Novel Nonproprietary Measures of Ambulatory Electronic Health Record Use Associated with Physician Work Exhaustion

Abstract

Background Accumulating evidence indicates an association between physician electronic health record (EHR) use after work hours and occupational distress including burnout. These studies are based on either physician perception of time spent in EHR through surveys which may be prone to bias or by utilizing vendor-defined EHR use measures which often rely on proprietary algorithms that may not take into account variation in physician's schedules which may underestimate time spent on the EHR outside of scheduled clinic time. The Stanford team developed and refined a nonproprietary EHR use algorithm to track the number of hours a physician spends logged into the EHR and calculates the Clinician Logged-in Outside Clinic (CLOC) time, the number of hours spent by a physician on the EHR outside of allocated time for patient care. Objective The objective of our study was to measure the association between CLOC metrics and validated measures of physician burnout and professional fulfillment. Methods Physicians from adult outpatient Internal Medicine, Neurology, Dermatology, Hematology, Oncology, Rheumatology, and Endocrinology departments who logged more than 8 hours of scheduled clinic time per week and answered the annual wellness survey administered in Spring 2019 were included in the analysis. Results We observed a statistically significant positive correlation between CLOC ratio (defined as the ratio of CLOC time to allocated time for patient care) and work exhaustion (Pearson's r = 0.14; p = 0.04), but not interpersonal disengagement, burnout, or professional fulfillment. Conclusion The CLOC metrics are potential objective EHR activity-based markers associated with physician work exhaustion. Our results suggest that the impact of time spent on EHR, while associated with exhaustion, does not appear to be a dominant factor driving the high rates of occupational burnout in physicians.

Using event logs to observe interactions with electronic health records: an updated scoping review shows increasing use of vendor-derived measures

“…Most studies were observational (91 articles) while a minority were experimental (11 articles). Nine of the observational studies examined associations between EHR use and an outcome in the cohort of observed users such as burnout, 6 , 7 , 33 , 46 , 47 , 67 , 69 turnover, 28 and stress. 71 Three observational studies examined associations between EHR use and clinical outcomes including next-day discharge, 78 length of stay, 84 and speed of consult response.…”

“… 4 , 6 , 19 , 25 , 27 , 29 , 32 , 34 , 36 , 39 , 40 , 42 , 48 , 49 , 51 , 53 , 55 , 66 , 69–71 An overlapping set of 22 articles, including 9 that also reported time period-based measures, reported at least 1 measure based on clinician schedules. 4 , 6 , 19 , 27 , 28 , 30 , 34 , 37 , 38 , 40 , 41 , 43 , 44 , 47–50 , 67 , 69 , 72 , 77 , 119 These included time outside scheduled hours on days with appointments, time on days without appointments, and time after the patient checked out. These schedule-based measures differed in whether they (1) measured active EHR use or all time logged into the EHR, (2) included mid-day meetings or breaks in scheduled hours, or (3) included the 30 or 60 min before and after the first and last appointment of the day in scheduled hours.…”

“…While 70 articles measured a duration of time, 2–4 , 6 , 7 , 19 , 24–62 , 66–73 , 76 , 77 , 79–81 , 83 , 92–96 , 98 , 102 , 108 , 109 , 111 , 119 12 of these measured a duration between 2 specific points in time (e.g., duration of an appointment, or shift), 60 , 68 , 76 , 80 , 81 , 83 , 92–94 , 96 , 102 , 111 leaving 58 articles which measured a duration of active EHR use. 2–4 , 6 , 7 , 19 , 24–59 , 61 , 62 , 66 , 67 , 69–73 , 77 , 79 , 95 , 98 , 108 , 109 , 119 Of these 58 articles, 34 described (or referenced an article that described) how active use was defined. 3 , 4 , 19 , 24–29 , 31 , 32 , 35 , 39 , <...…”

Perceived Value of the Electronic Health Record and Its Association with Physician Burnout

“…3 The comprehensive adoption of electronic health records (EHRs) has triggered many unintended consequences, including those contributing to physician burnout. [3][4][5][6][7][8][9][10] A study conducted with 1,800 physicians from Rhode Island found that burnout prevalence was considerably higher among physicians who used EHRs, with 27.2% of the group reporting one or more burnout symptoms, compared with 13.6% of physicians who did not use EHRs. 2,11 Another study showed that spending more than 6 hours per week on afterhours EHR work was strongly associated with the perception that EHR use affects both work-life balance and burnout.…”

“…2,11 Another study showed that spending more than 6 hours per week on afterhours EHR work was strongly associated with the perception that EHR use affects both work-life balance and burnout. 12 Sinha et al showed how EHR use correlates with physician exhaustion, 9 Marmor et al showed how time spent on EHR use during the day had an inverse relationship with patient satisfaction scores, 13 and Frintner et al showed how EHR use by pediatricians was associated with worse work-life balance, stress in balancing responsibilities, and less career and life satisfaction. 14 Studies have also shown differences between male and female clinicians on various factors associated with EHR use, including stress, frustration, and burnout rates.…”