Abstract
Managing messages in the electronic health record (EHR) inbox consumes substantial amounts of physician time. Certain factors associated with inbox management, such as poor usability and excessive and unnecessary inbox messages, have been associated with physician burnout. Additionally, inbox design, usability, and workflows are associated with physicians' situational awareness (ie, perception, comprehension, and projection of clinical status) and efficiency of processing EHR inbox messages. Understanding factors associated with inbox usability could improve future EHR inbox designs and workflows, thus reducing risk of burnout while improving patient safety. To determine barriers, facilitators, and suggestions associated with EHR inbox-related usability. This qualitative study included cognitive walkthroughs of EHR inbox management with 25 physicians (17 primary care physicians and 8 specialists) at 6 large health care organizations using 4 different EHR systems between May 6, 2015, and September 19, 2016. While processing EHR inbox messages, participants identified facilitators and barriers associated with EHR inbox situational awareness and processing efficiency and potential interventions to address such barriers. A qualitative analysis was performed on transcribed recordings using an inductive thematic approach with an 8-dimension sociotechnical model as a theoretical lens from May 6, 2015, to August 15, 2019. The cognitive walkthroughs identified 60 barriers, 32 facilitators, and 28 suggestions for improving the EHR inbox. Emergent data fit within 5 major themes: message processing complexity, inbox interface design, cognitive load, team communication, and inbox message content. Within these themes, similar barriers were identified across sites, such as poor usability due the high numbers of clicks needed to accomplish actions. In certain instances, an identified facilitator at one site provided the exact solution needed to address a barrier identified at another site. This qualitative study found that usability of the EHR inbox is often suboptimal and variable across sites, suggesting lack of shared best practices related to information management. Implementation of optimized design features and workflows will require EHR developers and health care organizations to collectively share this responsibility. Development of regional or national consortia to support collaborative sharing and implementation of EHR system best practices across EHR developers and health care organizations could also improve safety and efficiency and reduce physician burnout.
Highlights
Physician burnout is increasing[1] and has been associated with poor productivity,[2] worse patient satisfaction,[3,4] physician exhaustion and cognitive fatigue,[5] decreased rapport with patients,[6] delays in information processing,[7] increased medical errors,[8] and worse patient outcomes
Emergent data fit within 5 major themes: message processing complexity, inbox interface design, cognitive load, team communication, and inbox message content
This qualitative study found that usability of the electronic health record (EHR) inbox is often suboptimal and variable across sites, suggesting lack of shared best practices related to information management
Summary
Physician burnout is increasing[1] and has been associated with poor productivity,[2] worse patient satisfaction,[3,4] physician exhaustion and cognitive fatigue,[5] decreased rapport with patients,[6] delays in information processing,[7] increased medical errors,[8] and worse patient outcomes. Physicians spend approximately half of their clinic time on clerical and administrative tasks,[13,14] including processing electronic messages delivered via EHR system–based inboxes. Such inboxes function to email but deliver messages to clinicians, such as test results, messages from staff and other clinicians, medication refill requests, direct messages from patients via patient portals,[15,16,17] and additional computer-generated messages.[18] Management of the EHR inbox can add a substantial amount of time to physicians’ work lives. Primary care physicians spend between 49 and 85 minutes per day managing their inbox.[13,15,16] Some inbox messages are irrelevant to the recipient and can reduce their ability to quickly identify important and timely information.[17]
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