How does the electronic health record (EHR) drive burnout among doctors? As a physician, let me count the ways.
By understanding this, we can develop countermeasures to lower the impact and reduce the risk of physician burnout.
We’ve all seen the studies that show that for every hour we spend with a patient, we spend two hours on administrative work — and we take hours of work home with us each night. But as we’ll see, it’s not all just about the additional work that the EHR brings. Burnout is more than being exhausted due to overwork.
We’ll start by reviewing the six drivers of burnout:
- Work overload: too much to do your work well and maintain work-life balance.
- Lack of control: lack of a say over placing limits on your work or over how you do the work.
- Insufficient reward: not just money, but professional recognition and the satisfaction of connecting with patients.
- Breakdown of community: the relationships among co-workers and colleagues that provide support in tough times.
- Absence of fairness: the sense that expectations and support are different for you than others, and worse if decisions are made without communication.
- Mismatch of values: a disconnection in priorities between you and your organization.
The EHR actually does play a role in exacerbating burnout in all six key drivers. Let me review one or two factors for each of the six drivers.
1.) Work overload. This one is pretty easy. It takes two to six times as long to perform key tasks in the EHR compared to how we worked with paper charts. Rather than scribbling key notes into a written progress note and being done — or dictating very quickly because the transcriptionist could understand your rapid speech — keyboarding your notes, using templates with drop-down menus, or using speech recognition all slow you down. A prescription refill used to take five seconds of the doctor’s time (a nurse would hand you the slip and say, “Sign here.”). But now, it can take 20 to 200 seconds of clicking through the inbox, reviewing chart notes and entering orders, depending on the workflow and any questions that arise. There are many more examples.
There are good ways to deal with this: team care, scribes, Rx refill protocols by RNs, etc. Doctors need a supportive leadership team to give them the time, expertise, and financial support to develop these.
2.) Lack of control. This is another easy mark. You have no control over the layout of the screens (user interface) or how you are supposed to enter data. You may have choices of different approaches, but you likely did not have input into how those choices were or are designed. Alerts pop up when not needed and “meaningful use” attestations are required. While well-intentioned for the most part, the bulk of this is without value in improving quality and safety and negatively impacts the physician-patient relationship.
This can be mitigated by having teams of physicians partner with EHR technical staff to redesign user interfaces and develop appropriate guidance tools for alerts, coding aids, and expediting requirements. Giving physicians 10 to 20 percent of their time to work on issues that are most important to them also makes a difference. For many physicians, work to optimize the EHR will qualify.
3.) Insufficient reward. Physicians commit the decade of their 20s to develop the educational background and procedural skills needed to confidently and competently practice medicine. Most of us see this as the price of entry to experience the personal rewards of having healing relationships with our patients. As those relationships come under increasing strain, the reward is eroded. The joy of practicing medicine is gone.
This can be addressed by clinic leaders partnering with physicians to redesign workflows that foster connections with our patients. In an ideal world, the team working on this would include all stakeholders — including some patients.
4.) Breakdown of community. Doctors and nurses spend less time talking to each other these days. Rather than calling a colleague regarding a consult, we enter the referral order. Rather than discussing the patient with the nurse, we type in our orders. We sit side by side doing data entry and interacting with our machines without interacting with each other. Our days become a constant rush to get to the next patient, and we feel as though we can’t stop for some idle (community-building) chitchat. The doctors’ lounge is much emptier than before.
This can be improved by working as teams in the clinic or on the ward, calling a consult to discuss the case, and finding administration-supporting ways for physicians to get together at lunch or after hours.
5.) Absence of fairness. It’s not fair that the highest trained and compensated individual in the organization is forced to do the most mundane work (data entry) when similarly trained professionals in other fields have far more assistance. Decisions made by the administration regarding EHR support often are hard to rationalize and seem to be directed at physicians, or one department, if not well-communicated. As things seem more unfair, it’s harder to trust the administration and avoid an “us versus them” relationship.
Physicians are deeply committed to providing quality patient care. Administrators are deeply committed to keeping their organizations financially viable.
The options to fix this depend on improving communications and understanding between physicians and organizational leadership. Developing a regular forum in which physicians and leaders come together is key. We can use this to listen to each other and collaborate on solutions. Doctors need to participate in strategic planning, budgeting and managing operations with a commitment to the good of the organization. This may seem overly optimistic, but it is key to addressing a deep cause of burnout.
6.) Mismatch of values. Physicians are deeply committed to their mission of providing quality patient care. Administrators are deeply committed to keeping their organizations financially viable as a baseline and, ideally, continuously improving on all key initiatives. These can be aligned with the proper leadership, but they often come into conflict when resources are reduced in response to financial challenges — which creates tension between physicians and the administration. Because EHR is a major capital expense and is intricately involved in nearly every patient care workflow, it is embroiled in values conflicts that drive burnout.
This can be addressed with some of the same approaches used to address fairness issues. In addition, spending time shadowing each other (administrators following doctors as they care for patients to see the frustrations the EHR causes, and physicians attending a budget session to understand the financial constraints driving EHR investment decisions) will do a lot to foster empathy between the groups. This can set the stage for jointly developing mission, vision and values statements that are not simply platitudes, but as tools to guide decisionmaking, especially the tough decisions that are often EHR-related.
As we better understand these issues, we can develop a broad array of opportunities to reduce burnout. The key is opening our minds to the causes — and to new ways to collaborate with others in seeking the solutions.
Paul F. DeChant, M.D., is deputy chief health officer with Simpler Healthcare/IBM Watson Health in California. He provides executive coaching and thought leadership on preventing physician burnout. During his tenure as CEO of the Sutter Gould Medical Foundation, the organization achieved Consumer Reports’ highest overall rating of 170 medical groups in California for two years in a row, while physician satisfaction rose to the 87th percentile. This piece originally appeared in KevinMD.com and is used by permission.