electronic health record and physician burnout
Geoff A. Modest, M.D.
Wed 12/18/2019 7:25 AM
A study from the Mayo Clinics found a strong association between perceived electronic health record usability by physicians and professional burnout (see electronic med record MD burnout mayo2019 in dropbox, or doi.org/10.1016/j.mayocp.2019.09.024).
Details:
-- cross-sectional survey of US physicians from all specialty disciplines from October 2017 through March 2018, using the American Medical Association Physician Masterfile
-- 30,456 physicians were invited to do a survey, 5197 (17%) completed it.
-- 1250 (25%) of them were randomly chosen to receive a sub-survey evaluating electronic health record (EHR) usability; (70%) completed it, leaving 870 evaluable results
-- overall, 57% male, median age 53 (7% <35yo, 22% 35-44, 21% 45-54, 28% 55-64, 15% >65yo), median hours worked 50 (16% <40 hours, 20% 40-49, 24% 50-59, 21% 60-69, 8% 70-79, 7% >80 hrs), private practice 45%/academic medical center 30%/VA 2%, 11% single/77% married/4% partnered
-- EHR usability: measured by the System Usability Scale (SUS), a short, simple, and reliable measurement of technology usability, favored as an industry standard and used in more than 1300 studies, with a score of 0 to 100 (the higher the better). Usability reflects ”the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction”
-- Google search has an SUS score of 93 which ranks in the top .01% of technologies, and get the usability grade of A
-- Microsoft Excel has one of the lowest SUS, 57, which results in ranking in the bottom 22% and achieves a grade of F (it was the lowest of 7 frequently used tech products)
-- overall, an SUS score 68 is the average in prior studies
-- burnout was determined using the Maslach Burnout Inventory (MBI), a validated questionnaire considered the "criterion standard tool" for measuring burnout. Professional burnout was indicated with a score of >26 on depersonalization and/or >9 on emotional exhaustion subscales
-- overall demographic characteristics of the 870 participants vs the 5445 respondents to the full survey were generally similar. However, EHR survey respondents were more likely to be women (41% vs 30%). Age, years in practice, and prevalence for burnout were similar in the respondents and nonrespondents to this 2nd survey
Results:
-- the mean SUS score was 45.9, in the bottom 9% of usability scores across studies in other industries, achieving a grade of F [though, putting it in perspective, this is 11 points lower than Microsoft Excel]
-- 84% of respondents rated their EHR <68, the average SUS score across industries
-- the highest scores by specialty were in anesthesiology (SUS score of about 53) and general pediatrics ( SUS score of 51)
-- the lowest scores were in general surgery at 32, in orthopedic surgery at 38
-- other primary care scores included general internal medicine and pediatrics subspecialty at 50, internal medicine subspecialty at 45, family medicine at 42
-- on multivariable analysis controlling for sex, hours worked, and nights on-call, when compared to general medicine:
-- family medicine was 10 points less on the SUS scale, -10.27 (-17.73 to -2.81), p=0.007
-- radiology 9 points less, -9.08 (-17.59 to -0.57), p=0.04
-- other specialties 8 points less,-7.58 (-14.41 to -0.76), p=0.03
-- general surgery 14 points less, -13.93 (-22.67 to -5.18), p=0.002
-- orthopedic surgery 11 points less, -11.42 (-19.85 to -2.98), p=0.008
-- practice location: those in academic medical centers rated their EHR use less favorably (SUS 43), those in a VA hospital rated the more favorably (SUS 58), vs those in private practice (SUS 47)
-- older physicians were more likely to rate their EHR less usable (for each one year older, coefficient -0.19)
-- no relationship between SUS by physician sex
-- burnout: average MBI emotional exhaustion score was 24, depersonalization score 7.1
-- 397 of 864 respondents (46%) had at least one symptom of burnout
-- as SUS scores increased, emotional exhaustion and depersonalization scores decreased
-- on multivariable analysis adjusting for sex, medical specialty, practice setting, hours worked, and number of nights on-call: EHR SUS scores were independently associated with burnout
-- each one point more favorable SUS score was associated with a 3% lower odds of burnout, OR 0.97 (0.97-0.98),p<0.001
Commentary:
-- there has been a large-scale adoption of EHRs in the US, spurred on by the $27 billion in federal incentives starting in 2009
-- by 2015 EHRs were used in 96% of nonfederal acute care hospitals; and by 2017 EHRs were used by 86% of office-based physicians
-- studies have suggested that physicians spend 1 to 2 hours on EHRs and deskwork for every hour spent in direct face-to-face contact with patients, and an additional 1 to 2 hours of personal time daily outside of office hours
-- prior studies have documented significant physician dissatisfaction with EHRs (see https://gmodestmedblogs.blogspot.com/2016/09/electronic-medical-records-take-lots-of.html which looks at the amount of time spent by physicians, finding almost twice as much time on the EHR than on direct clinical face-time with patients; and http://gmodestmedblogs.blogspot.com/2015/12/provider-computer-use-and-patient.html which douments patient and provider dissatisfaction with provider computer use)
-- for those of us who have used Microsoft Excel, it is quite striking that the average physician score was 11 points lower; and the highest score in physician subspecialties (in anesthesiology) was still 4 points lower than Excel. All of the SUS scores by specialty were firmly in the F grade range
-- clearly there are non-EHR reasons for physician burnout. They note that the emergency medicine physicians, who may benefit from the EHR's ability to provide information rapidly, may still be at increased risk of burnout due to factors in the emergency department other than the EHR. their data showed that the SUS score for ED physicians was around 50, in the higher range for physicians, though their burnout scores were actually quite high, in the 60% range (see their figure 4). Surgery on the other hand had very low SUS score of around 33, yet a relatively low burnout score at 42% [ie, it is not just EHR usability that leads to burnout, but it is a significant risk factor]
-- they did not comment on which EHRs were being used, noting that installations of the same EHR may be different in different settings [though, my guess is that all of us think our EHR is the worst]
-- There is likely a selection bias as to who responded to the 1st survey, with likely higher response by those who are most dissatisfied with EHRs. However, those who did respond but did not respond to the 2nd sub-survey was similar to the ones who did respond to that one. But, overall there was a good representation of US physicians with respect to age, years of practice, and prevalence of burnout. Also, this study only looked at physicians and not other members of the healthcare team and the results may not be generalizable to them. And, though the metrics they used (SUS and MBI) are the ones largely adopted by industry, it is unclear how applicable they are to healthcare
-- it is pretty clear that EHRs in general in the US are oriented to more administrative tasks (maximizing billing, easy access to QI information) than for clinical uses, which likely explains why we feel so oppressed by clicking around the record so much: "death by clicks", as coined by a famous Boston physician). i did hear a talk where the presenter mentioned that EPIC (the one i've used which has remarkably large numbers of excessive clicks) in Canada takes clinicians 1/3 the time to complete a note (no need for lots of information to optimize billing in Canada....)
so,
--a pretty large study finding that the usability of EHRs hovers within the "F" range for all physician subspecialties
--and there was a pretty significant correlation between the lower EHR usability and higher physician burnout
--i personally think the real issue is that EHRs in the US are geared to maximizing billing, making the purchasers (hospital administrators) really happy with them. And, we clinicians are left struggling with huge amounts of extra time needed to complete our documentation, leading to clinician dissatisfaction and (inevitably) less time spent with patients and less patient satisfaction and more clinician turnover. And, one big issue in the US is that most clinicians do not have the benefit of organizations (eg unions) to help organize them to fight back against the EHRs (of course, there are some real clinical benefits to having readable and organized clinic notes, but none of the EHRs i have used, especially EPIC, are really organized around maximizing the efficiency of clinicians in practice). Perhaps the excessive amount of time we need to spend on the EHRs leads to more exhaustion and less ability to organize ourselves to fight back???
geoff
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