Association of Electronic Health Record Use With Physician Fatigue and Efficiency

Abstract

IMPORTANCE The use of electronic health records (EHRs) is directly associated with physician burnout. An underlying factor associated with burnout may be EHR-related fatigue owing to insufficient user-centered interface design and suboptimal usability. OBJECTIVE To examine the association between EHR use and fatigue, as measured by pupillometry, and efficiency, as measured by mouse clicks, time, and number of EHR screens, among intensive care unit (ICU) physicians completing a simulation activity in a prominent EHR. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional, simulation-based EHR usability assessment of a leading EHR system was conducted from March 20 to April 5, 2018, among 25 ICU physicians and physician trainees at a southeastern US academic medical center. Participants completed 4 simulation patient cases in the EHR that involved information retrieval and task execution while wearing eye-tracking glasses. Fatigue was quantified through continuous eye pupil data; EHR efficiency was characterized through task completion time, mouse clicks, and EHR screen visits. Data were analyzed from June 1, 2018, to August 31, 2019. MAIN OUTCOMES AND MEASURES Primary outcomes were physician fatigue, measured by pupillometry (with lower scores indicating greater fatigue), and EHR efficiency, measured by task completion times, number of mouse clicks, and number of screens visited during EHR simulation. RESULTS The 25 ICU physicians (13 women; mean [SD] age, 33.2 [6.1] years) who completed a simulation exercise involving 4 patient cases (mean [SD] completion time, 34:43 [11:41] minutes) recorded a total of 14 hours and 27 minutes of EHR activity. All physician participants experienced physiological fatigue at least once during the exercise, and 20 of 25 participants (80%) experienced physiological fatigue within the first 22 minutes of EHR use.

The burden of the digital environment: a systematic review on organization-directed workplace interventions to mitigate physician burnout

“… 4 , 5 Physicians experience high fatigue with short, continuous periods of EHR use, which is also associated with inefficiency of EHR use (ie, more clicks and more time) on subsequent cases. 6 The association of burnout with EHR design and usability has been identified, 7 in addition to the clerical burden of technology on workload (both cognitive and physical) and its associated workflows. 8 , 9 Despite the general acknowledgement that the evolving digital environment using health information technologies (eg, patient portals, clinical notes, computerized order-entry, electronic prescribing) for both regulatory and administrative purposes has altered physicians’ practice, interventions to lessen associated burnout have not been well characterized.…”

How effective are clinical decision support systems?

“…This lack of efficacy likely reflects the challenges of developing innovative, safe, and effective clinical decision support systems within commercial electronic health record platforms. First, well documented problems with usability23 and widespread dissatisfaction among clinicians using4 electronic health records might be a barrier to effective clinical decision support. Second, the underlying software architecture of electronic health records constrains options for the design of clinical decision support systems5 and might not be the best site for innovative approaches 6…”

Electronic display of a patient treatment over time: a perspective on clinicians’ burn-out

“…[1][2][3] Oncology clinicians seem to be particularly affected. [4][5][6][7][8] It is now acknowledged that use of electronic health record systems (EHRs), contributes to clinicians' dissatisfaction and burn-out [9][10][11][12][13] predominantly via the excessive requirements posed on clinicians for data entry. 14 A recent special issue in the Journal of the American Medical Informatics Association included a number of papers that focused on quantitative measures of time spent on data entry and numbers of entries, [15][16][17][18] all demonstrating that quantity of work is a key contributor to burn-out.…”