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Asgari E, Kaur J, Nuredini G, Balloch J, Taylor AM, Sebire N, Robinson R, Peters C, Sridharan S, Pimenta D. Impact of Electronic Health Record Use on Cognitive Load and Burnout Among Clinicians: Narrative Review. JMIR Med Inform 2024; 12:e55499. [PMID: 38607672 PMCID: PMC11053390 DOI: 10.2196/55499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/15/2024] [Accepted: 03/11/2024] [Indexed: 04/13/2024] Open
Abstract
The cognitive load theory suggests that completing a task relies on the interplay between sensory input, working memory, and long-term memory. Cognitive overload occurs when the working memory's limited capacity is exceeded due to excessive information processing. In health care, clinicians face increasing cognitive load as the complexity of patient care has risen, leading to potential burnout. Electronic health records (EHRs) have become a common feature in modern health care, offering improved access to data and the ability to provide better patient care. They have been added to the electronic ecosystem alongside emails and other resources, such as guidelines and literature searches. Concerns have arisen in recent years that despite many benefits, the use of EHRs may lead to cognitive overload, which can impact the performance and well-being of clinicians. We aimed to review the impact of EHR use on cognitive load and how it correlates with physician burnout. Additionally, we wanted to identify potential strategies recommended in the literature that could be implemented to decrease the cognitive burden associated with the use of EHRs, with the goal of reducing clinician burnout. Using a comprehensive literature review on the topic, we have explored the link between EHR use, cognitive load, and burnout among health care professionals. We have also noted key factors that can help reduce EHR-related cognitive load, which may help reduce clinician burnout. The research findings suggest that inadequate efforts to present large amounts of clinical data to users in a manner that allows the user to control the cognitive burden in the EHR and the complexity of the user interfaces, thus adding more "work" to tasks, can lead to cognitive overload and burnout; this calls for strategies to mitigate these effects. Several factors, such as the presentation of information in the EHR, the specialty, the health care setting, and the time spent completing documentation and navigating systems, can contribute to this excess cognitive load and result in burnout. Potential strategies to mitigate this might include improving user interfaces, streamlining information, and reducing documentation burden requirements for clinicians. New technologies may facilitate these strategies. The review highlights the importance of addressing cognitive overload as one of the unintended consequences of EHR adoption and potential strategies for mitigation, identifying gaps in the current literature that require further exploration.
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Affiliation(s)
- Elham Asgari
- Guy's and St Thomas' NHS Trust, London, United Kingdom
- Tortus AI, London, United Kingdom
| | - Japsimar Kaur
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | | | | | | | - Neil Sebire
- Great Ormond Street Hospital, London, United Kingdom
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Tawfik D, Bayati M, Liu J, Nguyen L, Sinha A, Kannampallil T, Shanafelt T, Profit J. Predicting Primary Care Physician Burnout From Electronic Health Record Use Measures. Mayo Clin Proc 2024:S0025-6196(24)00037-5. [PMID: 38573301 DOI: 10.1016/j.mayocp.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/08/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE To evaluate the ability of routinely collected electronic health record (EHR) use measures to predict clinical work units at increased risk of burnout and potentially most in need of targeted interventions. METHODS In this observational study of primary care physicians, we compiled clinical workload and EHR efficiency measures, then linked these measures to 2 years of well-being surveys (using the Stanford Professional Fulfillment Index) conducted from April 1, 2019, through October 16, 2020. Physicians were grouped into training and confirmation data sets to develop predictive models for burnout. We used gradient boosting classifier and other prediction modeling algorithms to quantify the predictive performance by the area under the receiver operating characteristics curve (AUC). RESULTS Of 278 invited physicians from across 60 clinics, 233 (84%) completed 396 surveys. Physicians were 67% women with a median age category of 45 to 49 years. Aggregate burnout score was in the high range (≥3.325/10) on 111 of 396 (28%) surveys. Gradient boosting classifier of EHR use measures to predict burnout achieved an AUC of 0.59 (95% CI, 0.48 to 0.77) and an area under the precision-recall curve of 0.29 (95% CI, 0.20 to 0.66). Other models' confirmation set AUCs ranged from 0.56 (random forest) to 0.66 (penalized linear regression followed by dichotomization). Among the most predictive features were physician age, team member contributions to notes, and orders placed with user-defined preferences. Clinic-level aggregate measures identified the top quartile of clinics with 56% sensitivity and 85% specificity. CONCLUSION In a sample of primary care physicians, routinely collected EHR use measures demonstrated limited ability to predict individual burnout and moderate ability to identify high-risk clinics.
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Affiliation(s)
- Daniel Tawfik
- Stanford University School of Medicine, Stanford, CA.
| | | | - Jessica Liu
- Stanford University School of Medicine, Stanford, CA
| | - Liem Nguyen
- Stanford University School of Engineering, Stanford, CA
| | | | | | - Tait Shanafelt
- Stanford University School of Medicine, Stanford, CA; Stanford Medicine WellMD & WellPhD Center, Stanford, CA
| | - Jochen Profit
- Stanford University School of Medicine, Stanford, CA
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Park HS, DeGroote NP, Lange A, Kavalieratos D, Brock KE. The Scope of Practice of an Embedded Pediatric Palliative Oncology Clinic. J Pain Symptom Manage 2024; 67:250-259.e5. [PMID: 38065424 DOI: 10.1016/j.jpainsymman.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/22/2023]
Abstract
CONTEXT Pediatric palliative care (PPC) improves end-of-life (EOL) outcomes for children with cancer. Though PPC visits are the 'intervention' in studies focused on EOL care, the content of PPC visits within pediatric oncology is poorly understood. OBJECTIVES This study aimed to understand the scope of PPC practice during visits for children with cancer and their families. METHODS This was a retrospective cohort study of patients 0-27 years with cancer seen in PPC clinic within an academic pediatric oncology center between 2017 and 2022. During each PPC visit, documenting providers chose the domains discussed or managed (goals of care, symptom management, and care coordination with respective subdomains). Data was abstracted from the electronic health record, PPC clinic database, and Cancer Registry. The differences in frequency and addressed domains were analyzed by demographics, visit type, diagnosis group, and proximity to EOL. RESULTS Across 351 patients, 1919 outpatient PPC visits occurred. Median domains were higher in visits <90 days vs. 91+ days from EOL (12.0 vs. 10.0; p < 0.0001); pain and hospice collaboration were particularly discussed closer to EOL. Psychological symptoms like anxiety (30.7% vs. 21.1%; p < 0.001) were addressed more in follow-ups than initial visits. Compared to brain tumor or leukemia/lymphoma visits, solid tumor visits addressed more symptom management subdomains, especially pain (79.9%; p < 0.0001). CONCLUSION The scope of PPC practice is broad and varied. Each visit encompasses many subdomains, the most common being care coordination with oncology teams and helping patients/families cope with the disease. More domains were addressed in solid tumor visits and near EOL.
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Affiliation(s)
- Hee Su Park
- Emory University School of Medicine (H.S.P), Atlanta, Georgia, USA
| | - Nicholas P DeGroote
- Aflac Cancer & Blood Disorders Center (N.P.D, A.L., K.E.B.), Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Anna Lange
- Aflac Cancer & Blood Disorders Center (N.P.D, A.L., K.E.B.), Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine (D.K.), Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - Katharine E Brock
- Aflac Cancer & Blood Disorders Center (N.P.D, A.L., K.E.B.), Children's Healthcare of Atlanta, Atlanta, Georgia, USA; Divisions of Pediatric Hematology/Oncology and Palliative Care (K.E.B.), Department of Pediatrics, Emory University, Atlanta, Georgia, USA.
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Alessa T. Clinicians' Attitudes Toward Electronic Health Records in Saudi Arabia. Cureus 2024; 16:e56281. [PMID: 38623130 PMCID: PMC11016994 DOI: 10.7759/cureus.56281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2024] [Indexed: 04/17/2024] Open
Abstract
AIM This study explored physicians' and nurses' attitudes toward an electronic health record (EHR) system and examined the features and factors that clinicians associated with the implementation of EHR systems. METHODS A self-administered anonymous questionnaire with high reliability and validity was adopted from existing research to gather clinicians' attitudes toward the EHR system implemented at King Khalid University Hospital, one of the biggest hospitals in Riyadh, Saudi Arabia. RESULTS A total of 438 questionnaire responses were received from the participants; 240 of them were physicians and 198 were nurses. The participants had a mean age of 43.7 years (standard deviation (SD) 17.1), 213 (52.7%) were female and 207 (47.3%) were male. Most participants (424, 96.8%) had one or more years of experience using computers, and a majority (304, 69.4%) had one or more years of experience using EHR systems. Most physicians and nurses (214, 89.5% vs. 174, 87.9%) were satisfied with their hospital's EHR system and felt that the system was highly usable and had the potential to improve communication between staff, facilitate easy storage of and access to information and lead to improved health outcomes for patients. The study found positive attitudes among clinicians concerning the quality of training and education around the new system (178, 74.2% of physicians vs. 142, 71.7% of nurses; p > 0.05) and toward leadership during the transition to HER (222, 92.5% vs. 183, 92.4%). On the other hand, a majority of nurses reported that the EHR system took longer to use and increased their workload compared with the previous analogue system (115 (47.9%) vs. 133 (67.2%); p ≤ 0.01 and 46.7% vs. 112 (64.1%)). A large majority of physicians and nurses surveyed (214 (89.2%) vs. 167 (84.3%)) stated that clinicians should be consulted in the design of such systems as a way to maximise the potential benefits of EHR and mitigate extra workload demands. CONCLUSION Most clinicians expressed overall satisfaction with the EHR system, but there were some areas of dissatisfaction among the respondents, such as increasing workload and stress among nurses. There is scope for further research to continue to explore physicians' and nurses' attitudes toward EHRs and for future experimental studies that examine the impact of EHRs on clinician workloads, patient health outcomes and quality of care.
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Affiliation(s)
- Tourkiah Alessa
- Biomedical Technology Department, College of Applied Medical Sciences, King Saud University, Riyadh, SAU
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Zigler CK, Adeyemi O, Boyd AD, Braciszewski JM, Cheville A, Cuthel AM, Dailey DL, Del Fiol G, Ezenwa MO, Faurot KR, Justice M, Ho PM, Lawrence K, Marsolo K, Patil CL, Paek H, Richesson RL, Staman KL, Schlaeger JM, O'Brien EC. Collecting patient-reported outcome measures in the electronic health record: Lessons from the NIH pragmatic trials Collaboratory. Contemp Clin Trials 2024; 137:107426. [PMID: 38160749 PMCID: PMC10922303 DOI: 10.1016/j.cct.2023.107426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/15/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
The NIH Pragmatic Trials Collaboratory supports the design and conduct of 27 embedded pragmatic clinical trials, and many of the studies collect patient reported outcome measures as primary or secondary outcomes. Study teams have encountered challenges in the collection of these measures, including challenges related to competing health care system priorities, clinician's buy-in for adoption of patient-reported outcome measures, low adoption and reach of technology in low resource settings, and lack of consensus and standardization of patient-reported outcome measure selection and administration in the electronic health record. In this article, we share case examples and lessons learned, and suggest that, when using patient-reported outcome measures for embedded pragmatic clinical trials, investigators must make important decisions about whether to use data collected from the participating health system's electronic health record, integrate externally collected patient-reported outcome data into the electronic health record, or collect these data in separate systems for their studies.
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Affiliation(s)
- Christina K Zigler
- Duke University School of Medicine, Durham, NC, United States of America.
| | - Oluwaseun Adeyemi
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, NY, United States of America
| | - Andrew D Boyd
- Department of Biomedical and Health Information Sciences, University of Illinois Chicago, Chicago, IL, United States of America
| | | | - Andrea Cheville
- Mayo Clinic Comprehensive Cancer Center, Rochester, MN, United States of America
| | - Allison M Cuthel
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, NY, United States of America
| | - Dana L Dailey
- St. Ambrose University, Davenport, IA, and University of Iowa, Iowa City, IA, United States of America
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Miriam O Ezenwa
- University of Florida College of Nursing, Gainesville, FL, United States of America
| | - Keturah R Faurot
- Department of Physical Medicine and Rehabilitation, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Morgan Justice
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - P Michael Ho
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Katherine Lawrence
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Keith Marsolo
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Crystal L Patil
- University of Michigan, School of Nursing, Ann Arbor, MI, United States of America
| | - Hyung Paek
- Yale University, New Haven, CT, United States of America
| | - Rachel L Richesson
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Karen L Staman
- Duke Clinical Research Institute, Durham, NC, United States of America
| | - Judith M Schlaeger
- University of Illinois Chicago, College of Nursing, Chicago, IL, United States of America
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
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Anderson JC, Bilal M, Burke CA, Gaidos JK, Lopez R, Oxentenko AS, Surawicz CM. Burnout Among US Gastroenterologists and Fellows in Training: Identifying Contributing Factors and Offering Solutions. J Clin Gastroenterol 2023; 57:1063-1069. [PMID: 36477385 DOI: 10.1097/mcg.0000000000001781] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/10/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Consequences of physician burnout include medical errors, higher rate of staff turnover, and decreased patient satisfaction. We examined the prevalence of burnout and identified the contributing factors in gastroenterologists and fellows in training. METHODS We performed 3 separate surveys through the American College of Gastroenterology. (1) A national survey of practicing gastroenterologists in the United States that measured burnout and contributing factors, (2) a survey of gastroenterology fellows in training to determine self-identified burnout, as well as mitigating and exacerbating factors, and (3) a follow-up survey of fellows during the COVID-19 pandemic. RESULTS One thousand and twenty-one persons responded (9.2% response rate) to the first survey, including 756 individuals who completed the Maslach Burnout Inventory survey. Overall, the prevalence of high burnout was 49.3%. Factors associated with high burnout included female sex, younger age, shorter duration in practice, considering the electronic health record non-user-friendly, 2 or more hours of patient-related work at home per day, 8 or more hours of outpatient time per day, 6 or more inpatient consults per day, taking call with procedures 10 or more times per year, and having children at home. With regard to lifestyle factors, taking 20 days or more of vacation time was associated with a lower rate of burnout. The level of burnout for fellows was observed to be high (42.7% in survey 2 and 35.3% in survey 3). CONCLUSIONS Burnout is high in gastroenterologists and fellows in training. Specific contributing factors were both systems based and personal and provide insight into changes that can be made to address burnout.
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Affiliation(s)
- Joseph C Anderson
- Department of Veterans Affairs Medical Center, Division of Gastroenterology and Hepatology, The Geisel School of Medicine at Dartmouth, Hanover, NH
- University of Connecticut School of Medicine, Farmington
| | - Mohammad Bilal
- The Division of Gastroenterology VA Medical Center, University of Minnesota Medical School, Minneapolis, MN
| | - Carol A Burke
- Division of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic
| | - Jill K Gaidos
- Division of Digestive Disease, Yale School of Medicine, New Haven, CT
| | - Rocio Lopez
- Center for Populations Health Research, Cleveland Clinic Lerner Research Institute, Cleveland, OH
| | - Amy S Oxentenko
- Department of Medicine, Division of Gastroenterology, Mayo Clinic, Phoenix, AZ
| | - Christina M Surawicz
- Division of Gastroenterology, University of Washington School of Medicine, Seattle WA
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Abstract
Data science has the potential to greatly enhance efforts to translate evidence into practice in critical care. The intensive care unit is a data-rich environment enabling insight into both patient-level care patterns and clinician-level treatment patterns. By applying artificial intelligence to these novel data sources, implementation strategies can be tailored to individual patients, individual clinicians, and individual situations, revealing when evidence-based practices are missed and facilitating context-sensitive clinical decision support. To achieve these goals, technology developers should work closely with clinicians to create unbiased applications that are integrated into the clinical workflow.
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Affiliation(s)
- Andrew J King
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3500 Terrace Street, Suite 600, Pittsburgh, PA 15261, USA
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3500 Terrace Street, Suite 600, Pittsburgh, PA 15261, USA; Department of Health Policy and Management, University of Pittsburgh School of Public Health, 130 De Soto Street, Pittsburgh, PA 15261, USA.
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Borges do Nascimento IJ, Abdulazeem H, Vasanthan LT, Martinez EZ, Zucoloto ML, Østengaard L, Azzopardi-Muscat N, Zapata T, Novillo-Ortiz D. Barriers and facilitators to utilizing digital health technologies by healthcare professionals. NPJ Digit Med 2023; 6:161. [PMID: 37723240 PMCID: PMC10507089 DOI: 10.1038/s41746-023-00899-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 08/01/2023] [Indexed: 09/20/2023] Open
Abstract
Digital technologies change the healthcare environment, with several studies suggesting barriers and facilitators to using digital interventions by healthcare professionals (HPs). We consolidated the evidence from existing systematic reviews mentioning barriers and facilitators for the use of digital health technologies by HP. Electronic searches were performed in five databases (Cochrane Database of Systematic Reviews, Embase®, Epistemonikos, MEDLINE®, and Scopus) from inception to March 2023. We included reviews that reported barriers or facilitators factors to use technology solutions among HP. We performed data abstraction, methodological assessment, and certainty of the evidence appraisal by at least two authors. Overall, we included 108 reviews involving physicians, pharmacists, and nurses were included. High-quality evidence suggested that infrastructure and technical barriers (Relative Frequency Occurrence [RFO] 6.4% [95% CI 2.9-14.1]), psychological and personal issues (RFO 5.3% [95% CI 2.2-12.7]), and concerns of increasing working hours or workload (RFO 3.9% [95% CI 1.5-10.1]) were common concerns reported by HPs. Likewise, high-quality evidence supports that training/educational programs, multisector incentives, and the perception of technology effectiveness facilitate the adoption of digital technologies by HPs (RFO 3.8% [95% CI 1.8-7.9]). Our findings showed that infrastructure and technical issues, psychological barriers, and workload-related concerns are relevant barriers to comprehensively and holistically adopting digital health technologies by HPs. Conversely, deploying training, evaluating HP's perception of usefulness and willingness to use, and multi-stakeholders incentives are vital enablers to enhance the HP adoption of digital interventions.
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Affiliation(s)
- Israel Júnior Borges do Nascimento
- Division of Country Health Policies and Systems (CPS), World Health Organization Regional Office for Europe, Copenhagen, 2100, Denmark
- Pathology and Laboratory Medicine, Medical College of Wisconsin, Milwaukee, WI, 53226-3522, USA
| | - Hebatullah Abdulazeem
- Department of Sport and Health Science, Techanische Universität München, Munich, 80333, Germany
| | - Lenny Thinagaran Vasanthan
- Physical Medicine and Rehabilitation Department, Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Edson Zangiacomi Martinez
- Department of Social Medicine and Biostatistics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, 14049-900, Brazil
| | - Miriane Lucindo Zucoloto
- Department of Social Medicine and Biostatistics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, 14049-900, Brazil
| | - Lasse Østengaard
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University Library of Southern Denmark, Odense, 5230, Denmark
| | - Natasha Azzopardi-Muscat
- Division of Country Health Policies and Systems (CPS), World Health Organization Regional Office for Europe, Copenhagen, 2100, Denmark
| | - Tomas Zapata
- Division of Country Health Policies and Systems (CPS), World Health Organization Regional Office for Europe, Copenhagen, 2100, Denmark
| | - David Novillo-Ortiz
- Division of Country Health Policies and Systems (CPS), World Health Organization Regional Office for Europe, Copenhagen, 2100, Denmark.
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Borges do Nascimento IJ, Abdulazeem HM, Vasanthan LT, Martinez EZ, Zucoloto ML, Østengaard L, Azzopardi-Muscat N, Zapata T, Novillo-Ortiz D. The global effect of digital health technologies on health workers' competencies and health workplace: an umbrella review of systematic reviews and lexical-based and sentence-based meta-analysis. Lancet Digit Health 2023; 5:e534-e544. [PMID: 37507197 PMCID: PMC10397356 DOI: 10.1016/s2589-7500(23)00092-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 03/31/2023] [Accepted: 04/29/2023] [Indexed: 07/30/2023]
Abstract
Systematic reviews have quantified the effectiveness, feasibility, acceptability, and cost-effectiveness of digital health technologies (DHTs) used by health-care workers. We aimed to collate available evidence on technologies' effect on health-care workers' competencies and performance. We searched the Cochrane Database of Systematic Reviews, Embase, MEDLINE, Epistemonikos, and Scopus for reviews published from database inception to March 1, 2023. Studies assessing the effects of DHTs on the organisational, socioeconomic, clinical, and epidemiological levels within the workplace, and on health-care workers' performance parameters, were included. Data were extracted and clustered into 25 domains using vote counting based on the direction of effect. The relative frequency of occurrence (RFO) of each domain was estimated using R software. AMSTAR-2 tool was used to appraise the quality of reporting, and the Confidence in the Evidence from Reviews of Qualitative research approach developed by Grading of Recommendations Assessment, Development and Evaluation was used to analyse the certainty of evidence among included studies. The 12 794 screened reviews generated 132 eligible records for assessment. Top-ranked RFO identifiers showed associations of DHT with the enhancement of health-care workers' performance (10·9% [95% CI 5·3-22·5]), improvement of clinical practice and management (9·8% [3·9-24·2]), and improvement of care delivery and access to care (9·2% [4·1-20·9]). Our overview found that DHTs positively influence the daily practice of health-care workers in various medical specialties. However, poor reporting in crucial domains is widely prevalent in reviews of DHT, hindering our findings' generalisability and interpretation. Likewise, most of the included reviews reported substantially more data from high-income countries. Improving the reporting of future studies and focusing on low-income and middle-income countries might elucidate and answer current knowledge gaps.
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Affiliation(s)
- Israel Júnior Borges do Nascimento
- Pathology and Laboratory Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; School of Medicine and University Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil; Division of Country Health Policies and Systems, World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | | | | | - Edson Zangiacomi Martinez
- Department of Social Medicine-Biostatistics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Miriane Lucindo Zucoloto
- Department of Social Medicine-Biostatistics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Lasse Østengaard
- Centre for Evidence-Based Medicine Odense and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark; University Library of Southern Denmark, University of Southern Denmark, Odense, Denmark
| | - Natasha Azzopardi-Muscat
- Division of Country Health Policies and Systems, World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Tomas Zapata
- Division of Country Health Policies and Systems, World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - David Novillo-Ortiz
- Division of Country Health Policies and Systems, World Health Organization Regional Office for Europe, Copenhagen, Denmark.
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Hilty DM, Groshong LW, Coleman M, Maheu MM, Armstrong CM, Smout SA, Crawford A, Drude KP, Krupinski EA. Best Practices for Technology in Clinical Social Work and Mental Health Professions to Promote Well-being and Prevent Fatigue. CLINICAL SOCIAL WORK JOURNAL 2023; 51:1-35. [PMID: 37360756 PMCID: PMC10233199 DOI: 10.1007/s10615-023-00865-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 06/28/2023]
Abstract
The shift to communication technologies during the pandemic has had positive and negative effects on clinical social worker practice. Best practices are identified for clinical social workers to maintain emotional well-being, prevent fatigue, and avoid burnout when using technology. A scoping review from 2000 to 21 of 15 databases focused on communication technologies for mental health care within four areas: (1) behavioral, cognitive, emotional, and physical impact; (2) individual, clinic, hospital, and system/organizational levels; (3) well-being, burnout, and stress; and (4) clinician technology perceptions. Out of 4795 potential literature references, full text review of 201 papers revealed 37 were related to technology impact on engagement, therapeutic alliance, fatigue and well-being. Studies assessed behavioral (67.5%), emotional (43.2%), cognitive (57.8%), and physical (10.8%) impact at the individual (78.4%), clinic (54.1%), hospital (37.8%) and system/organizational (45.9%) levels. Participants were clinicians, social workers, psychologists, and other providers. Clinicians can build a therapeutic alliance via video, but this requires additional skill, effort, and monitoring. Use of video and electronic health records were associated with clinician physical and emotional problems due to barriers, effort, cognitive demands, and additional workflow steps. Studies also found high user ratings on data quality, accuracy, and processing, but low satisfaction with clerical tasks, effort required and interruptions. Studies have overlooked the impact of justice, equity, diversity and inclusion related to technology, fatigue and well-being, for the populations served and the clinicians providing care. Clinical social workers and health care systems must evaluate the impact of technology in order to support well-being and prevent workload burden, fatigue, and burnout. Multi-level evaluation and clinical, human factor, training/professional development and administrative best practices are suggested.
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Affiliation(s)
- Donald M. Hilty
- Department of Psychiatry & Behavioral Sciences, UC Davis, 2230 Stockton Boulevard, Sacramento, CA 95817 USA
| | | | - Mirean Coleman
- National Association of Social Workers, Washington, DC USA
| | - Marlene M. Maheu
- Coalition for Technology in Behavioral Sciences, Telebehavioral Health Institute, Inc, 5173 Waring Road #124, San Diego, CA 92120 USA
| | - Christina M. Armstrong
- Department of Veterans Affairs, Connected Health Implementation Strategies, Office of Connected Care, Office of Health Informatics, U.S., 810 Vermont Avenue NW, Washington, DC 20420 USA
| | - Shelby A. Smout
- Virginia Commonwealth University, 3110 Kensington Ave Apt 3, Richmond, VA 23221 USA
| | - Allison Crawford
- Ontario Mental Health at CAMH, Toronto, Canada
- University of Toronto, Toronto, Canada
- Suicide Prevention Service, 1001 Queen St West, Toronto, ON M6J 1H4 Canada
| | - Kenneth P. Drude
- Coalition Technology in Behavioral Science, 680 E. Dayton Yellow Springs Rd, Fairborn, OH 45324 USA
| | - Elizabeth A. Krupinski
- Department of Radiology & Imaging Sciences, Emory University, 1364 Clifton Rd NE, Atlanta, GA 30322 USA
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Rotenstein LS, Apathy N, Holmgren AJ, Bates DW. Physician Note Composition Patterns and Time on the EHR Across Specialty Types: a National, Cross-sectional Study. J Gen Intern Med 2023; 38:1119-1126. [PMID: 36418647 PMCID: PMC10110827 DOI: 10.1007/s11606-022-07834-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/29/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The burden of clinical documentation in electronic health records (EHRs) has been associated with physician burnout. Numerous tools (e.g., note templates and dictation services) exist to ease documentation burden, but little evidence exists regarding how physicians use these tools in combination and the degree to which these strategies correlate with reduced time spent on documentation. OBJECTIVE To characterize EHR note composition strategies, how these strategies differ in time spent on notes and the EHR, and their distribution across specialty types. DESIGN Secondary analysis of physician-level measures of note composition and EHR use derived from Epic Systems' Signal data warehouse. We used k-means clustering to identify documentation strategies, and ordinary least squares regression to analyze the relationship between documentation strategies and physician time spent in the EHR, on notes, and outside scheduled hours. PARTICIPANTS A total of 215,207 US-based ambulatory physicians using the Epic EHR between September 2020 and May 2021. MAIN MEASURES Percent of note text derived from each of five documentation tools: SmartTools, copy/paste, manual text, NoteWriter, and voice recognition and transcription; average total and after-hours EHR time per visit; average time on notes per visit. KEY RESULTS Six distinct note composition strategies emerged in cluster analyses. The most common strategy was predominant SmartTools use (n=89,718). In adjusted analyses, physicians using primarily transcription and dictation (n=15,928) spent less time on notes than physicians with predominant Smart Tool use. (b=-1.30, 95% CI=-1.62, -0.99, p<0.001; average 4.8 min per visit), while those using mostly copy/paste (n=23,426) spent more time on notes (b=2.38, 95% CI=1.92, 2.84, p<0.001; average 13.1 min per visit). CONCLUSIONS Physicians' note composition strategies have implications for both time in notes and after-hours EHR use, suggesting that how physicians use EHR-based documentation tools can be a key lever for institutions investing in EHR tools and training to reduce documentation time and alleviate EHR-associated burden.
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Affiliation(s)
- Lisa S Rotenstein
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Nate Apathy
- Leonard Davis Institute of Health Economics, Wharton School, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, Philadelphia, PA, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - A Jay Holmgren
- University of California at San Francisco, San Francisco, CA, USA
| | - David W Bates
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
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12
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Abid M, Schneider AB. Clinical Informatics and the Electronic Medical Record. Surg Clin North Am 2023; 103:247-258. [PMID: 36948716 DOI: 10.1016/j.suc.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
The electronic medical record has fundamentally altered the way surgeons participate and practice medicine. There is now a wealth of data, once hidden behind paper records, that is, now available to surgeons to provide superior care to their patients. This article reviews the history of the electronic medical record, discusses use cases of additional data resources, and highlights the pitfalls of this relatively new technology.
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Affiliation(s)
- Mustafa Abid
- Department of Surgery, University of North Carolina, 101 Manning Drive, Chapel Hill, NC 27514, USA
| | - Andrew B Schneider
- Department of Surgery, University of North Carolina, 101 Manning Drive, Chapel Hill, NC 27514, USA.
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13
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A qualitative study of the dark and bright sides of physicians' electronic health record work outside work hours. Health Care Manage Rev 2023; 48:140-149. [PMID: 36820608 DOI: 10.1097/hmr.0000000000000361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
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.
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Nguyen OT, Turner K, Charles D, Sprow O, Perkins R, Hong YR, Islam JY, Khanna N, Alishahi Tabriz A, Hallanger-Johnson J, Bickel Young J, Moore CE. Implementing Digital Scribes to Reduce Electronic Health Record Documentation Burden Among Cancer Care Clinicians: A Mixed-Methods Pilot Study. JCO Clin Cancer Inform 2023; 7:e2200166. [PMID: 36972488 DOI: 10.1200/cci.22.00166] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
PURPOSE To address shortcomings of human scribes (eg, turnover), clinicians are considering digital scribes (DSs). To our knowledge, to date, no study has assessed DS implementation or clinician user experience in cancer centers. We assessed the DS's feasibility, acceptability, appropriateness, usability and its preliminary association on clinician well-being in a cancer center. We also identified implementation facilitators and barriers to DS use. METHODS Using a mixed-methods longitudinal pilot study design, we implemented a DS at a cancer center. Data collection included surveys at baseline and 1 month after DS use and a semistructured interview with clinicians. The survey assessed demographics, Mini Z (workplace stress and burnout), sleep quality, and implementation outcomes (feasibility, acceptability, appropriateness, and usability). The interview assessed how the DS was used and its impacts on workflows and recommendations for future implementations of the DS. We used paired t tests to assess differences in Mini Z and sleep quality measures over time. RESULTS Across nine survey responses and eight interviews, we found that although feasibility scores were slightly lower than our cutoff point (15.2 v 16.0), clinicians rated the DS as marginally acceptable (16.0) and appropriate (16.3). Usability was considered marginally usable (68.6 v 68.0). Although the DS did not significantly improve burnout (3.6 v 3.9, P = .081), it improved perceptions of having sufficient documentation time (2.1 v 3.6, P = .005). Clinicians identified suggestions for future implementations, including training needs and usability improvements. CONCLUSION Our preliminary findings suggest that DS implementation is marginally acceptable, appropriate, and usable among cancer care clinicians. Individualized training and on-site support may improve implementation.
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Affiliation(s)
- Oliver T Nguyen
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Kea Turner
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
- Department of Oncologic Science, University of South Florida, Tampa, FL
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Dannelle Charles
- Participant, Research, Interventions, and Measurement Core, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Olivia Sprow
- Department of Epidemiology, University of Florida, Gainesville, FL
| | - Randa Perkins
- Department of Internal Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Young-Rock Hong
- Department of Health Services Research, Management, and Policy, Gainesville, FL
| | - Jessica Y Islam
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Neel Khanna
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
- Department of Oncologic Science, University of South Florida, Tampa, FL
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | | | - Jennifer Bickel Young
- Department of Oncologic Science, University of South Florida, Tampa, FL
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
- Wellness Office, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Colin E Moore
- Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
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15
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Nguyen OT, Hanna K, Merlo LJ, Parekh A, Tabriz AA, Hong YR, Feldman SS, Turner K. Early Performance of the Patients Over Paperwork Initiative among Family Medicine Physicians. South Med J 2023; 116:255-263. [PMID: 36863044 PMCID: PMC9991071 DOI: 10.14423/smj.0000000000001526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
OBJECTIVES In 2019, the Centers for Medicare & Medicaid Services began implementing the Patients Over Paperwork (POP) initiative in response to clinicians reporting burdensome documentation regulations. To date, no study has evaluated how these policy changes have influenced documentation burden. METHODS Our data came from the electronic health records of an academic health system. Using quantile regression models, we assessed the association between the implementation of POP and clinical documentation word count using data from family medicine physicians in an academic health system from January 2017 to May 2021 inclusive. Studied quantiles included the 10th, 25th, 50th, 75th, and 90th quantiles. We controlled for patient-level (race/ethnicity, primary language, age, comorbidity burden), visit-level (primary payer, level of clinical decision making involved, whether a visit was done through telemedicine, whether a visit was for a new patient), and physician-level (sex) characteristics. RESULTS We found that the POP initiative was associated with lower word counts across all of the quantiles. In addition, we found lower word counts among notes for private payers and telemedicine visits. Conversely, higher word counts were observed in notes that were written by female physicians, notes for new patient visits, and notes involving patients with greater comorbidity burden. CONCLUSIONS Our initial evaluation suggests that documentation burden, as measured by word count, has declined over time, particularly following implementation of the POP in 2019. Additional research is needed to see whether the same occurs when examining other medical specialties, clinician types, and longer evaluation periods.
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Affiliation(s)
- Oliver T. Nguyen
- Department of Community Health & Family Medicine, University of Florida, Gainesville
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Karim Hanna
- Department of Family Medicine, Morsani College of Medicine, University of South Florida, Tampa
| | - Lisa J. Merlo
- Department of Psychiatry, University of Florida, Gainesville
| | - Arpan Parekh
- Department of Community Health & Family Medicine, University of Florida, Gainesville
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Department of Oncological Sciences, University of South Florida, Tampa
| | - Young-Rock Hong
- Department of Health Services Research, Management, and Policy, University of Florida, Gainesville
| | - Sue S. Feldman
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham
| | - Kea Turner
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Department of Oncological Sciences, University of South Florida, Tampa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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16
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Nguyen OT, Turner K, Parekh A, Alishahi Tabriz A, Hanna K, Merlo LJ, Hong YR. Merit-based incentive payment system participation and after-hours documentation among US office-based physicians: Findings from the 2021 National Electronic Health Records Survey. J Eval Clin Pract 2023; 29:397-402. [PMID: 36416004 DOI: 10.1111/jep.13796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND After-hours documentation burden among US clinicians is often uncompensated work and has been associated with burnout, leading health systems to identify root causes and seek interventions to reduce this. A few studies have suggested quality programme participation (e.g., Merit-Based Incentive Payment System [MIPS]) was associated with a higher administrative burden. However, the association between MIPS participation and after-hours documentation has not been fully explored. Thus, this study aims to assess whether participation in the MIPS programme was independently associated with after-hours documentation burden. METHODS We used 2021 data from the National Electronic Health Records Survey. We used a multivariable ordinal logistic regression model to assess whether MIPS participation was associated with the amount of after-hours documentation burden when controlling for other factors. We controlled for physician age, specialty, sex, number of practice locations, number of physicians, practice ownership, whether team support (e.g., scribes) is used for documentation tasks, and whether the practice accepts Medicaid patients. RESULTS We included 1801 office-based US physician respondents with complete data for variables of interest. After controlling for other factors, MIPS participation was associated with greater odds of spending a greater number of hours on after-hours documentation (odds ratio = 1.44, 95% confidence interval 1.06-1.95). CONCLUSIONS MIPS participation may increase after-hours documentation burden among US office-based physicians, suggesting that physicians may require additional resources to more efficiently report data.
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Affiliation(s)
- Oliver T Nguyen
- Department of Health Outcomes and Behaviour, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Kea Turner
- Department of Health Outcomes and Behaviour, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA.,Department of Oncologic Science, University of South Florida, Tampa, Florida, USA.,Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Arpan Parekh
- Department of Community Health & Family Medicine, University of Florida, Gainesville, Florida, USA
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and Behaviour, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA.,Department of Oncologic Science, University of South Florida, Tampa, Florida, USA
| | - Karim Hanna
- Department of Family Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Lisa J Merlo
- Department of Psychiatry, University of Florida, Gainesville, Florida, USA
| | - Young-Rock Hong
- Department of Health Services Research, Management, and Policy, University of Florida, Gainesville, Florida, USA
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17
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Alobayli F, O’Connor S, Holloway A, Cresswell K. Electronic Health Record Stress and Burnout Among Clinicians in Hospital Settings: A Systematic Review. Digit Health 2023; 9:20552076231220241. [PMID: 38130797 PMCID: PMC10734365 DOI: 10.1177/20552076231220241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 11/23/2023] [Indexed: 12/23/2023] Open
Abstract
Background There is growing evidence to suggest that EHRs may be associated with clinician stress and burnout, which could hamper their effective use and introduce risks to patient safety. Objective This systematic review aimed to examine the association between EHR use and clinicians' stress and burnout in hospital settings, and to identify the contributing factors influencing this relationship. Methods The search included peer-reviewed published studies between 2000 and 2023 in English in CINAHL, Ovid Medline, Embase, and PsychINFO. Studies that provided specific data regarding clinicians' stress and/or burnout related to EHRs in hospitals were included. A quality assessment of included studies was conducted. Results Twenty-nine studies were included (25 cross-sectional surveys, one qualitative study, and three mixed methods), which focused on physicians (n = 18), nurses (n = 10) and mixed professions (n = 3). Usability issues and the amount of time spent on the EHR were the most significant predictors, but intensity of the working environment influenced high EHR-related workload and thereby also contributed to stress and burnout. The differences in clinicians' specialties influenced the levels of stress and burnout related to EHRs. Conclusions This systematic review showed that EHR use was a perceived contributor to clinicians' stress and burnout in hospitals, primarily driven by poor usability and excessive time spent on EHRs. Addressing these issues requires tailored EHR systems, rigorous usability testing, support for the needs of different specialities, qualitative research on EHR stressors, and expanded research in Non-Western contexts.
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Affiliation(s)
- Fatimah Alobayli
- Nursing Studies, School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
| | - Siobhan O’Connor
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Aisha Holloway
- Nursing Studies, School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
| | - Kathrin Cresswell
- College of Medicine and Veterinary Medicine, Usher Institute, The University of Edinburgh, Edinburgh, UK
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18
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McGonagle EA, Karavite DJ, Grundmeier RW, Schmidt SK, May LS, Cohen DM, Cruz AT, Tu SP, Bajaj L, Dayan PS, Mistry RD. Evaluation of an Antimicrobial Stewardship Decision Support for Pediatric Infections. Appl Clin Inform 2023; 14:108-118. [PMID: 36754066 PMCID: PMC9908419 DOI: 10.1055/s-0042-1760082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 11/16/2022] [Indexed: 02/10/2023] Open
Abstract
OBJECTIVES Clinical decision support (CDS) has promise for the implementation of antimicrobial stewardship programs (ASPs) in the emergency department (ED). We sought to assess the usability of a newly developed automated CDS to improve guideline-adherent antibiotic prescribing for pediatric community-acquired pneumonia (CAP) and urinary tract infection (UTI). METHODS We conducted comparative usability testing between an automated, prototype CDS-enhanced discharge order set and standard order set, for pediatric CAP and UTI antibiotic prescribing. After an extensive user-centered design process, the prototype CDS was integrated into the electronic health record, used passive activation, and embedded locally adapted prescribing guidelines. Participants were randomized to interact with three simulated ED scenarios of children with CAP or UTI, across both systems. Measures included task completion, decision-making and usability errors, clinical actions (order set use and correct antibiotic selection), as well as objective measures of system usability, utility, and workload using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). The prototype CDS was iteratively refined to optimize usability and workflow. RESULTS Usability testing in 21 ED clinical providers demonstrated that, compared to the standard order sets, providers preferred the prototype CDS, with improvements in domains such as explanations of suggested antibiotic choices (p < 0.001) and provision of additional resources on antibiotic prescription (p < 0.001). Simulated use of the CDS also led to overall improved guideline-adherent prescribing, with a 31% improvement for CAP. A trend was present toward absolute workload reduction. Using the NASA-TLX, workload scores for the current system were median 26, interquartile ranges (IQR): 11 to 41 versus median 25, and IQR: 10.5 to 39.5 for the CDS system (p = 0.117). CONCLUSION Our CDS-enhanced discharge order set for ED antibiotic prescribing was strongly preferred by users, improved the accuracy of antibiotic prescribing, and trended toward reduced provider workload. The CDS was optimized for impact on guideline-adherent antibiotic prescribing from the ED and end-user acceptability to support future evaluative trials of ED ASPs.
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Affiliation(s)
- Erin A. McGonagle
- Department of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Dean J. Karavite
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Robert W. Grundmeier
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Sarah K. Schmidt
- Department of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Larissa S. May
- Department of Emergency Medicine, University of California at Davis School of Medicine, Davis, California, United States
| | - Daniel M. Cohen
- Department of Pediatrics, The Ohio State University School of Medicine, Columbus, Ohio, United States
| | - Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States
| | - Shin-Ping Tu
- Department of Medicine, University of California at Davis School of Medicine, Davis, California, United States
| | - Lalit Bajaj
- Department of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Peter S. Dayan
- Department of Emergency Medicine and Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York, United States
| | - Rakesh D. Mistry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
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Lou SS, Liu H, Harford D, Lu C, Kannampallil T. Characterizing the macrostructure of electronic health record work using raw audit logs: an unsupervised action embeddings approach. J Am Med Inform Assoc 2022; 30:539-544. [PMID: 36478460 PMCID: PMC9933072 DOI: 10.1093/jamia/ocac239] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/26/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022] Open
Abstract
Raw audit logs provide a comprehensive record of clinicians' activities on an electronic health record (EHR) and have considerable potential for studying clinician behaviors. However, research using raw audit logs is limited because they lack context for clinical tasks, leading to difficulties in interpretation. We describe a novel unsupervised approach using the comparison and visualization of EHR action embeddings to learn context and structure from raw audit log activities. Using a dataset of 15 767 634 raw audit log actions performed by 88 intern physicians over 6 months of EHR use across inpatient and outpatient settings, we demonstrated that embeddings can be used to learn the situated context for EHR-based work activities, identify discrete clinical workflows, and discern activities typically performed across diverse contexts. Our approach represents an important methodological advance in raw audit log research, facilitating the future development of metrics and predictive models to measure clinician behaviors at the macroscale.
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Affiliation(s)
- Sunny S Lou
- Department of Anesthesiology, School of Medicine, Washington University in St Louis, St Louis, Missouri, USA,Institute for Informatics, School of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Hanyang Liu
- Department of Computer Science and Engineering, McKelvey School of Engineering, Washington University in St Louis, St Louis, Missouri, USA
| | - Derek Harford
- Department of Anesthesiology, School of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Chenyang Lu
- Department of Computer Science and Engineering, McKelvey School of Engineering, Washington University in St Louis, St Louis, Missouri, USA
| | - Thomas Kannampallil
- Corresponding Author: Thomas Kannampallil, PhD, Institute for Informatics, School of Medicine, Washington University in St Louis, 660 S. Euclid Avenue, Campus Box 8054, St Louis, MO 63110, USA;
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20
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Rodríguez-Fernández JM, Loeb JA, Hier DB. It's time to change our documentation philosophy: writing better neurology notes without the burnout. Front Digit Health 2022; 4:1063141. [PMID: 36518562 PMCID: PMC9742203 DOI: 10.3389/fdgth.2022.1063141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/10/2022] [Indexed: 08/23/2023] Open
Abstract
Succinct clinical documentation is vital to effective twenty-first-century healthcare. Recent changes in outpatient and inpatient evaluation and management (E/M) guidelines have allowed neurology practices to make changes that reduce the documentation burden and enhance clinical note usability. Despite favorable changes in E/M guidelines, some neurology practices have not moved quickly to change their documentation philosophy. We argue in favor of changes in the design, structure, and implementation of clinical notes that make them shorter yet still information-rich. A move from physician-centric to team documentation can reduce work for physicians. Changing the documentation philosophy from "bigger is better" to "short but sweet" can reduce the documentation burden, streamline the writing and reading of clinical notes, and enhance their utility for medical decision-making, patient education, medical education, and clinical research. We believe that these changes can favorably affect physician well-being without adversely affecting reimbursement.
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Affiliation(s)
| | - Jeffrey A. Loeb
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL, United States
| | - Daniel B. Hier
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL, United States
- Department of Electrical and Computer Engineering, Missouri University of Science and Technology, Rolla, MO, United States
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21
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Moore A, Chavez C, Fisher MP. Factors Enhancing Trust in Electronic Communication Among Patients from an Internal Medicine Clinic: Qualitative Results of the RECEPT Study. J Gen Intern Med 2022; 37:3121-3127. [PMID: 35048293 PMCID: PMC8768442 DOI: 10.1007/s11606-021-07345-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/15/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Electronic health records are now the norm in US healthcare. Bidirectional patient portals allow frequent communication between patients and their healthcare team. Many studies have examined the importance of patient engagement and trust between patients and their healthcare team, typically in the context of face-to-face interactions. Little is known about how patient trust and engagement are built or enhanced through electronic communications. COVID-19 provided a unique time in history for this novel exploration. OBJECTIVE Our objective was to learn how patients experience trust formation through electronic communication (patient messaging and video visits) with their healthcare team. DESIGN Our research was guided by grounded theory methodology. Qualitative interviews were conducted between February and December 2020 with patients or their caregivers from an internal medicine clinic in Colorado. PARTICIPANTS Fifty-one participants were recruited by age group and gender to represent the clinic's adult ambulatory care demographics. Seven were patients' caregivers who were purposefully recruited. Average age was 53 with an educated, middle class, and largely white predominance in our eventual sample. APPROACH Thirty-minute semi-structured interviews were conducted using an interview guide informed by a validated physician-patient trust scale. Interviews were conducted by telephone, recorded via Zoom, and transcribed. Results were analyzed and coded in ATLAS.ti utilizing the constant comparative method, with two coders. KEY RESULTS Patients experienced enhanced trust in their healthcare team through electronic communications. Interpersonal and system factors contributed to trust formation. Promptness of reply was the most salient factor in trust formation with a majority desiring same day response. CONCLUSIONS Patients now rely on electronic communication with their healthcare team. Opportunities exist to leverage this to improve health outcomes. Important research in expanded demographic groups, along with ambulatory healthcare redesign, will be necessary to optimize benefits of electronic communication with patients and meet patient expectations.
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Affiliation(s)
- Annie Moore
- Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA. .,University of Colorado School of Medicine, Aurora, USA.
| | - Catia Chavez
- ACCORDS, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Michael P Fisher
- Department of Health Sciences, Towson University, Towson, MD, USA
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22
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Livaudais M, Deng D, Frederick T, Grey-Theriot F, Kroth PJ. Perceived Value of the Electronic Health Record and Its Association with Physician Burnout. Appl Clin Inform 2022; 13:778-784. [PMID: 35981548 PMCID: PMC9388222 DOI: 10.1055/s-0042-1755372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/01/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND There is a common belief that seniority and gender are associated with clinicians' perceptions of the value of electronic health record (EHR) technology and the propensity for burnout. Insufficient evidence exists on the relationship between these variables. OBJECTIVE The aim of this study was to investigate how seniority/years of practice, gender, and screened burnout status are associated with opinions of EHR use on quality, cost, and efficiency of care. METHODS We surveyed ambulatory primary care and subspecialty clinicians at three different institutions to screen for burnout status and to measure their opinions (positive, none, negative, don't know) on how EHR technology has impacted three important attributes of health care: quality, cost, and efficiency of care. We used chi-square tests to analyze association between years of practice (≤10 years or 11+ years), gender, and screened burnout status and the reported attributes. We used a Bonferroni-corrected α = 0.0167 for significance to protect against type I error among multiple comparisons. RESULTS Overall, 281 clinicians responded from 640 that were surveyed with 44% overall response rate. There were no significant associations of years in practice (≤10 years or 11+ years) or gender (p > 0.0167 for both) with any of the health care attributes. Clinicians who screened burnout negative (n = 154, 55%) were more likely to indicate that EHR technology has a positive impact on both the quality (p = 0.0025) and efficiency (p = 0.0003) health care attributes compared with those who screened burnout positive (n = 127, 45%). CONCLUSION Burnout status is significantly associated with clinicians' perceived value of EHR technologies, while years of practice and gender are not. This contests the popular notion that junior clinicians view EHR technology more favorably than their more senior counterparts. Hence, burnout status may be an important factor associated with the overall value clinicians ascribe to EHR technologies.
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Affiliation(s)
- Maria Livaudais
- Department of Public Health, California State University East Bay, California, United States
| | - Derek Deng
- Department of Biomedical Informatics, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, United States
| | - Tracy Frederick
- Department of Biomedical Informatics, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, United States
| | - Francine Grey-Theriot
- Department of Biomedical Informatics, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, United States
| | - Philip J. Kroth
- Department of Biomedical Informatics, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, United States
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23
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Srivastava A, Ayyalasomayajula S, Bao C, Ayabakan S, Delen D. Relationship between electronic health records strategy and user satisfaction: a longitudinal study using clinicians' online reviews. J Am Med Inform Assoc 2022; 29:1577-1583. [PMID: 35640010 DOI: 10.1093/jamia/ocac082] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 05/03/2022] [Accepted: 05/13/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE We investigated how the electronic health records (EHRs) strategies concerning EHR sourcing and vendor switching impact user satisfaction over time. MATERIALS AND METHODS This study used a novel longitudinal dataset created by scraping clinicians' Glassdoor.com reviews on 109 US health systems from 2012 to 2017 and combining it with the Healthcare Information and Management Systems Society (HIMSS) database. We performed sentiment analysis of clinician reviews to construct our main dependent variable, user satisfaction. Our main independent variables, EHR single sourcing and vendor switching, were constructed using the HIMSS database. RESULTS Our fixed effects model showed that as health systems gain more experience with EHR, a single vendor sourcing strategy was associated with higher user satisfaction. Further, there was no significant impact of vendor switching on user satisfaction. CONCLUSION This work adds to the current understanding of EHR-driven clinician burnout using a novel longitudinal dataset. We show how organizational-level EHR strategy can impact user satisfaction and that providers and EHR vendors can mine clinician reviews online to understand their evolving needs and sentiments.
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Affiliation(s)
- Ankita Srivastava
- Department of Information and Process Management, Bentley University, Waltham, Massachusetts, USA
| | - Surya Ayyalasomayajula
- Department of Management Science and Information Systems, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Chenzhang Bao
- Department of Management Science and Information Systems, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Sezgin Ayabakan
- Department of Management Information Systems, Temple University, Philadelphia, Pennsylvania, USA
| | - Dursun Delen
- Department of Management Science and Information Systems, Oklahoma State University, Stillwater, Oklahoma, USA.,Department of Industrial Engineering, Faculty of Engineering and Natural Sciences, Istinye University, Istanbul, Turkey
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24
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Jedwab RM, Hutchinson AM, Manias E, Calvo RA, Dobroff N, Redley B. Change in nurses’ psychosocial characteristics pre- and post-electronic medical record system implementation coinciding with the SARS-CoV-2 pandemic: pre- and post-cross-sectional surveys. Int J Med Inform 2022; 163:104783. [PMID: 35512624 PMCID: PMC9052633 DOI: 10.1016/j.ijmedinf.2022.104783] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/27/2022] [Accepted: 04/24/2022] [Indexed: 01/07/2023]
Abstract
Background The impacts of electronic medical record implementation on nurses, the largest healthcare workforce, have not been comprehensively examined. Negative impacts on nurses have implications for quality of patient care delivery and workforce retention. Objective To investigate changes in nurses’ well-being, intention to stay, burnout, work engagement, satisfaction, motivation and experience using technology pre- and post-implementation of an organisation-wide electronic medical record in Victoria, Australia. Methods The natural experiment comprised an electronic medical record system implementation across six hospitals of a large tertiary healthcare organisation. Cross-sectional surveys were collected pre-electronic medical record implementation prior to the SARS-CoV-2 pandemic in 2019, and 18-months post-electronic medical record implementation during the pandemic in 2020, and findings compared. Results A total of 942 surveys were analysed (550 pre-electronic medical record (response rate 15.52%) and 392 post-electronic medical record (response rate 9.50%)). Post-electronic medical record, nurses’ work satisfaction (r = 0.23, p=<0.001), intention to stay (r = 0.11, p = 0.001) and well-being (r = 0.17, p=<0.001) decreased. Nurses’ perceived competence increased (r = 0.10, p = 0.002) despite decreased autonomy (r = 0.10, p = 0.003). Two of three dimensions of work engagement worsened (vigour r = 0.13, p=<0.001; dedication r = 0.13, p=<0.001) and all dimensions of burnout increased (exhaustion r = 0.08, p = 0.012, cynicism r = 0.07, p = 0.04 and reduced efficiency r = 0.32, p=<0.001). Nurses reported more burnout symptoms (95% CI 4.6–4.7%, p = 0.036), were less engaged (95% CI 49.6–49.9%, p=<0.001) and career trajectory satisfaction decreased (r = 0.15, p=<0.001). Matched data from 52 nurses showed changes in the same direction for all items except career trajectory satisfaction, hence validated findings from the larger unmatched sample. Conclusions Implementation of an electronic medical record immediately followed by the SARS-CoV-2 pandemic was associated with negative changes in nurses’ well-being, intention to stay, burnout, work engagement and satisfaction.
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Affiliation(s)
- Rebecca M Jedwab
- Deakin University School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, 221 Burwood Highway, Burwood, Melbourne, Victoria 3125 Australia; Monash Health Nursing and Midwifery Informatics, 246 Clayton Road, Clayton, Melbourne, Victoria 3168 Australia.
| | - Alison M Hutchinson
- Deakin University School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, 221 Burwood Highway, Burwood, Melbourne, Victoria 3125 Australia; Monash Health, Nursing and Midwifery, 246 Clayton Road, Clayton, Melbourne, Victoria 3168 Australia.
| | - Elizabeth Manias
- Deakin University School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, 221 Burwood Highway, Burwood, Melbourne, Victoria 3125 Australia.
| | - Rafael A Calvo
- Imperial College Faculty of Engineering, Dyson School of Design Engineering, Imperial College Rd, South Kensington, London SW7 9EG, United Kingdom.
| | - Naomi Dobroff
- Monash Health Nursing and Midwifery Informatics, 246 Clayton Road, Clayton, Melbourne, Victoria 3168 Australia; Deakin University School of Nursing and Midwifery, 221 Burwood Highway, Burwood, Melbourne, Victoria 3125 Australia.
| | - Bernice Redley
- Deakin University School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, 221 Burwood Highway, Burwood, Melbourne, Victoria 3125 Australia; Monash Health, Nursing and Midwifery, 246 Clayton Road, Clayton, Melbourne, Victoria 3168 Australia.
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25
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Edgcomb J, Coverdale J, Aggarwal R, Guerrero APS, Brenner AM. Applications of Clinical Informatics to Child Mental Health Care: a Call to Action to Bridge Practice and Training. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2022; 46:11-17. [PMID: 35175570 PMCID: PMC8852995 DOI: 10.1007/s40596-022-01595-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Juliet Edgcomb
- University of California Los Angeles Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA.
| | | | | | | | - Adam M Brenner
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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26
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Faulkenberry JG, Luberti A, Craig S. Electronic health records, mobile health, and the challenge of improving global health. Curr Probl Pediatr Adolesc Health Care 2022; 52:101111. [PMID: 34969611 DOI: 10.1016/j.cppeds.2021.101111] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Technology continues to impact healthcare around the world. This provides great opportunities, but also risks. These risks are compounded in low-resource settings where errors in planning and implementation may be more difficult to overcome. Global Health Informatics provides lessons in both opportunities and risks by building off of general Global Health. Global Health Informatics also requires a thorough understanding of the local environment and the needs of low-resource settings. Forming effective partnerships and following the lead of local experts are necessary for sustainability; it also ensures that the priorities of the local community come first. There is an opportunity for partnerships between low-resource settings and high income areas that can provide learning opportunities to avoid the pitfalls that plague many digital health systems and learn how to properly implement technology that truly improves healthcare.
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Affiliation(s)
- J Grey Faulkenberry
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia.
| | - Anthony Luberti
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia
| | - Sansanee Craig
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia
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27
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Nguyen OT, Turner K, Apathy NC, Magoc T, Hanna K, Merlo LJ, Harle CA, Thompson LA, Berner ES, Feldman SS. Primary care physicians' electronic health record proficiency and efficiency behaviors and time interacting with electronic health records: a quantile regression analysis. J Am Med Inform Assoc 2021; 29:461-471. [PMID: 34897493 PMCID: PMC8800512 DOI: 10.1093/jamia/ocab272] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/05/2021] [Accepted: 11/23/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Oliver T Nguyen
- Corresponding Author: Oliver T. Nguyen, MSHI, Department of Community Health and Family Medicine, University of Florida, College of Medicine, PO Box 100211, Gainesville, FL 32610, USA;
| | - Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida, USA,Department of Oncological Sciences, University of South Florida, Tampa, Florida, USA
| | - Nate C Apathy
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tanja Magoc
- Clinical and Translational Science Institute, University of Florida, Gainesville, Florida, USA
| | - Karim Hanna
- Department of Family Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Lisa J Merlo
- Department of Psychiatry, University of Florida, Gainesville, Florida, USA
| | - Christopher A Harle
- Clinical and Translational Science Institute, University of Florida, Gainesville, Florida, USA,Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | - Lindsay A Thompson
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA,Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Eta S Berner
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sue S Feldman
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, Alabama, USA
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28
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Hilty DM, Armstrong CM, Smout SA, Crawford A, Maheu MM, Drude KP, Chan S, Yellowlees PM, Krupinski EA. PROVIDER TECHNOLOGY, FATIGUE AND WELL-BEING: A SCOPING REVIEW (Preprint). J Med Internet Res 2021; 24:e34451. [PMID: 35612880 PMCID: PMC9178447 DOI: 10.2196/34451] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/20/2022] [Accepted: 04/18/2022] [Indexed: 11/13/2022] Open
Abstract
Background Video and other technologies are reshaping the delivery of health care, yet barriers related to workflow and possible provider fatigue suggest that a thorough evaluation is needed for quality and process improvement. Objective This scoping review explored the relationship among technology, fatigue, and health care to improve the conditions for providers. Methods A 6-stage scoping review of literature (from 10 databases) published from 2000 to 2020 that focused on technology, health care, and fatigue was conducted. Technologies included synchronous video, telephone, informatics systems, asynchronous wearable sensors, and mobile health devices for health care in 4 concept areas related to provider experience: behavioral, cognitive, emotional, and physical impact; workplace at the individual, clinic, hospital, and system or organizational levels; well-being, burnout, and stress; and perceptions regarding technology. Qualitative content, discourse, and framework analyses were used to thematically analyze data for developing a spectrum of health to risk of fatigue to manifestations of burnout. Results Of the 4221 potential literature references, 202 (4.79%) were duplicates, and our review of the titles and abstracts of 4019 (95.21%) found that 3837 (90.9%) were irrelevant. A full-text review of 182 studies revealed that 12 (6.6%) studies met all the criteria related to technology, health care, and fatigue, and these studied the behavioral, emotional, cognitive, and physical impact of workflow at the individual, hospital, and system or organizational levels. Video and electronic health record use has been associated with physical eye fatigue; neck pain; stress; tiredness; and behavioral impacts related to additional effort owing to barriers, trouble with engagement, emotional wear and tear and exhaustion, cognitive inattention, effort, expecting problems, multitasking and workload, and emotional experiences (eg, anger, irritability, stress, and concern about well-being). An additional 14 studies that evaluated behavioral, emotional, and cognitive impacts without focusing on fatigue found high user ratings on data quality, accuracy, and processing but low satisfaction with clerical tasks, the effort required in work, and interruptions costing time, resulting in more errors, stress, and frustration. Our qualitative analysis suggests a spectrum from health to risk and provides an outline of organizational approaches to human factors and technology in health care. Business, occupational health, human factors, and well-being literature have not studied technology fatigue and burnout; however, their findings help contextualize technology-based fatigue to suggest guidelines. Few studies were found to contextually evaluate differences according to health professions and practice contexts. Conclusions Health care systems need to evaluate the impact of technology in accordance with the Quadruple Aim to support providers’ well-being and prevent workload burden, fatigue, and burnout. Implementation and effectiveness approaches and a multilevel approach with objective measures for clinical, human factors, training, professional development, and administrative workflow are suggested. This requires institutional strategies and competencies to integrate health care quality, technology and well-being outcomes.
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Affiliation(s)
- Donald M Hilty
- Department of Psychiatry & Behavioral Sciences, University of California Davis School of Medicine, Sacramento, CA, United States
- Northern California Veterans Affairs Health Care System, Mather, CA, United States
| | - Christina M Armstrong
- Office of Connected Care, Department of Veterans Affairs, Washington, DC, United States
| | - Shelby A Smout
- Virginia Commonwealth University, Richmond, VA, United States
| | - Allison Crawford
- Extension for Community Healthcare Outcomes, Ontario Mental Health at Centre for Addiction and Mental Health, University of Toronto Virtual Mental Health, and Canada Suicide Prevention Service, Toronto, ON, Canada
| | - Marlene M Maheu
- Telebehavioral Health Institute, LLC and Coalition for Technology in Behavioral Science, San Diego, CA, United States
| | - Kenneth P Drude
- Coalition for Technology in Behavioral Science & Ohio Board of Psychology, Dayton, OH, United States
| | - Steven Chan
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine & Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - Peter M Yellowlees
- Department of Psychiatry & Behavioral Sciences, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Elizabeth A Krupinski
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States
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29
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Melnick ER, Fong A, Nath B, Williams B, Ratwani RM, Goldstein R, O’Connell RT, Sinsky CA, Marchalik D, Mete M. Analysis of Electronic Health Record Use and Clinical Productivity and Their Association With Physician Turnover. JAMA Netw Open 2021; 4:e2128790. [PMID: 34636911 PMCID: PMC8511970 DOI: 10.1001/jamanetworkopen.2021.28790] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/08/2021] [Indexed: 12/20/2022] Open
Abstract
Importance Physician turnover takes a heavy toll on patients, physicians, and health care organizations. Survey research has established associations of electronic health record (EHR) use with professional burnout and reduction in professional effort, but these findings are subject to response fatigue and bias. Objective To evaluate the association of physician productivity and EHR use patterns, as determined by vendor-derived EHR use data platforms, with physician turnover. Design, Setting, and Participants This retrospective cohort study was conducted among nonteaching ambulatory physicians at a large ambulatory practice network based in New England. Data were collected from March 2018 to February 2020. Main Outcomes and Measures Physician departure from the practice network; 4 time-based core measures of EHR use, normalized to 8 hours of scheduled clinical time; teamwork, percentage of a physician's orders that are placed by other members of the care team; and productivity measures of patient volume, intensity, and demand. Results Among 335 physicians assessed for eligibility, 314 unique physicians (89.2%) were included in the analysis (123 [39%] women; 100 [32%] aged 45-54 years), with 5663 physician-months of data. The turnover rate was 5.1%/year (32 of 314 physicians). Physicians completed a mean 2.6 appointments/hour (95% CI, 2.5-2.6 appointments/hour) and 206 appointments/month (95% CI, 197-215 appointments/month) with 5.5 hours (95% CI, 5.3-5.8 hours) of EHR time for every 8 hours of scheduled patient time. After controlling for gender, medical specialty, and time, the following variables were associated with turnover: inbox time (odds ratio [OR], 0.70; 95% CI, 0.61-0.82; P < .001), teamwork (OR, 0.68; 95% CI, 0.52-0.87; P = .003), demand (ie, proportion of available appointments filled: OR, 0.49; 95% CI, 0.35-0.70; P < .001), and age 45 to 54 years vs 25 to 34 years (OR, 0.19; 95% CI, 0.04-0.93; P = .04). Conclusions and Relevance In this study, physician productivity and EHR use metrics were associated with physician departure. Prospectively tracking these metrics could identify physicians at high risk of departure who would benefit from early, team-based, targeted interventions. The counterintuitive finding that less time spent on the EHR (in particular inbox management) was associated with physician departure warrants further investigation.
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Affiliation(s)
- Edward R. Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Allan Fong
- MedStar Health National Center for Human Factors in Healthcare, Columbia, Maryland
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Brian Williams
- Northeast Medical Group, Yale–New Haven Health, Stratford, Connecticut
| | - Raj M. Ratwani
- MedStar Health National Center for Human Factors in Healthcare, Columbia, Maryland
| | - Richard Goldstein
- Northeast Medical Group, Yale–New Haven Health, Stratford, Connecticut
| | - Ryan T. O’Connell
- Northeast Medical Group, Yale–New Haven Health, Stratford, Connecticut
| | | | - Daniel Marchalik
- Department of Urology, MedStar Health, Washington, DC
- MedStar Health Research Institute, Hyattsville, Maryland
| | - Mihriye Mete
- MedStar Health Research Institute, Hyattsville, Maryland
- Department of Psychiatry, Georgetown University Medical Center, Washington, DC
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30
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McFarland DC, Hlubocky F. Therapeutic Strategies to Tackle Burnout and Emotional Exhaustion in Frontline Medical Staff: Narrative Review. Psychol Res Behav Manag 2021; 14:1429-1436. [PMID: 34552358 PMCID: PMC8450185 DOI: 10.2147/prbm.s256228] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/02/2021] [Indexed: 12/30/2022] Open
Abstract
Burnout and emotional exhaustion in frontline healthcare workers and their implications for the health of patients, individual clinicians, and organizations are increasingly described among various healthcare settings. Yet therapeutic strategies to address burnout and other work-related conditions are outpaced by innumerable descriptions of burnout prevalence across healthcare disciplines. This review provides a framework that should be helpful in beginning the process of addressing burnout and its related conditions. It begins with an elucidation of key inter-related concepts of work-related conditions that should be considered in the differential diagnosis along with other mental health conditions that are concomitantly elevated in healthcare clinicians (eg, depression and substance abuse) but require a different approach to treatment. Factors that lead to increased resilience, engagement, and thriving in clinical workplaces are considered. While strategies are dichotomized between organizational level interventions and individual or personal interventions to address burnout, the idea of identifying and addressing root causes of burnout and related conditions is highlighted. The efficacy and feasibility of interventions that incorporate mindfulness-based stress reduction, cognitive behavioral strategies, meaning-centered therapy, and compassion training are highlighted as interventions with proven efficacy and durability that should be considered based on work-related stressors and appeal to clinicians.
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Affiliation(s)
- Daniel C McFarland
- Department of Medicine, Northwell Health Cancer Institute, Lenox Hill Hospital, New York, NY, USA
| | - Fay Hlubocky
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, MacLean Center for Clinical Medical Ethics, and the Cancer Research Center, Chicago, IL, USA
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31
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Poon EG, Trent Rosenbloom S, Zheng K. Health information technology and clinician burnout: Current understanding, emerging solutions, and future directions. J Am Med Inform Assoc 2021; 28:895-898. [PMID: 33871016 DOI: 10.1093/jamia/ocab058] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 02/01/2023] Open
Affiliation(s)
- Eric G Poon
- Duke Health Technology Solutions, Duke University Health System, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - S Trent Rosenbloom
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Department of Pediatrics & Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kai Zheng
- Department of Informatics, University of California, Irvine, Irvine, California, USA
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