Electronic Health Record Usability Research Articles

Implementation of Changes to Medical Student Documentation at Duke University Health System: Balancing Education With Service.

When the Centers for Medicare and Medicaid Services (CMS) changed policies about medical student documentation, students with proper supervision may now document their history, physical exam, and medical decision making in the electronic health record (EHR) for billable encounters. Since documentation is a core entrustable professional activity for medical students, the authors sought to evaluate student opportunities for documentation and feedback across and between clerkships. In February 2018, a multidisciplinary workgroup was formed to implement student documentation at Duke University Health System, including educating trainees and supervisors, tracking EHR usage, and enforcing CMS compliance. From August 2018 to August 2019, locations and types of student-involved services (student-faculty or student-resident-faculty) were tracked using billing data from attestation statements. Student end-of-clerkship evaluations included opportunity for documentation and receipt of feedback. Since documentation was not allowed before August 2018, it was not possible to compare with prior student experiences. In the first half of the academic year, 6,972 patient encounters were billed as student-involved services, 52% (n = 3,612) in the inpatient setting and 47% (n = 3,257) in the outpatient setting. Most (74%) of the inpatient encounters also involved residents, and most (92%) of outpatient encounters were student-teaching physician only.Approximately 90% of students indicated having had opportunity to document in the EHR across clerkships, except for procedure-based clerkships such as surgery and obstetrics. Receipt of feedback was present along with opportunity for documentation more than 85% of the time on services using evaluation and management coding. Most students (> 90%) viewed their documentation as having a moderate or high impact on patient care. Changes to student documentation were successfully implemented and adopted; changes met both compliance and education needs within the health system without resulting in potential abuses of student work for service.

Comparison of Methods for Alcohol and Drug Screening in Primary Care Clinics

Guidelines recommend that adult patients receive screening for alcohol and drug use during primary care visits, but the adoption of screening in routine practice remains low. Clinics frequently struggle to choose a screening approach that is best suited to their resources, workflows, and patient populations. To evaluate how to best implement electronic health record (EHR)-integrated screening for substance use by comparing commonly used screening methods and examining their association with implementation outcomes. This article presents the outcomes of phases 3 and 4 of a 4-phase quality improvement, implementation feasibility study in which researchers worked with stakeholders at 6 primary care clinics in 2 large urban academic health care systems to define and implement their optimal screening approach. Site A was located in New York City and comprised 2 clinics, and site B was located in Boston, Massachusetts, and comprised 4 clinics. Clinics initiated screening between January 2017 and October 2018, and 93 114 patients were eligible for screening for alcohol and drug use. Data used in the analysis were collected between January 2017 and October 2019, and analysis was performed from July 13, 2018, to March 23, 2021. Clinics integrated validated screening questions and a brief counseling script into the EHR, with implementation supported by the use of clinical champions (ie, clinicians who advocate for change, motivate others, and use their expertise to facilitate the adoption of an intervention) and the training of clinic staff. Clinics varied in their screening approaches, including the type of visit targeted for screening (any visit vs annual examinations only), the mode of administration (staff-administered vs self-administered by the patient), and the extent to which they used practice facilitation and EHR usability testing. Data from the EHRs were extracted quarterly for 12 months to measure implementation outcomes. The primary outcome was screening rate for alcohol and drug use. Secondary outcomes were the prevalence of unhealthy alcohol and drug use detected via screening, and clinician adoption of a brief counseling script. Patients of the 6 clinics had a mean (SD) age ranging from 48.9 (17.3) years at clinic B2 to 59.1 (16.7) years at clinic B3, were predominantly female (52.4% at clinic A1 to 64.6% at clinic A2), and were English speaking. Racial diversity varied by location. Of the 93,114 patients with primary care visits, 71.8% received screening for alcohol use, and 70.5% received screening for drug use. Screening at any visit (implemented at site A) in comparison with screening at annual examinations only (implemented at site B) was associated with higher screening rates for alcohol use (90.3%-94.7% vs 24.2%-72.0%, respectively) and drug use (89.6%-93.9% vs 24.6%-69.8%). The 5 clinics that used a self-administered screening approach had a higher detection rate for moderate- to high-risk alcohol use (14.7%-36.6%) compared with the 1 clinic that used a staff-administered screening approach (1.6%). The detection of moderate- to high-risk drug use was low across all clinics (0.5%-1.0%). Clinics with more robust practice facilitation and EHR usability testing had somewhat greater adoption of the counseling script for patients with moderate-high risk alcohol or drug use (1.4%-12.5% vs 0.1%-1.1%). In this quality improvement study, EHR-integrated screening was feasible to implement in all clinics and unhealthy alcohol use was detected more frequently when self-administered screening was used at any primary care visit. The detection of drug use was low at all clinics, as was clinician adoption of counseling. These findings can be used to inform the decision-making of health care systems that are seeking to implement screening for substance use. ClinicalTrials.gov Identifier: NCT02963948.

Ask About What Matters: An Intervention to Improve Accessible Advance Care Planning Documentation

ContextAdvance care planning (ACP) informs future medical decision-making, especially for patients with advanced age or serious illness. For clinicians to act on these preferences, or continue the ACP conversation as illness progresses, documentation of ACP discussions must be readily accessible within the electronic health record (EHR). ObjectivesDevelop an intervention to improve accessible ACP documentation for hospitalized patients and assess its impact on viewing and documentation of ACP conversations within a specific EHR location. MethodsAdult patients age 75 or older or with serious illness discharged during a two-year period were included. The EHR's ACP Navigator was targeted as the intended location for documenting ACP-related activities. We implemented a hospital-wide, multipronged intervention that included increased ACP Navigator visibility and a process for workflow-congruent ACP documentation. Accessible ACP documentation was measured by documentation within the ACP Navigator and was analyzed by interrupted time-series analysis. ACP Navigator access was measured by user audit logs. ResultsAfter the intervention, 6703 of 16,117 (41.6%) patient encounters had accessible ACP documentation, compared to 3689 of 13,143 (28.1%) preintervention (P < .001). In the intervention's first month, accessible ACP documentation increased 5.3% (P < .001, CI 2.9%–7.6%), followed by a 1.3% monthly increase relative to the preintervention period (P < .001, CI 1.0%–1.6%). ACP Navigator access for patients with ACP documentation increased in the intervention period (52.2% vs. 39.8%, P < .001). ConclusionAn institution-wide intervention significantly increased accessible ACP documentation within a centralized location of the EHR. EHR usability changes improved rates of accessible ACP documentation and subsequent views of this documentation.

Associations of physician burnout with organizational electronic health record support and after-hours charting.

In 2017, 43.9% of US physicians reported symptoms of burnout. Poor electronic health record (EHR) usability and time-consuming data entry contribute to burnout. However, less is known about how modifiable dimensions of EHR use relate to burnout and how these associations vary by medical specialty. Using the KLAS Arch Collaborative’s large-scale nationwide physician (MD/DO) data, we used ordinal logistic regression to analyze associations between self-reported burnout and after-hours charting and organizational EHR support. We examined how these relationships differ by medical specialty, adjusting for confounders. Physicians reporting ≤ 5 hours weekly of after-hours charting were twice as likely to report lower burnout scores compared to those charting ≥6 hours (aOR: 2.43, 95% CI: 2.30, 2.57). Physicians who agree that their organization has done a great job with EHR implementation, training, and support (aOR: 2.14, 95% CI: 2.01, 2.28) were also twice as likely to report lower scores on the burnout survey question compared to those who disagree. Efforts to reduce after-hours charting and improve organizational EHR support could help address physician burnout.

Clinician Burnout Associated With Sex, Clinician Type, Work Culture, and Use of Electronic Health Records

Electronic health records (EHRs) are considered a potentially significant contributor to clinician burnout. To describe the association of EHR usage, sex, and work culture with burnout for 3 types of clinicians at an academic medical institution. This cross-sectional study of 1310 clinicians at a large tertiary care academic medical center analyzed EHR usage metrics for the month of April 2019 with results from a well-being survey from May 2019. Participants included attending physicians, advanced practice providers (APPs), and house staff from various specialties. Data were analyzed between March 2020 and February 2021. Clinician demographic characteristics, EHR metadata, and an institution-wide survey. Study metrics included clinician demographic data, burnout score, well-being measures, and EHR usage metadata. Of the 1310 clinicians analyzed, 542 (41.4%) were men (mean [SD] age, 47.3 [11.6] years; 448 [82.7%] White clinicians, 52 [9.6%] Asian clinicians, and 21 [3.9%] Black clinicians) and 768 (58.6%) were women (mean [SD] age, 42.6 [10.3] years; 573 [74.6%] White clinicians, 105 [13.7%] Asian clinicians, and 50 [6.5%] Black clinicians). Women reported more burnout (survey score ≥50: women, 423 [52.0%] vs men, 258 [47.6%]; P = .008) overall. No significant differences in EHR usage were found by sex for multiple metrics of time in the EHR, metrics of volume of clinical encounters, or differences in products of clinical care. Multivariate analysis of burnout revealed that work culture domains were significantly associated with self-reported results for commitment (odds ratio [OR], 0.542; 95% CI, 0.427-0.688; P < .001) and work-life balance (OR, 0.643; 95% CI, 0.559-0.739; P < .001). Clinician sex significantly contributed to burnout, with women having a greater likelihood of burnout compared with men (OR, 1.33; 95% CI, 1.01-1.75; P = .04). An increased number of days spent using the EHR system was associated with less likelihood of burnout (OR, 0.966; 95% CI, 0.937-0.996; P = .03). Overall, EHR metrics accounted for 1.3% of model variance (P = .001) compared with work culture accounting for 17.6% of variance (P < .001). In this cross-sectional study, sex-based differences in EHR usage and burnout were found in clinicians. These results also suggest that local work culture factors may contribute more to burnout than metrics of EHR usage.

The association between perceived electronic health record usability and professional burnout among US nurses.

To measure nurse-perceived electronic health records (EHR) usability with a standardized metric of technology usability and evaluate its association with professional burnout. A cross-sectional survey of a random sample of US nurses was conducted in November 2017. EHR usability was measured with the System Usability Scale (SUS; range 0-100) and burnout with the Maslach Burnout Inventory. Among the 86858 nurses who were invited, 8638 (9.9%) completed the survey. The mean nurse-rated EHR SUS score was 57.6 (SD 16.3). A score of 57.6 is in the bottom 24% of scores across previous studies and categorized with a grade of "F." On multivariable analysis adjusting for age, gender, race, ethnicity, relationship status, children, highest nursing-related degree, mean hours worked per week, years of nursing experience, advanced certification, and practice setting, nurse-rated EHR usability was associated with burnout with each 1 point more favorable SUS score and associated with a 2% lower odds of burnout (OR 0.98; 95% CI, 0.97-0.99; P < .001). Nurses rated the usability of their current EHR in the low marginal range of acceptability using a standardized metric of technology usability. EHR usability and the odds of burnout were strongly associated with a dose-response relationship.

Emergency Physician Perceptions of Electronic Health Record Usability and Safety.

Despite requirements for electronic health record (EHR) vendor usability testing, usability challenges persist, contributing to patient safety concerns. We sought to identify emergency physicians' perceived EHR usability and safety strengths and shortcomings across major EHR vendor products. Fifty-five emergency physicians from 4 different hospitals were interviewed. The interviews were qualitatively analyzed, and physician comments were aligned with a usability taxonomy to identify emerging themes by vendor and hospital. Of the 194 comments about usability, the 3 most commonly discussed usability topics were Workflow Support (33.5% of comments), Visual Display (20.1%), and Data Entry (14.4%). Electronic health record usability strengths were centered on Visual Display, and the most common shortcoming was the lack of Workflow Support. Fourteen cross-hospital/cross-vendor themes, 6 vendor-specific themes, and 4 hospital-specific themes were identified. Usability shortcomings that spanned across hospitals and vendors may suggest a need for more applied research and improved design to resolve these issues. Shortcomings that are localized to a specific product or hospital may be due to customization and may be addressable by learning from other organizations.

Electronic Health Record Usability: Associations With Nurse and Patient Outcomes in Hospitals.

Electronic health record (EHR) usability issues represent an emerging threat to the wellbeing of nurses and patients; however, few large studies have examined these relationships. To examine associations between EHR usability and nurse job (burnout, job dissatisfaction, and intention to leave) and surgical patient (inpatient mortality and 30-day readmission) outcomes. A cross-sectional analysis of linked American Hospital Association, state patient discharge, and nurse survey data was conducted. The sample included 343 hospitals, 1,281,848 surgical patients, and 12,004 nurses. Logistic regression models were used to assess relationships between EHR usability and outcomes, before and after accounting for EHR adoption level (comprehensive vs. basic or less) and other confounders. In fully adjusted models, nurses who worked in hospitals with poorer EHR usability had significantly higher odds of burnout [odds ratio (OR), 1.41; 95% confidence interval (CI), 1.21-1.64], job dissatisfaction (OR, 1.61; 95% CI, 1.37-1.90) and intention to leave (OR, 1.31; 95% CI, 1.09-1.58) compared with nurses working in hospitals with better usability. Surgical patients treated in hospitals with poorer EHR usability had significantly higher odds of inpatient mortality (OR, 1.21; 95% CI, 1.09-1.35) and 30-day readmission (OR, 1.06; 95% CI, 1.01-1.12) compared with patients in hospitals with better usability. Comprehensive EHR adoption was associated with higher odds of nurse burnout (OR, 1.14; 95% CI, 1.01-1.28). Employing EHR systems with suboptimal usability was associated with higher odds of adverse nurse job outcomes and surgical patient mortality and readmission. EHR usability may be more important to nurse job and patient outcomes than comprehensive EHR adoption.

Beyond Getting Rid of Stupid Stuff in the Electronic Health Record (Beyond-GROSS): Protocol for a User-Centered, Mixed-Method Intervention to Improve the Electronic Health Record System.

BackgroundUp to 60% of health care providers experience one or more symptoms of burnout. Perceived clinician burden resulting in burnout arises from factors such as electronic health record (EHR) usability or lack thereof, perceived loss of autonomy, and documentation burden leading to less clinical time with patients. Burnout can have detrimental effects on health care quality and contributes to increased medical errors, decreased patient satisfaction, substance use, workforce attrition, and suicide.ObjectiveThis project aims to improve the user-centered design of the EHR by obtaining direct input from clinicians about deficiencies. Fixing identified deficiencies via user-centered design has the potential to improve usability, thereby increasing satisfaction by reducing EHR-induced burnout.MethodsQuantitative and qualitative data will be obtained from clinician EHR users. The input will be received through a form built in a REDCap database via a link embedded in the home page of the EHR. The REDCap data will be analyzed in 2 main dimensions, based on nature of the input, what section of the EHR is affected, and what is required to fix the issue(s). Identified issues will be escalated to relevant stakeholders responsible for rectifying the problems identified. Data analysis, project evaluation, and lessons learned from the evaluation will be incorporated in a Plan-Do-Study-Act (PDSA) manner every 4-6 weeks.ResultsThe pilot phase of the study began in October 2020 in the Gastroenterology Division at Mount Sinai Hospital, New York City, NY, which includes 39 physicians and 15 nurses. The pilot is expected to run over a 4-6–month period. The results of the REDCap data analysis will be reported within 1 month of completing the pilot phase. We will analyze the nature of requests received and the impact of rectified issues on the clinician EHR user. We expect that the results will reveal which sections of the EHR have the highest deficiencies while also highlighting issues about workflow difficulties. Perceived impact of the project on provider engagement, patient safety, and workflow efficiency will also be captured by evaluation survey and other qualitative methods where possible.ConclusionsThe project aims to improve user-centered design of the EHR by soliciting direct input from clinician EHR users. The ultimate goal is to improve efficiency, reduce EHR inefficiencies with the possibility of improving staff engagement, and lessen EHR-induced clinician burnout. Our project implementation includes using informatics expertise to achieve the desired state of a learning health system as recommended by the National Academy of Medicine as we facilitate feedback loops and rapid cycles of improvement.International Registered Report Identifier (IRRID)PRR1-10.2196/25148

Electronic Health Record Usage Patterns: Assessing Telemedicine's Impact on the Provider Experience During the COVID-19 Pandemic.

Telemedicine has been widely implemented during the coronavirus disease 2019 (COVID-19) pandemic; however, its impact on those providing care remains largely understudied. Provider documentation data collected by the electronic health record (EHR) represents an underutilized tool for assessing the provider experience. Through Epic Signal, we collected data regarding the actions logged in the EHR by health care providers of the Montefiore Health System (Bronx, NY) before and after the implementation of telemedicine during the pandemic. Focusing on five metrics (appointments per day, visits closed same day, time spent outside 7 AM-7 PM, time spent on unscheduled days, and pajama time), we performed a preliminary analysis of providers across the institution, by specialty, and according to demographic characteristics such as gender and years since graduation. We observed that after telemedicine implementation, a greater proportion of providers had fewer appointments per day, closed more notes same day, and spent less time in the EHR outside of normal working hours for each of the time-related metrics. We additionally found that providers who graduated longer ago as well as female providers spent more time documenting in the EHR after hours. This brief analysis highlights the potential of using EHR data to inform decisions based on provider well-being, specifically in the setting of telemedicine implementation.

Electronic health record usability and workload changes over time for provider and nursing staff following transition to new EHR

The ubiquity of EHRs in healthcare means that small EHR inefficiencies can have a major impact on clinician workload. We conducted a sequential explanatory mixed methods study to: 1) identify EHR-associated workload and usability effects for clinicians following an EHR change over time, 2) determine workload and usability differences for providers (MD and Advance Practice Nurses) versus nurses (RNs and MAs), 3) determine if usability predicts workload, 4) identify potential sources of EHR design flaws. Workload (NASA-Task Load Index) and usability (System Usability Scale) measures were administered pre, 6–8 month and 30–32 months post-implementation. We found significant increase in perceived workload post-implementation that persisted for 2.5 years (p < .001). The workload increase was associated with usability ratings, which in turn may relate to EHR interface design violations identified by a heuristic evaluation. Our findings suggest further innovation and attention to interface design flaws are needed to improve EHR usability and reduce clinician workload.

Moving toward a sociotechnical systems approach to continuous health information technology design: the path forward for improving electronic health record usability and reducing clinician burnout.

Based on our analysis of descriptions provided by four EHR vendors on their EHR usability efforts, we provide three recommendations aimed at improving the usability of health information technology and reducing clinician burnout. First, EHR vendors need to dedicate increased attention to the design of the entire sociotechnical (work) system, including the EHR technology and its usability as well as the interactions of the technology with other system elements. Second, EHR vendors need to deepen and broaden their understanding of the work of clinicians and care teams by using diverse and mixed method. Third, in collaboration with health care organizations, EHR vendors should engage in cycles of continuous design and learning in order to improve the usability of health IT.

A systematic review of contributing factors of and solutions to electronic health record-related impacts on physician well-being.

Physicians often describe the electronic health record (EHR) as a cumbersome impediment to meaningful work, which has important implications for physician well-being. This systematic review (1) assesses organizational, physician, and information technology factors associated with EHR-related impacts on physician well-being; and (2) highlights potential improvements to EHR form and function, as recommended by frontline physicians. The MEDLINE, Embase, CINAHL, PsycINFO, ProQuest, and Web of Science databases were searched for literature describing EHR use by physicians and markers of well-being. After reviewing 7388 article, 35 ultimately met the inclusion criteria. Multiple factors across all levels were associated with EHR-related well-being among physicians. Notable predictors amenable to interventions include (1) total EHR time, (2) after-hours EHR time, (3) on-site EHR support, (4) perceived EHR usability, (5) in-basket burden, and (6) documentation burden. Physician recommendations also echoed these themes. There are multiple complex factors involved in EHR-related well-being among physicians. Our review shows physicians have recommendations that span from federal regulations to organizational policies to EHR modifications. Future research should assess multipronged interventions that address these factors. As primary stakeholders, physicians should be included in the planning and implementation of such modifications to ensure compatibility with physician needs and clinical workflows.

Advancing electronic health record vendor usability maturity: Progress and next steps.

Despite basic federal requirements promoting a user-centered design approach to electronic health record (EHR) development and usability testing there have been usability and safety risks with EHR technology. Four EHR vendors were asked to provide written descriptions of their usability practices, and we reviewed these descriptions to identify areas where there has been advancement and areas for improvement. All 4 vendors described user-centered design processes and usability testing methods that demonstrate advancement from previous studies of vendor practices. Importantly, vendors are also beginning to address aspects of EHR implementation that play a critical role in shaping EHR usability. There are important areas for improvement in vendor practices including a greater focus on safety and on measurement and benchmarking. Vendors sharing their current usability practices demonstrates a step toward greater transparency which has typically been lacking.

Using virtual simulation and electronic health records to assess student nurses' documentation and critical thinking skills

IntroductionElectronic health records have become a standard documentation platform to house patient information in most US hospitals. To improve documentation, providers suggest establishing electronic health record user education at the classroom level so students can interact with patient data early. The purpose of this study was to assess student nurses' clinical documentation and critical thinking skills using virtual patients and a simulated electronic health record system. MethodsEighty-four undergraduate nursing students completed assessments on four assigned virtual patients and entered their findings into a simulated electronic health record system. Benner's five stage novice to expert theory was used to evaluate performance of six assessment items. ResultsSignificant differences (p = 0.046) were seen in median scores between the first and second assignments, and between the second and fourth assignments (p = 0.021) with minimal improvements from one assignment to the next. DiscussionData entered in the electronic health record showed that students started at an advance beginner's level and moved to be proficient in documenting basic patient information using critical thinking skills by the end of the first semester. ConclusionIt is important to expose students to electronic health record systems before entering the workforce or while training in a hospital setting to enhance readiness for clinical practice with electronic documentation and critical thinking skills.

Cardiovascular Assessment Tool for Breast Cancer Survivors and Oncology Providers: Usability Study.

BackgroundCardiovascular health is of increasing concern to breast cancer survivors and their health care providers, as many survivors are more likely to die from cardiovascular disease than cancer. Implementing clinical decision support tools to address cardiovascular risk factor awareness in the oncology setting may enhance survivors’ attainment or maintenance of cardiovascular health.ObjectiveWe sought to evaluate survivors’ awareness of cardiovascular risk factors and examine the usability of a novel electronic health record enabled cardiovascular health tool from the perspective of both breast cancer survivors and oncology providers.MethodsBreast cancer survivors (n=49) recruited from a survivorship clinic interacted with the cardiovascular health tool and completed pre and posttool assessments about cardiovascular health knowledge and perceptions of the tool. Oncologists, physician assistants, and nurse practitioners (n=20) who provide care to survivors also viewed the cardiovascular health tool and completed assessments of perceived usability and acceptability.ResultsEnrolled breast cancer survivors (84% White race, 4% Hispanic ethnicity) had been diagnosed 10.8 years ago (SD 6.0) with American Joint Committee on Cancer stage 0, I, or II (45/49, 92%). Prior to viewing the tool, 65% of survivors (32/49) reported not knowing their level for one or more cardiovascular health factors (range 0-4). On average, only 45% (range 0%-86%) of survivors’ known cardiovascular health factors were at an ideal level. More than 50% of survivors had ideal smoking status (45/48, 94%) or blood glucose level (29/45, 64%); meanwhile, less than 50% had ideal blood pressure (12/49, 24%), body mass index (12/49, 24%), cholesterol level (17/35, 49%), diet (7/49, 14%), and physical activity (10/49. 20%). More than 90% of survivors thought the tool was easy to understand (46/47, 98%), improved their understanding (43/47, 91%), and was helpful (45/47, 96%); overall, 94% (44/47 survivors) liked the tool. A majority of survivors (44/47, 94%) thought oncologists should discuss cardiovascular health during survivorship care. Most (12/20, 60%) oncology providers (female: 12/20, 60%; physicians: 14/20, 70%) had been practicing for more than 5 years. Most providers agreed the tool provided useful information (18/20, 90%), would help their effectiveness (18/20, 90%), was easy to use (20/20, 100%), and presented information in a useful format (19/20, 95%); and 85% of providers (17/20) reported they would use the tool most or all of the time when providing survivorship care.ConclusionsThese usability data demonstrate acceptability of a cardiovascular health clinical decision support tool in oncology practices. Oncology providers and breast cancer survivors would likely value the integration of such apps in survivorship care. By increasing awareness and communication regarding cardiovascular health, electronic health record–enabled tools may improve survivorship care delivery for breast cancer and ultimately patient outcomes.

Quantified electronic health record (EHR) use by academic surgeons

BackgroundThe electronic health record has improved medical billing, research, and sharing of patient data, but its clinical use by physicians has been linked to rising physician burnout leading to numerous subjective editorials about the electronic health record inefficiencies and detriment to frontline caregivers. This study aimed to quantify electronic health record use by surgeons. MethodsThe study is a retrospective review and descriptive analysis of deidentified electronic health record data from September 2016 to June 2017. A binary time series was created for each attending to calculate electronic health record system login times. The primary outcome was the total amount of time a surgeon logged into the electronic health record system during the study period. ResultsFifty-one general surgery attendings (31 males, 20 females), spanning 9 specialties spent a mean of 2.0 hours per day and 13.8 hours per week logged into the electronic health record. The top 15% of users were logged in for an average of 4.6 hours per weekday. Sixty-five percent of overall electronic health record use occurred on-site, and 35% was remote. A greater proportion of remote use occurred during nighttime hours and Sundays. Clinic days required the largest amount of electronic health record use time compared with operating room and administrative days. ConclusionGeneral surgery attendings spend a considerable amount of time using the electronic health record. Ultimately, the goal of these quantitative electronic health record results is to correlate with burnout and job satisfaction data to facilitate the implementation of programs to improve efficiency and decrease the burden of charting. Further investigation needs to focus on subgroups who are high electronic health record users to better identify the barriers to efficient electronic health record use.

Electronic health records and clinician burnout: A story of three eras.

The study sought to provide physicians, informaticians, and institutional policymakers with an introductory tutorial about the history of medical documentation, sources of clinician burnout, and opportunities to improve electronic health records (EHRs). We now have unprecedented opportunities in health care, with the promise of new cures, improved equity, greater sensitivity to social and behavioral determinants of health, and data-driven precision medicine all on the horizon. EHRs have succeeded in making many aspects of care safer and more reliable. Unfortunately, current limitations in EHR usability and problems with clinician burnout distract from these successes. A complex interplay of technology, policy, and healthcare delivery has contributed to our current frustrations with EHRs. Fortunately, there are opportunities to improve the EHR and health system. A stronger emphasis on improving the clinician's experience through close collaboration by informaticians, clinicians, and vendors can combine with specific policy changes to address the causes of burnout. This tutorial is intended for clinicians, informaticians, policymakers, and regulators, who are essential participants in discussions focused on improving clinician burnout. Learners in biomedicine, regardless of clinical discipline, also may benefit from this primer and review. We include (1) an overview of medical documentation from a historical perspective; (2) a summary of the forces converging over the past 20 years to develop and disseminate the modern EHR; and (3) future opportunities to improve EHR structure, function, user base, and time required to collect and extract information.

Perceived Electronic Health Record Usability as a Predictor of Task Load and Burnout Among US Physicians: Mediation Analysis.

BackgroundElectronic health record (EHR) usability and physician task load both contribute to physician professional burnout. The association between perceived EHR usability and workload has not previously been studied at a national level. Better understanding these interactions could give further information as to the drivers of extraneous task load.ObjectiveThis study aimed to determine the relationship between physician-perceived EHR usability and workload by specialty and evaluate for associations with professional burnout.MethodsA secondary analysis of a cross-sectional survey of US physicians from all specialties was conducted from October 2017 to March 2018. Among the 1250 physicians invited to respond to the subsurvey analyzed here, 848 (67.8%) completed it. EHR usability was assessed with the System Usability Scale (SUS; range: 0-100). Provider task load (PTL) was assessed using the mental demand, physical demand, temporal demand, and effort required subscales of the National Aeronautics and Space Administration Task Load Index (range: 0-400). Burnout was measured using the Maslach Burnout Inventory.ResultsThe mean scores were 46.1 (SD 22.1) for SUS and 262.5 (SD 71.7) for PTL. On multivariable analysis adjusting for age, gender, relationship status, medical specialty, practice setting, hours worked per week, and number of nights on call per week, physician-rated EHR usability was associated with PTL, with each 1-point increase in SUS score (indicating more favorable) associated with a 0.57-point decrease in PTL score (P<.001). On mediation analysis, higher SUS score was associated with lower PTL score, which was associated with lower odds of burnout.ConclusionsA strong association was observed between EHR usability and workload among US physicians, with more favorable usability associated with less workload. Both outcomes were associated with the odds of burnout, with task load acting as a mediator between EHR usability and burnout. Improving EHR usability while decreasing task load has the potential to allow practicing physicians more working memory for medical decision making and patient communication.

Building the evidence-base to reduce electronic health record-related clinician burden.

Clinicians face competing pressures of being clinically productive while using imperfect electronic health record (EHR) systems and maximizing face-to-face time with patients. EHR use is increasingly associated with clinician burnout and underscores the need for interventions to improve clinicians' experiences. With an aim of addressing this need, we share evidence-based informatics approaches, pragmatic next steps, and future research directions to improve 3 of the highest contributors to EHR burden: (1) documentation, (2) chart review, and (3) inbox tasks. These approaches leverage speech recognition technologies, natural language processing, artificial intelligence, and redesign of EHR workflow and user interfaces. We also offer a perspective on how EHR vendors, healthcare system leaders, and policymakers all play an integral role while sharing responsibility in helping make evidence-based sociotechnical solutions available and easy to use.