Abstract
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. 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. 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. 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. The 25 ICU physicians (13 women; mean [SD] age, 32.1 [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. Physicians who experienced EHR-related fatigue in 1 patient case were less efficient in the subsequent patient case, as demonstrated by longer task completion times (r = -0.521; P = .007), higher numbers of mouse clicks (r = -0.562; P = .003), and more EHR screen visits (r = -0.486; P = .01). This study reports high rates of fatigue among ICU physicians during short periods of EHR simulation, which were negatively associated with EHR efficiency and included a carryover association across patient cases. More research is needed to investigate the underlying causes of EHR-associated fatigue, to support user-centered EHR design, and to inform safe EHR use policies and guidelines.
Highlights
Use of electronic health records (EHRs) is directly associated with physician burnout.[1,2] Many physicians have voiced dissatisfaction with the click-heavy, data-busy interfaces of existing EHRs.[1,3] Other factors associated with EHR frustration include scrolling through pages of notes and navigating through multiscreen workflows in the search for information.[4]
Physicians who experienced EHR-related fatigue in 1 patient case were less efficient in the subsequent patient case, as demonstrated by longer task completion times (r = −0.521; P = .007), higher numbers of mouse clicks (r = −0.562; P = .003), and more EHR screen visits (r = −0.486; P = .01)
This study reports high rates of fatigue among intensive care unit (ICU) physicians during short periods of EHR simulation, which were negatively associated with EHR efficiency and included a carryover association across patient cases
Summary
Use of electronic health records (EHRs) is directly associated with physician burnout.[1,2] Many physicians have voiced dissatisfaction with the click-heavy, data-busy interfaces of existing EHRs.[1,3] Other factors associated with EHR frustration include scrolling through pages of notes and navigating through multiscreen workflows in the search for information.[4]. Poor EHR design exacerbates this cycle, potentially affecting decision-making and causing delays in care,[6] medical errors,[6,13] and unanticipated patient safety events, especially in high-risk environments.[14,15,16] Despite the challenges of today’s EHR interfaces, much work remains to achieve truly user-centered EHR systems with better designs that improve efficiency (ie, mouse clicks and time), streamline decision-making processes, and support patient safety.[17,18] Whereas traditional EHR usability testing often focuses on intrinsic, vendor-specific aspects of the system (such as screen layouts and workflows), it is important to distinguish EHR efficiency as extrinsic and dynamic—as much a function of the user as the system itself
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