Unintended consequences of the electronic medical record on physicians in training and their mentors

Best Practices for Technology in Clinical Social Work and Mental Health Professions to Promote Well-being and Prevent Fatigue

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.

Surgeon Burnout and Usage of Personal Communication Devices: Examining the Technology "Empowerment/Enslavement Paradox"

INTRODUCTION

Access to patients' electronic medical records (EMRs) on personal communication devices (PCDs) is beneficial but can negatively impact surgeons. In a recent op-ed, Cohen et al. explored this technology "empowerment/enslavement paradox" and its potential effect on surgeon burnout. We examined if there is a relationship between accessing EMRs on PCDs and surgeon burnout.

METHODS

This was a cohort study with retrospective and prospective arms. Trainees and attendings with a background in general surgery completed the Maslach Burnout Index for Medical Personnel, a validated survey scored on three areas of burnout (emotional exhaustion, depersonalization, and low personal accomplishment). Data on login frequency to EMRs on PCDs over the previous 6 mo were obtained. Pearson correlation coefficients were calculated to determine if burnout and login frequency were associated.

RESULTS

There were 52 participants included. Residents were 61.5% (n = 32) of participants. The mean login frequency over 6 mo was 431.0 ± 323.9. The mean scores (out of 6) for emotional exhaustion, depersonalization, and personal accomplishment were 2.3 ± 1.1, 1.9 ± 1.2, and 4.9 ± 0.8, respectively. There was no correlation between burnout and logins. Residents had higher median depersonalization scores (2.3 versus 1.2, P = 0.03) and total logins (417.5 versus 210.0, P < 0.001) than attendings. Participants who overestimated logins had higher median emotional exhaustion and depersonalization scores than those who underestimated (2.6 versus 1.4, P = 0.03, and 2.4 versus 0.8, P = 0.003, respectively).

CONCLUSIONS

Using EMRs on PCDs is common, but frequency of logins did not correlate with burnout scores in this study. However, perception of increased workload may contribute to experiencing burnout.

Perspectives on the Intersection of Electronic Health Records and Health Care Team Communication, Function, and Well-being

Importance

Understanding of the interplay between the electronic health record (EHR), health care team relations, and physician well-being is currently lacking. Approaches to cultivate interpersonal interactions may be necessary to complement advancements in health information technology with high-quality team function.

Objective

To examine ways in which the EHR, health care team functioning, and physician well-being intersect and interact.

Design, Setting, and Participants

Secondary qualitative analysis of semistructured interview data from 2 studies used keyword-in-context approaches to identify excerpts related to teams. Thematic analysis was conducted using pattern coding, then organized using the relationship-centered organization model. Two health care organizations in California from March 16 to October 13, 2017, and February 28 to April 21, 2022, participated, with respondents including attending and resident physicians.

Main Outcome and Measures

Across data sets, themes centered around the interactions between the EHR, health care team functioning, and physician well-being. The first study data focused on EHR-related distressing events and their role in attending physician and resident physician emotions and actions. The second study focused on EHR use and daily EHR irritants.

Results

The 73 respondents included attending physicians (53 [73%]) and resident physicians (20 [27%]). Demographic data were not collected. Participants worked in ambulatory specialties (33 [45%]), hospital medicine (10 [14%]), and surgery (10 [14%]). The EHR was reported to be the dominant communication modality among all teams. Interviewees indicated that the EHR facilitates task-related communication and is well suited to completing simple, uncomplicated tasks. However, EHR-based communication limited the rich communication and social connection required for building relationships and navigating conflict. The EHR was found to negatively impact team function by promoting disagreement and introducing areas of conflict into team relationships related to medical-legal pressures, role confusion, and undefined norms around EHR-related communication. In addition, interviewees expressed that physician EHR-related distress affects interactions within the team, eroding team well-being.

Conclusions and Relevance

In this study, the EHR supported task-oriented and efficient communication among team members to get work done and care for patients; however, participants felt that the technology shifts attention away from the human needs of the care team that are necessary for developing relationships, building trust, and resolving conflicts. Interventions to cultivate interpersonal interactions and team function are necessary to complement the efficiency benefits of health information technology.

Some Things Change, Some Things Stay the Same: Trends in Canadian Education in Paediatric Cardiology and the Cardiac Sciences

Education in paediatric cardiology has evolved along with clinical care. The availability and application of new technologies in education, in particular, have had a significant impact. Artificial intelligence; virtual, augmented, and mixed reality learning tools; and gamification of learning have all resulted in new opportunities for today's trainees compared with those of the past. A new training model is also being used. Though currently focused on residency education, competency-based medical education is also being applied to undergraduate education in some Canadian medical schools. Competency-based medical education offers a more transparent relationship between education and physicians' social contract with society. It provides greater accountability for programmes and learners to teach and learn the skills required to function as competent specialists. However, it has not come without challenges. Coincident with the application of this model for learners, there has been increased educational accountability for physicians in practice and for the institutions training them. Despite these changes, some things have remained the same. On the positive side, the importance of good clinical teachers to effective learning remains constant. Unfortunately, the mistreatment of learners within our education system also remains and is perhaps the most important challenge facing medical education in Canada today. Learning to be better teachers and learner advocates is an important goal for all of those involved in educating Canadian medical learners.

Medical school curriculum in the digital age: perspectives of clinical educators and teachers

BACKGROUND

There is a need to reexamine Singapore's medical school curricula in light of the increasing digitalization of healthcare. Notwithstanding Singapore's digital competitiveness, there is a perceived gap in preparing its medical students for the digital age. Furthermore, limited research has evaluated the extent to which skills in using digital technologies should be taught to medical students in Asian medical schools to prepare them for future clinical practice- a gap that is filled by this study. Using Singapore as a case study, it explores the views of some local clinical educators and teachers towards the need to impart skills in digital technologies to medical students. It also offers recommendations on ways to balance the clinicians' concerns about these technologies with the digital competencies needed for clinical practice.

METHODS

Findings were drawn from individual interviews with 33 clinical educators and teachers from Singapore's public and private healthcare sectors. They were recruited using purposive sampling. Data were interpreted using qualitative thematic analysis.

RESULTS

Participants included vice deans of education from all three local medical schools and senior consultants from a wide variety of disciplines. Overall, they acknowledged two benefits of equipping students with skills in digital technologies including promoting the culture of innovation and improving work efficiency. However, they also highlighted four main concerns of imparting these skills: (i) erosion of basic clinical skills, (ii) neglect of a generalist approach to healthcare characterized by holistic management of patients, inter-professional collaboration, and commitment to breadth of practice within each specialty, (iii) rapid pace of technological advances, and (iv) de-personalisation by technology.

CONCLUSIONS

The findings show that medical students in Singapore would benefit from a curriculum that teaches them to use digital technologies alongside core clinical skills.

Restricted use of copy and paste in electronic health records potentially improves healthcare quality

ABSTRACT

The copy-and-paste feature is commonly used for clinical documentation, and a policy is needed to reduce overdocumentation. We aimed to determine if the restricted use of copy and paste by doctors could improve inpatient healthcare quality.Clinical documentation in an inpatient dataset compiled from 2016 to 2018 was used. Copied-and-pasted text was detected in word templates using natural language programming with a threshold of 70%. The prevalence of copying and pasting after the policy introduction was accessed by segmented regression for trend analysis. The rate of readmission for the same disease within 14 days was assessed to evaluate inpatient healthcare quality, and the completion of discharge summary notes within 3 days was assessed to determine the timeliness of note completion. The relationships between these factors were used cross-correlation to detect lag effect. Poisson regression was performed to identify the relative effect of the copy and paste restriction policy on the 14-day readmission rate or the discharge note completion rate within 3 days.The prevalence of copying and pasting initially decreased, then increased, and then flatly decreased. The cross-correlation results showed a significant correlation between the prevalence of copied-and-pasted text and the 14-day readmission rate (P < .001) and a relative risk of 1.105 (P < .005), with a one-month lag. The discharge note completion rate initially decreased and not affected long term after restriction policy.Appropriate policies to restrict the use of copying and pasting can lead to improvements in inpatient healthcare quality. Prospective research with cost analysis is needed.

Participatory Design of a Medication Module in an Electronic Medical Record for Paediatric Palliative Care: A Think-Aloud Approach with Nurses and Physicians

BACKGROUND

Electronic medical records (EMRs) play a key role in improving documentation and quality of care in paediatric palliative care (PPC). Inadequate EMR design can cause incorrect prescription and administration of medications. Due to the fact of complex diseases and the resulting high level of medical complexity, patients in PPC are vulnerable to medication errors. Consequently, involving users in the development process is important. Therefore, the aim of this study was to evaluate the acceptance of a medication module from the perspective of potential users in PPC and to involve them in the development process.

METHODS

A qualitative observational study was conducted with 10 nurses and four physicians using a concurrent think-aloud protocol and semi-structured qualitative interviews. A qualitative content analysis was applied based on a unified theory of acceptance and use of technology.

RESULTS

Requirements from the user's perspective could be identified as possible influences on acceptance and actual use. Requirements were grouped into the categories "performance expectancies" and "effort expectancies".

CONCLUSIONS

The results serve as a basis for further development. Attention should be given to the reduction of display fragmentation, as it decreases cognitive load. Further approaches to evaluation should be taken.

Assessment of Entrustable Professional Activities Using a Web-Based Simulation Platform During Transition to Emergency Medicine Residency: Mixed Methods Pilot Study

BACKGROUND

The 13 core entrustable professional activities (EPAs) are key competency-based learning outcomes in the transition from undergraduate to graduate medical education in the United States. Five of these EPAs (EPA2: prioritizing differentials, EPA3: recommending and interpreting tests, EPA4: entering orders and prescriptions, EPA5: documenting clinical encounters, and EPA10: recognizing urgent and emergent conditions) are uniquely suited for web-based assessment.

OBJECTIVE

In this pilot study, we created cases on a web-based simulation platform for the diagnostic assessment of these EPAs and examined the feasibility and acceptability of the platform.

METHODS

Four simulation cases underwent 3 rounds of consensus panels and pilot testing. Incoming emergency medicine interns (N=15) completed all cases. A maximum of 4 "look for" statements, which encompassed specific EPAs, were generated for each participant: (1) performing harmful or missing actions, (2) narrowing differential or wrong final diagnosis, (3) errors in documentation, and (4) lack of recognition and stabilization of urgent diagnoses. Finally, we interviewed a sample of interns (n=5) and residency leadership (n=5) and analyzed the responses using thematic analysis.

RESULTS

All participants had at least one missing critical action, and 40% (6/15) of the participants performed at least one harmful action across all 4 cases. The final diagnosis was not included in the differential diagnosis in more than half of the assessments (8/15, 54%). Other errors included selecting incorrect documentation passages (6/15, 40%) and indiscriminately applying oxygen (9/15, 60%). The interview themes included psychological safety of the interface, ability to assess learning, and fidelity of cases. The most valuable feature cited was the ability to place orders in a realistic electronic medical record interface.

CONCLUSIONS

This study demonstrates the feasibility and acceptability of a web-based platform for diagnostic assessment of specific EPAs. The approach rapidly identifies potential areas of concern for incoming interns using an asynchronous format, provides feedback in a manner appreciated by residency leadership, and informs individualized learning plans.

PROVIDER TECHNOLOGY, FATIGUE AND WELL-BEING: A SCOPING REVIEW (Preprint)

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.

Otolaryngology resident clinic participation and attending electronic health record efficiency-A user activity logs study

OBJECTIVES

In an era of increasing electronic health record (EHR) use monitoring and optimization, this study aims to quantify resident contributions and measure the effect of otolaryngology resident coverage in clinic on attending otolaryngologist EHR usage.

METHODS

In one academic otolaryngology department, monthly attending provider efficiency profile metrics, data collected by the EHR vendor (Epic Systems Corporation) between January and June 2019 were accessed. Using weekly resident schedules, resident coverage of attending outpatient clinics was categorized by junior (post-graduate year [PGY] 1-3) and senior levels (PGY-4 through fellows) and correlated with attending EHR metrics using linear mixed effect models.Results: Thirteen attending otolaryngologists on average spent 58.8 minutes per day interacting with the EHR. In modeling, one day of trainee clinic coverage was associated with a 22 minutes reduction (95% CI [-37, -6]) in total daily attending EHR time and a 12 minutes reduction (95% CI [-21, -3]) in per day note time (P < .05). When stratifying by trainee level, senior coverage was associated with significantly reduced total daily time in EHR, per day time in clinical review, notes, and orders, as well as per appointment time in notes and clinical review (P < .05). Junior coverage was only associated with reduced per day note time (P < .05).

CONCLUSIONS

Increasing resident clinic coverage was inversely related to attending time spent in the EHR and writing notes. Resident contributions to EHR workflows and hospital system productivity should continue to be studied and considered in EHR use measurement studies.

LEVEL OF EVIDENCE

Level 4.

Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review

BACKGROUND

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OBJECTIVE

Electronic health records (EHRs) are linked with documentation burden resulting in clinician burnout. While clear classifications and validated measures of burnout exist, documentation burden remains ill-defined and inconsistently measured. We aim to conduct a scoping review focused on identifying approaches to documentation burden measurement and their characteristics.

MATERIALS AND METHODS

Based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews (ScR) guidelines, we conducted a scoping review assessing MEDLINE, Embase, Web of Science, and CINAHL from inception to April 2020 for studies investigating documentation burden among physicians and nurses in ambulatory or inpatient settings. Two reviewers evaluated each potentially relevant study for inclusion/exclusion criteria.

RESULTS

Of the 3482 articles retrieved, 35 studies met inclusion criteria. We identified 15 measurement characteristics, including 7 effort constructs: EHR usage and workload, clinical documentation/review, EHR work after hours and remotely, administrative tasks, cognitively cumbersome work, fragmentation of workflow, and patient interaction. We uncovered 4 time constructs: average time, proportion of time, timeliness of completion, activity rate, and 11 units of analysis. Only 45.0% of studies assessed the impact of EHRs on clinicians and/or patients and 40.0% mentioned clinician burnout.

DISCUSSION

Standard and validated measures of documentation burden are lacking. While time and effort were the core concepts measured, there appears to be no consensus on the best approach nor degree of rigor to study documentation burden.

CONCLUSION

Further research is needed to reliably operationalize the concept of documentation burden, explore best practices for measurement, and standardize its use.

The Electronic Medical Record and Nephrology Fellowship Education in the United States: An Opinion Survey

BACKGROUND AND OBJECTIVES

An unintended consequence of electronic medical record use in the United States is the potential effect on graduate physician training. We assessed educational burdens and benefits of electronic medical record use on United States nephrology fellows by means of a survey.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used an anonymous online opinion survey of all United States nephrology program directors (n=148), their faculty, and fellows. Program directors forwarded survey links to fellows and clinical faculty, indicating to how many they forwarded the link. The three surveys had parallel questions to permit comparisons.

RESULTS

Twenty-two percent of program directors (n=33) forwarded surveys to faculty (n=387) and fellows (n=216; 26% of United States nephrology fellows). Faculty and fellow response rates were 25% and 33%, respectively; 51% of fellows agreed/strongly agreed that the electronic medical record contributed positively to their education. Perceived positive effects included access flexibility and ease of obtaining laboratory/radiology results. Negative effects included copy-forward errors and excessive, irrelevant documentation. Electronic medical record function was reported to be slow, disrupted, or completely lost monthly or more by >40%, and these were significantly less likely to agree that the electronic medical record contributed positively to their education. Electronic medical record completion time demands contributed to fellow reluctance to do procedures (52%), participate in conferences (57%), prolong patient interactions (74%), and do patient-directed reading (55%). Sixty-five percent of fellows reported often/sometimes exceeding work-hours limits due to documentation time demands; 85% of faculty reported often/sometimes observing copy-forward errors. Limitations include potential nonresponse and social desirability bias.

CONCLUSIONS

Respondents reported that the electronic medical record enhances fellow education with efficient and geographically flexible patient data access, but the time demands of data and order entry reduce engagement in educational activities, contribute to work-hours violations, and diminish direct patient interactions.

Neurological Dashboards and Consultation Turnaround Time at an Academic Medical Center

BACKGROUND

Neurologists perform a significant amount of consultative work. Aggregative electronic health record (EHR) dashboards may help to reduce consultation turnaround time (TAT) which may reflect time spent interfacing with the EHR.

OBJECTIVES

This study was aimed to measure the difference in TAT before and after the implementation of a neurological dashboard.

METHODS

We retrospectively studied a neurological dashboard in a read-only, web-based, clinical data review platform at an academic medical center that was separate from our institutional EHR. Using our EHR, we identified all distinct initial neurological consultations at our institution that were completed in the 5 months before, 5 months after, and 12 months after the dashboard go-live in December 2017. Using log data, we determined total dashboard users, unique page hits, patient-chart accesses, and user departments at 5 months after go-live. We calculated TAT as the difference in time between the placement of the consultation order and completion of the consultation note in the EHR.

RESULTS

By April 30th in 2018, we identified 269 unique users, 684 dashboard page hits (median hits/user 1.0, interquartile range [IQR] = 1.0), and 510 unique patient-chart accesses. In 5 months before the go-live, 1,434 neurology consultations were completed with a median TAT of 2.0 hours (IQR = 2.5) which was significantly longer than during 5 months after the go-live, with 1,672 neurology consultations completed with a median TAT of 1.8 hours (IQR = 2.2; p = 0.001). Over the following 7 months, 2,160 consultations were completed and median TAT remained unchanged at 1.8 hours (IQR = 2.5).

CONCLUSION

At a large academic institution, we found a significant decrease in inpatient consult TAT 5 and 12 months after the implementation of a neurological dashboard. Further study is necessary to investigate the cognitive and operational effects of aggregative dashboards in neurology and to optimize their use.