Variety of factors affect physicians’ use of EHRs, burnout potential

Research suggests that organizational culture affects documentation requirements and patient loads, and the pandemic has amplified the stresses of documenting care.


As the nation’s healthcare system gets a temporary breather from the COVID-19 pandemic, it’s time to take a fresh look at how best to address clinician burnout.

A great deal of attention has shifted to the toll the pandemic has taken on healthcare professionals, a recent study brings fresh analysis of the stress that electronic health records systems impose on clinicians.


Study shows female clinicians spend a higher percentage of their EHR time outside of patient appointment hours compared to their male counterparts.


Research by athenahealth, the Watertown, Mass.-based systems provider, suggests that EHR systems still are consuming a large percentage of physicians’ time. It also shows that records systems are still not fully embraced by clinicians and not perceived to be a benefit to patient care, says Nele Jessel, M.D., chief medical officer for the company.

Workload requirements a concern

Healthcare administrators need to reexamine the current workload placed on physicians, particularly documentation and patient visit requirements, she says. “These are some of the things that the C-suite needs to be thinking about in terms of mitigating burnout,” Jessel adds.

The changing nature of care delivery, exacerbated by the pandemic, has increased the need for better integration of medical information, contends Jessica Sweeney-Platt, vice president of research and editorial strategy for athenahealth.

“The healthcare ecosystem is shifting, from one focused around inpatient care to delivering care outside the four walls of the practice,” she explains, highlighting the surge in virtual services. “The healthcare experience is becoming much more diffused, and the clinician needs to have it knit together. They’re getting a lot of fragmented information, and now getting [patient-generated health data] from wearables – and this all has to be knit together in a coherent story.”

To conduct the research, athenahealth analyzed data from 8.1 million hours of active EHR work completed by 14,520 clinicians using its applications over five months in 2021. Clinicians were invited to participate in interviews based on the percentage of time they spent using the EHR system outside of patient appointment hours.

The study indicates there’s been no reduction in the time physicians are spending using EHRs to document care. The research gauges the EHR time-patient ratio, which it calculates by taking the amount of time spent using the EHR over a week, divided by the number of patient encounters for a week, thus estimating EHR time based on providers’ patient load.

EHRs are time-consuming; usage varies by clinician gender

In general, physicians spend about 25 minutes per patient documenting in the EHR. The amount of documentation time varies slightly depending on how many primary care clinicians are employed by a practice, the study shows.


"Change is needed so clinicians see EHR use as beneficial."


There are also variations by specialty. Orthopedic surgeons spent the least amount of time documenting, while neurologists and primary care physicians spend the most.

Clinicians involved in adult primary care spend 75% of their EHR time completing documentation of encounters and 16% in the document inbox. By contrast, mental health clinicians spend 83% of their EHR time on encounters and only 7% within the inbox.

Researchers conclude that a healthcare organization’s size and its culture each contribute to the time-patient ratio. Organizations that require more complex documentation have clinicians who spend more time working in the EHR during and after patient encounters. Those organizations are likely to be larger and have more detailed internal policies on charting.

Further analysis released during the recent HIMSS22 conference shows that female clinicians across specialties and clinical roles see fewer patients per week and spend a higher percentage of their EHR documentation time outside of patient appointment hours than male clinicians.

And while female and male clinicians spend the same amount of time on cumulative patient documentation per week, female clinicians spend more documentation time on a per-patient basis – they schedule an average of 60 encounters per week, while their male counterparts have an average of 73 encounters per week, according to the study.

Female clinicians spend a higher percentage of their EHR time outside of patient appointment hours compared to their male counterparts (24.5 vs. 21.6 minutes per visit).

Influence of ‘organizational culture’

The researchers contend that much of the documentation load is a result of “organizational culture,” which is believed to have a bigger impact that individual clinician skills. Cultural factors include training; IT support; willingness to assign documentation to support staff; and giving physicians more flexibility in deciding the number of patients they’ll see in a day.


“It’s no wonder that physicians are feeling at their wit’s end; it’s just not sustainable.”


To change the culture, organizations must rethink what is being asked of clinicians, the researchers conclude.

“Organizations that require more complex documentation, because of payers' or internal policies, have clinicians who spend more time in the EHR overall, as well as outside of patient encounters,” which the study describes as “pajama time” – after-hours completion of charting at home.

Many clinicians believe that they have two jobs – treating patients and spending at least as much time documenting treatment. And the study confirms that perception is accurate, Sweeney-Platt says. “It’s no wonder that physicians are feeling at their wit’s end; it’s just not sustainable. The fundamental problem is autonomy and how their time is spent.”

In today’s climate, clinicians that want a better work-life balance have no choice but to see fewer patients and “take a hit on reimbursement,” she says.


"EHRs replicate what paper records used to do...the systemic inefficiency just compounds the frustration, and it leads to avoidance behavior."


Making substantial changes in organizational requirements for documentation is challenging because of increasing demands from payers for more information in records, including specificity in recording conditions, treatment decisions, quality and more, Jessel adds. “There’s been an increase in transparency (requirements),” she says. “It was hard for payers to audit (records) before and hard to access paper records. Now, it’s not. And that leads to different documentation requirements.”

Easing burdens

Easing clinicians’ documentation burdens will require the wider use of standards as well as user interface redesigns that give users more flexibility and make EHRs “less cognitively taxing,” Sweeney-Platt says.

The bottom line

Change is needed so clinicians see EHR use as beneficial, Jessel concludes.

Right now, EHRs replicate what paper records used to do, she says, and so the systemic inefficiency “just compounds the frustration, and it leads to avoidance behavior – we all avoid things that we hate. It compounds the problem of burnout. We have to do something to reframe their own narratives in their heads.”


See more about this study in the AthenaHealth blog post:

Research shows gender, specialty, geography among top factors contributing to “pajama time” work for clinicians

See innovative solutions to improve clinician and care team experiences:

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