is,” Hayes contends. “In the last few years, documentation is increased and it is hard to unteach that. The reality is that whether its private practices or cardiology, coding departments are calling for clinicians to add documentation so the organization can get paid.”
That’s led to criticism that EHRs are “data collection devices,” and that negates the potential value of digital records systems in organizing information to better support clinicians’ thought processes and harmonize patient encounters in a logical way. “A pregnancy is one event, not nine encounters,” Hayes says. “An EHR should help clinicians in a way that makes patients’ lives better.”
Rationalizing documentation to lessen burdens on clinicians is the focus of several organizations and initiatives. For example, the American Medical Informatics Association (AMIA) is leading the 25x5 Initiative, which seeks to reduce the documentation burden by 25 percent of the current state in five years.
The AMIA effort includes calls to action for:
- • Providers and health systems, to set principles for adding documentation to the EHR, integrate notes across disciplines and better educate clinicians on effectiveness of documentation.
- • Health IT vendors, to promote interoperability, simplify views within EHRs to aid access to information and disseminate best training practices.
- • Policy and advocacy groups, to automate the capture of billing code information, and to develop technology that can standardize ways to manage and create reimbursement/payment data.
A deeper problem
However, clinicians’ documentation burdens belie a deeper issue with EHRs – the underlying purpose of these systems has its basis in enabling the capture the details of care to justify the codes used in setting reimbursement – more requirements for detail in clinical notes over time have supported billing, quality initiatives and other reporting requirements.
That documentation load doesn’t translate into better care. It loads more responsibility on clinicians to compile voluminous notes on the front end and then wade through the notes to find key clinical data after they’re written.
A new approach is necessary, contends Subha Airan-Javia, MD, associate professor at Penn Medicine and founder and CEO of CareAlign. She believes healthcare organizations need to move to a team-based workflow, which would alleviate the pressure on individual clinicians to manage patient care.
“With every other industry, people have a technology stack, a team workflow platform. There’s a concept of project management, and we need that in medicine. It’s often said that we practice as a team but we work alone.”
Advanced computing capabilities – such as artificial intelligence, ambient listening, chatbots and EHRs with support capabilities – are needed to help clinicians manage and lighten their workloads, says Eve Bloomgarden, MD, an endocrinologist and thyroid subspecialist at NorthShore University HealthSystem, and co-founder of IMPACT4HC, a coalition of physicians in Illinois.
Technology that spots burnout risks
But even though it’s not able to solve clinician burnout, it has the potential to identify those who are having problems with documentation and offer solutions.
A primary tool for gauging physician challenges with documentation is the audit log, with has been identified by the Office of the National Coordinator for Health Information Technology as “a uniquely rich data source that can be efficiently leveraged to measure EHR burden.”
ONC-certified EHRs must be capable of generating audit logs “based on a set of specific events, which make it possible to create comprehensive reports on clinicians’ EHR use.” These logs can help see how much time is required to do certain tasks, such as note-taking, chart review and messaging.
In its blog, ONC reports that, in 2021, “more than two-thirds of hospitals had access to measures from their EHR developer that quantified the amount of time clinicians spent documenting in the EHR.”
For example, Epic provides this type of analysis for users of its records system through its Signal capabilities, which enables executives to drill down into audit trail data and identify clinicians who are struggling to complete charting or working after hours to finish up, says Sam Butler, MD, a physician, and Danessa Sandmann, an implementation executive.
From Epic’s research, key predictors of burnout include the percent of encounters closed by a physician the same day; after-hours work to complete notes; and the number of in-basket messages received per day.
Executives can use Signal to work with clinicians whose data show them to be outliers, Butler said. Long times spent in documentation can be shortened by using macros and templates. That enables resources to be focused on helping clinicians and, in some cases, spotting those at risk for burning out.