Association of Perceived Electronic Health Record Usability With Patient Interactions and Work-Life Integration Among US Physicians

Electronic Health Record Usability, Satisfaction, and Burnout for Family Physicians

Importance

Electronic health record (EHR) work has been associated with decreased physician well-being. Understanding the association between EHR usability and physician satisfaction and burnout, and whether team and technology strategies moderate this association, is critical to informing efforts to address EHR-associated physician burnout.

Objectives

To measure family physician satisfaction with their EHR and EHR usability across functions and evaluate the association of EHR usability with satisfaction and burnout, as well as the moderating association of 4 team and technology EHR efficiency strategies.

Design, Setting, and Participants

This study uses data from a cross-sectional survey conducted from December 12, 2021, to October 17, 2022, of all family physicians seeking American Board of Family Medicine recertification in 2022.

Exposure

Physicians perceived EHR usability across 6 domains, as well as adoption of 4 EHR efficiency strategies: scribes, support from other staff, templated text, and voice recognition or transcription.

Main Outcomes and Measures

Physician EHR satisfaction and frequency of experiencing burnout measured with a single survey item ("I feel burned out from my work"), with answers ranging from "never" to "every day."

Results

Of the 2067 physicians (1246 [60.3%] younger than 50 years; 1051 men [50.9%]; and 1729 [86.0%] practicing in an urban area) who responded to the survey, 562 (27.2%) were very satisfied and 775 (37.5%) were somewhat satisfied, while 346 (16.7%) were somewhat dissatisfied and 198 (9.6%) were very dissatisfied with their EHR. Readability of information had the highest usability, with 543 physicians (26.3%) rating it as excellent, while usefulness of alerts had the lowest usability, with 262 physicians (12.7%) rating it as excellent. In multivariable models, good or excellent usability for entering data (β = 0.09 [95% CI, 0.05-0.14]; P < .001), alignment with workflow processes (β = 0.11 [95% CI, 0.06-0.16]; P < .001), ease of finding information (β = 0.14 [95% CI, 0.09-0.19]; P < .001), and usefulness of alerts (β = 0.11 [95% CI, 0.06-0.16]; P < .001) were associated with physicians being very satisfied with their EHR. In addition, being very satisfied with the EHR was associated with reduced frequency of burnout (β = -0.64 [95% CI, -1.06 to -0.22]; P < .001). In moderation analysis, only physicians with highly usable EHRs saw improvements in satisfaction from adopting efficiency strategies.

Conclusions and Relevance

In this survey study of physician EHR usability and satisfaction, approximately one-fourth of family physicians reported being very satisfied with their EHR, while another one-fourth reported being somewhat or very dissatisfied, a concerning finding amplified by the inverse association between EHR satisfaction and burnout. Electronic health record-based alerts had the lowest reported usability, suggesting EHR vendors should focus their efforts on improving alerts. Electronic health record efficiency strategies were broadly adopted, but only physicians with highly usable EHRs realized gains in EHR satisfaction from using these strategies, suggesting that EHR burden-reduction interventions are likely to have heterogenous associations across physicians with different EHRs.

An Electronic Health Record-Integrated Application for Standardizing Care and Monitoring Patients With Autosomal Dominant Polycystic Kidney Disease Enrolled in a Tolvaptan Clinic: Design and Implementation Study

Background

Tolvaptan is the only US Food and Drug Administration-approved drug to slow the progression of autosomal dominant polycystic kidney disease (ADPKD), but it requires strict clinical monitoring due to potential serious adverse events.

Objective

We aimed to share our experience in developing and implementing an electronic health record (EHR)-based application to monitor patients with ADPKD who were initiated on tolvaptan.

Methods

The application was developed in collaboration with clinical informatics professionals based on our clinical protocol with frequent laboratory test monitoring to detect early drug-related toxicity. The application streamlined the clinical workflow and enabled our nursing team to take appropriate actions in real time to prevent drug-related serious adverse events. We retrospectively analyzed the characteristics of the enrolled patients.

Results

As of September 2022, a total of 214 patients were enrolled in the tolvaptan program across all Mayo Clinic sites. Of these, 126 were enrolled in the Tolvaptan Monitoring Registry application and 88 in the Past Tolvaptan Patients application. The mean age at enrollment was 43.1 (SD 9.9) years. A total of 20 (9.3%) patients developed liver toxicity, but only 5 (2.3%) had to discontinue the drug. The 2 EHR-based applications allowed consolidation of all necessary patient information and real-time data management at the individual or population level. This approach facilitated efficient staff workflow, monitoring of drug-related adverse events, and timely prescription renewal.

Conclusions

Our study highlights the feasibility of integrating digital applications into the EHR workflow to facilitate efficient and safe care delivery for patients enrolled in a tolvaptan program. This workflow needs further validation but could be extended to other health care systems managing chronic diseases requiring drug monitoring.

Physician Work-Personal Intersection: A Scoping Review of Terms, Definitions, and Measures

PURPOSE

A substantial body of evidence describes the multidimensional relationship between the intersection of physicians' work and personal lives and health care quality and costs, workforce sustainability, and workplace safety culture. However, there is no clear consensus on the terms, definitions, or measures used in physician work-personal intersection (WPI) research. In this scoping review, the authors aimed to describe the terms and definitions used by researchers to describe physician WPI, summarize the measurement tools used, and formulate a conceptual model of WPI that can inform future research.

METHOD

The authors searched PubMed, CINAHL, Scopus, and Web of Science for studies that investigated U.S. practicing physicians' WPI and measured WPI as an outcome from January 1990 to March 2022. The authors applied thematic analysis to all WPI terms, definitions, and survey questions or prompts in the included studies to create a conceptual model of physician WPI.

RESULTS

Ultimately, 102 studies were included in the final analysis. The most commonly used WPI terms were work-life balance, work-life integration, and work-home or work-life conflict(s). There was no consistency in the definition of any terms across studies. There was heterogeneity in the way WPI was measured, and only 8 (7.8%) studies used a validated measurement tool. The authors identified 6 key driver domains of WPI: work and personal demands; colleague and institutional support and resources; personal identity, roles, health, and values; work schedule and flexibility; partner and family support; and personal and professional strategies.

CONCLUSIONS

The authors found significant variability in the terms, definitions, and measures used to study physician WPI. They offer a conceptual model of the WPI construct that can be used to more consistently study physician WPI in the future. Future work should further investigate the validity of this model and generate consensus around WPI terms, definitions, and measures.

Physician Burnout: Evidence-Based Roadmaps to Prioritizing and Supporting Personal Wellbeing

Current literature validates the magnitude of physician burnout as a complex challenge affecting physicians, patients, and healthcare delivery that mandates science-informed intervention. Physician burnout affects both individual practitioners and patient care delivery. Interventions, defined as roadmaps, to prioritizing and supporting personal wellbeing encompass organizational, individual, and moral injury, with virtually no consensus on optimal approaches. The purpose of this conceptual review is to present evidence-based innovative insights on contributing factors, mitigation, and designing adaptive systems to combat and prevent burnout. Science-informed policy initiatives that support long-term organizational changes endorsed by both leadership and institutional stakeholders are keys to sustaining personal wellbeing and ending burnout.

More Tethered to the EHR: EHR Workload Trends Among Academic Primary Care Physicians, 2019-2023

PURPOSE

The purpose of this study is to evaluate recent trends in primary care physician (PCP) electronic health record (EHR) workload.

METHODS

This longitudinal study observed the EHR use of 141 academic PCPs over 4 years (May 2019 to March 2023). Ambulatory full-time equivalency (aFTE), visit volume, and panel size were evaluated. Electronic health record time and inbox message volume were measured per 8 hours of scheduled clinic appointments.

RESULTS

From the pre-COVID-19 pandemic year (May 2019 to February 2020) to the most recent study year (April 2022 to March 2023), the average time PCPs spent in the EHR per 8 hours of scheduled clinic appointments increased (+28.4 minutes, 7.8%), as did time in orders (+23.1 minutes, 58.9%), inbox (+14.0 minutes, 24.4%), chart review (+7.2 minutes, 13.0%), notes (+2.9 minutes, 2.3%), outside scheduled hours on days with scheduled appointments (+6.4 minutes, 8.2%), and on unscheduled days (+13.6 minutes, 19.9%). Primary care physicians received more patient medical advice requests (+5.4 messages, 55.5%) and prescription messages (+2.3, 19.5%) per 8 hours of scheduled clinic appointments, but fewer patient calls (-2.8, -10.5%) and results messages (-0.3, -2.7%). While total time in the EHR continued to increase in the final study year (+7.7 minutes, 2.0%), inbox time decreased slightly from the year prior (-2.2 minutes, -3.0%). Primary care physicians' average aFTE decreased 5.2% from 0.66 to 0.63 over 4 years.

CONCLUSIONS

Primary care physicians' time in the EHR continues to grow. While PCPs' inbox time may be stabilizing, it is still substantially higher than pre-pandemic levels. It is imperative health systems develop strategies to change the EHR workload trajectory to minimize PCPs' occupational stress and mitigate unnecessary reductions in effective physician workforce resulting from the increased EHR burden.

How to make the electronic health record your friend

PURPOSE OF REVIEW

The electronic health record (EHR) has become ubiquitous among healthcare providers. It has revolutionized how we care for patients allowing for instant access to records, improved order entry, and improved patient outcomes. However, it has also been implicated as a source of stress, burnout, and workplace dissatisfaction among its users. The article provides an overview of factors associated with burnout focusing on the pediatrician and pediatric subspecialist workflows and will summarize practical tips based on clinical informatics principles for addressing these factors.

RECENT FINDINGS

Several metrics related to EHR including training, efficiency and lack of usability have been cited as factors associated with burnout. Organizational, personal, and interpersonal factors as well as work culture are more associated with burnout than EHR use.

SUMMARY

Organizational strategies to address burnout include first monitoring metrics including physician satisfaction and wellbeing, incorporating mindfulness and teamwork, and decreasing stress from the EHR by providing training, standardized workflows, and efficiency tools. All clinicians should feel empowered to customize workflows and seek organizational help for improving EHR use.

A qualitative study of the dark and bright sides of physicians' electronic health record work outside work hours

BACKGROUND

The introduction of electronic health records (EHRs) has contributed considerably to EHR work outside work (WOW) hours for physicians. Prior research has identified the pressures associated with stress resulting from EHR WOW, yet developing a nuanced understanding of how physicians appraise and respond to this stress, and the resulting impacts, remains absent from the literature.

PURPOSE

Grounded in the technostress model, this study takes a qualitative approach to explore both the pressures and opportunities associated with EHR WOW.

METHODS

Thematic analysis of data from semistructured interviews was utilized to examine the pressures and opportunities associated with EHR WOW among primary care pediatricians (n = 15) affiliated with a large Midwestern pediatric health system.

RESULTS

The physicians in this study regularly spent time working in the EHR outside work hours. They felt the EHR contributed to their documentation burden, which ultimately increased their EHR WOW, and reported a sense of burden from ubiquitous EHR availability. Conversely, they appreciated the flexibility the EHR provided in terms of work-life balance. Suggestions for improvement under the direct purview of practice management included enhanced EHR usability, improvements in workflow during work hours to free up time to document, and more training on both EHR documentation strategies and ongoing software upgrades.

CONCLUSION

Physicians perceive that the EHR exerts certain pressures while affording new opportunities and conveniences. This study provides evidence of both the pressures and opportunities of EHR WOW and their effect on physician well-being.

PRACTICE IMPLICATIONS

Specific opportunities are identified for health administrators to enable physicians to better manage EHR WOW.

Patient Safety Issues From Information Overload in Electronic Medical Records

BACKGROUND AND OBJECTIVE

Electronic health records (EHRs) have become ubiquitous in medicine and continue to grow in informational content. Little has been documented regarding patient safety from the resultant information overload. The objective of this literature review is to better understand how information overload in EHR affects patient safety.

METHODS

A literature search was performed using the Transparent Reporting of Systematic Reviews and Meta-Analyses standards for literature review. PubMed and Web of Science were searched and articles selected that were relevant to EHR information overload based on keywords.

RESULTS

The literature search yielded 28 articles meeting the criteria for the study. Information overload was found to increase physician cognitive load and error rates in clinical simulations. Overabundance of clinically irrelevant information, poor data display, and excessive alerting were consistently identified as issues that may lead to information overload.

CONCLUSIONS

Information overload in EHRs may result in higher error rates and negatively impact patient safety. Further studies are necessary to define the role of EHR in adverse patient safety events and to determine methods to mitigate these errors. Changes focused on the usability of EHR should be considered with the end user (physician) in mind. Federal agencies have a role to play in encouraging faster adoption of improved EHR interfaces.

Roadmap to a more useful and usable electronic health record

Background

A decade after the Health Information Technology for Economic and Clinical Health (HITECH) Act, electronic health records (EHRs) largely remain poorly designed and contribute to clinician burnout.

Objective

The purpose of this study was to understand clinicians’ wants, needs, and perceived barriers imposed by the EHR; implement best practices in user-centered design; and create a clinician-centered EHR framework validated via a functional EHR prototype.

Methods

Usability evaluations were performed using a simulated patient with a complex clinical scenario. Convergent parallel mixed methods linked to action research and agile development were used to create an EHR prototype based on clinician-centered design. Prototype functionality was validated via a final usability evaluation.

Results

Between 2015 and 2017, 53 clinicians from 8 cardiology practices (4 academic and 4 private) participated in initial evaluations of their installed EHR. In 2019, 25 clinicians participated in final evaluations of their EHR vs our EHR prototype. Initial evaluations documented that clinicians judged the EHRs as poorly designed, scoring a mean of 47.1 on the System Usability Scale. Clinicians expressed that EHRs impeded workflow and communication and prolonged their workday. In the final evaluations, no improvement in installed EHRs was found (mean score 48.1); however, the EHR prototype was assessed as significantly more usable (mean score 77.8; P <.001).

Conclusion

A decade after the HITECH Act, EHRs still receive low usability scores. By applying user-centered design, an EHR prototype with improved features, functionality, and workflow integration was developed. Clinician testing of the EHR prototype demonstrated it was significantly more useful and usable to clinicians, thus identifying a framework and pathway for substantive improvement of EHR systems.

Primary care physicians' electronic health record proficiency and efficiency behaviors and time interacting with electronic health records: a quantile regression analysis

OBJECTIVE

This study aimed to understand the association between primary care physician (PCP) proficiency with the electronic health record (EHR) system and time spent interacting with the EHR.

MATERIALS AND METHODS

We examined the use of EHR proficiency tools among PCPs at one large academic health system using EHR-derived measures of clinician EHR proficiency and efficiency. Our main predictors were the use of EHR proficiency tools and our outcomes focused on 4 measures assessing time spent in the EHR: (1) total time spent interacting with the EHR, (2) time spent outside scheduled clinical hours, (3) time spent documenting, and (4) time spent on inbox management. We conducted multivariable quantile regression models with fixed effects for physician-level factors and time in order to identify factors that were independently associated with time spent in the EHR.

RESULTS

Across 441 primary care physicians, we found mixed associations between certain EHR proficiency behaviors and time spent in the EHR. Across EHR activities studied, QuickActions, SmartPhrases, and documentation length were positively associated with increased time spent in the EHR. Models also showed a greater amount of help from team members in note writing was associated with less time spent in the EHR and documenting.

DISCUSSION

Examining the prevalence of EHR proficiency behaviors may suggest targeted areas for initial and ongoing EHR training. Although documentation behaviors are key areas for training, team-based models for documentation and inbox management require further study.

CONCLUSIONS

A nuanced association exists between physician EHR proficiency and time spent in the EHR.

The association between perceived electronic health record usability and professional burnout among US nurses

OBJECTIVES

To measure nurse-perceived electronic health records (EHR) usability with a standardized metric of technology usability and evaluate its association with professional burnout.

METHODS

A cross-sectional survey of a random sample of US nurses was conducted in November 2017. EHR usability was measured with the System Usability Scale (SUS; range 0-100) and burnout with the Maslach Burnout Inventory.

RESULTS

Among the 86 858 nurses who were invited, 8638 (9.9%) completed the survey. The mean nurse-rated EHR SUS score was 57.6 (SD 16.3). A score of 57.6 is in the bottom 24% of scores across previous studies and categorized with a grade of "F." On multivariable analysis adjusting for age, gender, race, ethnicity, relationship status, children, highest nursing-related degree, mean hours worked per week, years of nursing experience, advanced certification, and practice setting, nurse-rated EHR usability was associated with burnout with each 1 point more favorable SUS score and associated with a 2% lower odds of burnout (OR 0.98; 95% CI, 0.97-0.99; P < .001).

CONCLUSIONS

Nurses rated the usability of their current EHR in the low marginal range of acceptability using a standardized metric of technology usability. EHR usability and the odds of burnout were strongly associated with a dose-response relationship.

Characterizing physician EHR use with vendor derived data: a feasibility study and cross-sectional analysis

OBJECTIVE

To derive 7 proposed core electronic health record (EHR) use metrics across 2 healthcare systems with different EHR vendor product installations and examine factors associated with EHR time.

MATERIALS AND METHODS

A cross-sectional analysis of ambulatory physicians EHR use across the Yale-New Haven and MedStar Health systems was performed for August 2019 using 7 proposed core EHR use metrics normalized to 8 hours of patient scheduled time.

RESULTS

Five out of 7 proposed metrics could be measured in a population of nonteaching, exclusively ambulatory physicians. Among 573 physicians (Yale-New Haven N = 290, MedStar N = 283) in the analysis, median EHR-Time8 was 5.23 hours. Gender, additional clinical hours scheduled, and certain medical specialties were associated with EHR-Time8 after adjusting for age and health system on multivariable analysis. For every 8 hours of scheduled patient time, the model predicted these differences in EHR time (P < .001, unless otherwise indicated): female physicians +0.58 hours; each additional clinical hour scheduled per month -0.01 hours; practicing cardiology -1.30 hours; medical subspecialties -0.89 hours (except gastroenterology, P = .002); neurology/psychiatry -2.60 hours; obstetrics/gynecology -1.88 hours; pediatrics -1.05 hours (P = .001); sports/physical medicine and rehabilitation -3.25 hours; and surgical specialties -3.65 hours.

CONCLUSIONS

For every 8 hours of scheduled patient time, ambulatory physicians spend more than 5 hours on the EHR. Physician gender, specialty, and number of clinical hours practicing are associated with differences in EHR time. While audit logs remain a powerful tool for understanding physician EHR use, additional transparency, granularity, and standardization of vendor-derived EHR use data definitions are still necessary to standardize EHR use measurement.

A systematic review of contributing factors of and solutions to electronic health record-related impacts on physician well-being

OBJECTIVE

Physicians often describe the electronic health record (EHR) as a cumbersome impediment to meaningful work, which has important implications for physician well-being. This systematic review (1) assesses organizational, physician, and information technology factors associated with EHR-related impacts on physician well-being; and (2) highlights potential improvements to EHR form and function, as recommended by frontline physicians.

MATERIALS AND METHODS

The MEDLINE, Embase, CINAHL, PsycINFO, ProQuest, and Web of Science databases were searched for literature describing EHR use by physicians and markers of well-being.

RESULTS

After reviewing 7388 article, 35 ultimately met the inclusion criteria. Multiple factors across all levels were associated with EHR-related well-being among physicians. Notable predictors amenable to interventions include (1) total EHR time, (2) after-hours EHR time, (3) on-site EHR support, (4) perceived EHR usability, (5) in-basket burden, and (6) documentation burden. Physician recommendations also echoed these themes.

CONCLUSIONS

There are multiple complex factors involved in EHR-related well-being among physicians. Our review shows physicians have recommendations that span from federal regulations to organizational policies to EHR modifications. Future research should assess multipronged interventions that address these factors. As primary stakeholders, physicians should be included in the planning and implementation of such modifications to ensure compatibility with physician needs and clinical workflows.

Assessment of Electronic Health Record Use Between US and Non-US Health Systems

Importance

Understanding how the electronic health record (EHR) system changes clinician work, productivity, and well-being is critical. Little is known regarding global variation in patterns of use.

Objective

To provide insights into which EHR activities clinicians spend their time doing, the EHR tools they use, the system messages they receive, and the amount of time they spend using the EHR after hours.

Design, Setting, and Participants

This cross-sectional study analyzed the deidentified metadata of ambulatory care health systems in the US, Canada, Northern Europe, Western Europe, the Middle East, and Oceania from January 1, 2019, to August 31, 2019. All of these organizations used the EHR software from Epic Systems and represented most of Epic Systems's ambulatory customer base. The sample included all clinicians with scheduled patient appointments, such as physicians and advanced practice practitioners.

Exposures

Clinician EHR use was tracked by deidentified and aggregated metadata across a variety of clinical activities.

Main Outcomes and Measures

Descriptive statistics for clinician EHR use included time spent on clinical activities, note documentation (as measured by the percentage of characters in the note generated by automated or manual data entry source), messages received, and time spent after hours.

Results

A total of 371 health systems were included in the sample, of which 348 (93.8%) were located in the US and 23 (6.2%) were located in other countries. US clinicians spent more time per day actively using the EHR compared with non-US clinicians (mean time, 90.2 minutes vs 59.1 minutes; P < .001). In addition, US clinicians vs non-US clinicians spent significantly more time performing 4 clinical activities: notes (40.7 minutes vs 30.7 minutes; P < .001), orders (19.5 minutes vs 8.75 minutes; P < .001), in-basket messages (12.5 minutes vs 4.80 minutes; P < .001), and clinical review (17.6 minutes vs 14.8 minutes; P = .01). Clinicians in the US composed more automated note text than their non-US counterparts (77.5% vs 60.8% of note text; P < .001) and received statistically significantly more messages per day (33.8 vs 12.8; P < .001). Furthermore, US clinicians used the EHR for a longer time after hours, logging in 26.5 minutes per day vs 19.5 minutes per day for non-US clinicians (P = .01). The median US clinician spent as much time actively using the EHR per day (90.1 minutes) as a non-US clinician in the 99th percentile of active EHR use time per day (90.7 minutes) in the sample. These results persisted after controlling for organizational characteristics, including structure, type, size, and daily patient volume.

Conclusions and Relevance

This study found that US clinicians compared with their non-US counterparts spent substantially more time actively using the EHR for a wide range of clinical activities or tasks. This finding suggests that US clinicians have a greater EHR burden that may be associated with nontechnical factors, which policy makers and health system leaders should consider when addressing clinician wellness.