Study: EHRs Contribute to Family Physician Stress, Burnout

January 16, 2019 12:06 pm Michael Devitt – In theory, health information technology is supposed to improve communication among health care professionals, make it easier to access and review patient data, cut through the billing and insurance bureaucracy, and enhance the overall health experience for physicians and patients alike.

Survey Methods and Outcomes

The researchers used survey data from the Rhode Island Department of Health to conduct their analysis. Since 2009, the health department has surveyed practicing physicians about health IT use and the effect of technology on workflow, patient care and job satisfaction. In 2017, the department updated its survey to include questions about health IT-related stress, specifically focusing on stress related to EHR use.

The survey was sent to nearly 4,200 physicians with active Rhode Island licenses; resident and fellow physicians were excluded. A variety of demographic and practice data were obtained, including the respondent's age, gender, specialty type, practice setting and size, whether they provide primary care, whether they use an EHR, and whether they use a medical scribe.

The main study outcome was the prevalence of self-reported burnout, which was tracked using a single question that rated burnout symptoms on a five-point scale. The researchers also tracked health IT-related stress, which was defined by reporting one or more of the following measures:

• having insufficient time for documentation while at work,
  
• spending moderately high or excessive amounts of time on the EHR while at home, and
  
• agreeing with the statement that EHRs add to the frustration of one's day.

Respondents who used an EHR answered additional questions, such as whether they had remote access to the EHR (and if so, whether they used it remotely), and under what circumstances they used the EHR most often.

Study Findings

Almost 43 percent of the physicians (1,792) returned the survey. Of those, nearly 26 percent reported one or more symptoms of burnout.

Overall, family physicians reported a higher prevalence of burnout than physicians in any other specialty, with 35.7 percent of FPs experiencing at least one burnout symptom. Similar rates were reported by dermatologists (34.6 percent) and hospitalists (30.8 percent), while anesthesiologists had the lowest prevalence (14.3 percent).

Burnout prevalence also was considerably higher among physicians who used EHRs, with 27.2 percent of that group reporting one or more burnout symptoms, compared with 13.6 percent of physicians who did not use an EHR.

More than 91 percent of respondents reported using an EHR. Of those, nearly 70 percent reported at least one measure of health IT-related stress. Family physicians had the third-highest prevalence of health IT-related stress (83.2 percent), just behind orthopedic surgery and general internal medicine.

Although EHRs made some parts of a physician's job easier, the negatives often outweighed the positives. More than three-quarters of physicians who used EHRs said they improve the billing process, and more than 69 percent thought EHRs improve communication among physicians and staff. But only about half of physicians thought EHRs improved patient care or clinical workflow, and less than 30 percent reported that they improve job satisfaction.

In fact, aggravation with EHRs was the most commonly cited stress measure across almost every specialty, with more than 64 percent of physicians who used EHRs agreeing or strongly agreeing that they add to one's daily frustration level. More than 46 percent reported having insufficient time for documentation, and nearly 40 percent spent moderately high or excessive time on EHRs at home.

Of the respondents who reported being primary care physicians, more than one-third stated that they experienced all three health IT stress measures. The highest percentage was found in internists (39.5 percent), followed closely by family physicians (37.0 percent) and pediatricians (33.6 percent).

In contrast, less than 10 percent of anesthesiologists, radiologists and hospitalists reported experiencing all three stress measures. Based on the wide discrepancy among specialties, principal study author Rebekah Gardner, M.D., an associate professor of medicine at Brown University's Warren Alpert Medical School in Providence, advised that taking a one-size-fits-all approach to addressing physician burnout isn't the best way to go.

"To me, it's a signal to health care organizations that if they're going to fix burnout, one solution is not going to work for all physicians in their organization," Gardner said in a press release.(news.brown.edu) "They need to look at the physicians by specialty and make sure that if they are looking for a technology-related solution, then that's really the problem in their group."

Clear Links Between Stress and Burnout

Regardless of specialty, the researchers found that after adjusting for demographics and other variables, there were clear associations between burnout and each of the health IT-related stress measures. Specifically, they found that

• physicians who reported not having enough time for EHR documentation were 2.81 times more likely to show symptoms of burnout than those who reported having sufficient time;
  
• physicians who spent moderately high or excessive amounts of time on their EHR at home were 1.93 times more likely to show burnout symptoms than those who spent minimal or no time on the EHR at home; and
  
• physicians who agreed that EHRs add to the frustration of the day were 2.44 times more likely to show burnout symptoms than those who disagreed.

The authors gave several reasons why insufficient documentation time may contribute to burnout, especially among family physicians. First, spending time working on an EHR "poses a direct challenge to connecting with patients," which is "one of the more sustaining aspects of primary care practice."

The authors also noted that because documentation time typically is not reimbursed, this task "may contribute to physicians' frustration, particularly if, as our study shows, a majority of physicians feel that EHRs do not improve patient care."

The researchers recommended that health care organizations "regularly and systematically measure health IT-related stress and burnout" among their workers, and that analyses should be broken down by specialty. They also encouraged organizations to interview individual physicians who report low stress and burnout levels to help identify what works well for them and how that could be applied to physicians who are experiencing high stress and burnout levels.

"Given the toll of burnout on clinicians, patients and the health care system, measuring and addressing health IT-related stress is an important step in reducing workforce burden and improving the care of our patients," they concluded.

AAFP's Medical Informatics Expert's Take

Family physician Steven Waldren, M.D., M.S., an AAFP vice president and the Academy's chief medical informatics officer, told AAFP News that he was not surprised at the level of stress associated with EHR use. "Unfortunately, this study is in line with several other studies on this topic," he said.

Waldren attributed the high levels of stress and burnout reported by family physicians to a number of factors. "The diversity of patient types and issues that FPs treat, along with the complexity of their patients with multiple chronic diseases, compound the shortcomings of current EHRs," Waldren said. He also noted that some family physicians may be required financially to see high numbers of patients, which could cause additional stress.

Waldren said the Academy is well aware that family physicians are dissatisfied with EHRs and struggle with the amount of time involved in documentation. The AAFP is actively taking steps to solve those problems.

"The AAFP has advocated and continues to advocate for improved usability of EHRs and for reduction of the administrative burden evoked by regulations that are contributing to FP frustration and burnout," Waldren said. He cited the Academy's approval of an informatics project in October 2018 as part of the AAFP's ongoing efforts to drive innovation and make health IT work for family physicians.

He also pointed to several other projects the Academy will be pursuing in 2019 that are designed to reduce administrative burden and improve EHR interoperability and that will allow family physicians to spend more time seeing and caring for patients.