20 Apr Burnout Among Physicians Only Partly Due To Electronic Medical Records
MedicalResearch.com Interview with:
Eugenia McPeek Hinz MD MS FAMIA
Associate CMIO – DHTS
Duke University Health System
MedicalResearch.com: What is the background for this study?
Response: Clinician burnout rates have hovered around 50% for much of the past decade. Burnout is a significant concern in healthcare for its effects on care givers and associated downstream adverse implications on patient care for quality and safety. The ubiquitous presence of Electronic Health Records (EHR) along with the increased clerical components and after hours use has been a significant concern for contributing to provider burnout.
MedicalResearch.com: What are the main findings?
Response: Our study used audit logs to look across 1310 individuals in three clinician groups (attending physicians, Advanced Practice Providers (APPs: physician assistants and nurse practitioners) and graduate medical education (GME) trainees (residents and fellows) for burnout and corresponding use of the EHR. Our results confirm other previous published findings for similar rates of burnout across all providers but especially in women, attending physicians, and APPs. This study is also one of the firsts to look at APPs and GME trainee burnout in context of the EHR.
Using a multivariate modeling of burnout comparing clinician demographics to EHR usage metrics to local work culture, we found local work culture accounting for 17.6% model variance compared to only 1.3% variance for EHR metrics to clinician burnout. Female sex independently contributed more to likelihood of clinician burnout (adjusted OR 1.33 (1.01-1.75) and significantly interacted with work culture domains of commitment and work-life balance.
We additionally found that time in the EHR after-hours had no correlation with burnout, with most providers spending 20-30% of their total time after hours in the EHR. We also found females spent more total time in the EHR compared to their male peers. All of this suggests that the time when a provider spends time in the EHR is not as important for burnout as the total volume of time spent in the EHR.
MedicalResearch.com: What should readers take away from your report?
Response: The EHR contribution to burnout as measured by EHR audit logs is small. Comparatively speaking, work does a better job of predicting burnout. This is important because so much attention and frankly blame is placed on the EHR, and that blame did not have the evidence behind it in our analyses. Second, burnout (emotional exhaustion) is high in these EHR users, but particularly so for women, attendings and APPs.
In this sample, we found a lack of correlation of audit log data of after hour time in the EHR to burnout. This suggests a recall bias whereby clinicians find the EHR a convenient target for frustrations with their clinical work, since work in the EHR is a digital interaction rather than a human one. We all have experiences and stories that we can conjure up about the EHR, and it is a safe target for blame because it cannot defend itself.
The take home message from this work and specifically the work culture survey, is that working in a toxic brew of disruptive colleagues and feeling like you don’t fit in at work are significantly more potent predictors of burnout in our study than the EHR.
This does not obviate the well documented Health IT issues that every EHR instantiation has to address. Some of the bigger challenges, for instance, include designing health system processes effectively into the EHR user interfaces, governance for content improvement, avoiding alert fatigue with clinical decision support and effective training and ongoing support. Overall, our results may not be as generalizable to other health systems due to contextual effect related to our well-established EHR implementation in our 9th year on our current EHR.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: Future research should include patient outcomes and clinician care metrics to EHR audit log data. Without clinical measures of potential value of EHR activities to the care of the patient, discrimination of the value of time and volume of work in the EHR cannot be fully assessed. Essentially does the time and clinical activities in the EHR by the clinician result in better clinical outcomes for patients. To accomplish this, future research should include the combination of patient outcomes, percentage of clinical care time of the provider, EHR usage metrics for total time and metrics of clinical output, as well as clinician sex and measures of burnout.
Future research should also look more carefully at the work culture in which burnout is occurring, the teamwork norms, leadership norms, patient safety norms and should extend these predictors of burnout beyond EHR users to all healthcare workers.
MedicalResearch.com: Is there anything else you would like to add?
Response: We are grateful to the physicians, APPs and GME trainees who took the extra time and effort to complete the survey we used that enabled this project in the first place. They are our colleagues, friends, and we remain students of what they continue to teach us.
McPeek-Hinz E, Boazak M, Sexton JB, et al. Clinician Burnout Associated With Sex, Clinician Type, Work Culture, and Use of Electronic Health Records. JAMA Netw Open. 2021;4(4):e215686. doi:10.1001/jamanetworkopen.2021.5686
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