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How Big a Role Is Health IT Playing in Physician Burnout?

May 23, 2016
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Increase in documentation requirements seen as ‘death by a thousand cuts.’


The Boston Globe featured an article May 17 under the headline “New $1.2b Partners computer system brings prescription for frustration.
The story details the frustration of some Partners Healthcare providers with how the Epic implementation has gone initially. It starts with an anecdote of maternity nurse Judy Lydon, who says she has “become a captive of the keyboard, spending far more of her time recording every blood pressure reading, every feeding, every diaper change. The demands of the new system are so taxing and time-consuming, Lydon said, that the computer has come between her and her patients.”

The voices of providers are growing louder in expressing concerns that they spend too much time entering data and completing charts and not enough in human interactions with patients. There’s evidence that it is leading some clinicians to leave the profession. In fact, John Halamka, M.D., CIO of Beth Israel Deaconess Medical Center and well-respected for his dedication to advancing health IT, was pessimistic after analyzing the Notice of Proposed Rulemaking for MACRA. “As a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory,” he wrote in his May 5 blog post.

So how bad is physician burnout and how related is it to frustrations with health IT? One group of researchers is trying to find the answers. I spoke recently with Philip Kroth, M.D., associate chief medical officer and director of biomedical informatics research, training and scholarship at the University of New Mexico Hospitals. He and colleagues from several other health systems are in the middle of a two-year, AHRQ-funded study of the factors associated with clinician stress and burnout called MS-Squared (Minimizing Stress, Maximizing Success from Health Information and Communications Technologies).

The first phase of the study involved questionnaires and focus groups with 41 primary-care clinicians at UNM, Stanford University and Centura Health in Colorado. The goal, Kroth said, is to determine the reasons health IT contributes to stress or burnout and some possible solutions that could inform better user interface design. The second phase, just being launched, will dive deeper with surveys of 450 clinicians.

Working with Kroth on the MS-Squared study are Nancy Morioka-Douglas, Stanford University; Sharry Veres, Centura Health; Sara Poplau, Minneapolis Medical Research Foundation; Katherine Pollock, Cabrini Partnership Programs; and Mark Linzer, Hennepin County Medical Center.

The message from many of the participants in the focus groups is that they are spending too much time with EHRs at home, Kroth said. “We think, just talking to people anecdotally, that for every full day they spend in the clinic, they have two hours of documentation to do with the EHR afterward. “So either you do that at home or you stay late at work,” he said. “We asked people what their coping strategy is. Some say they are writing shorter notes; some say, ‘I never work at home; I keep my home and work life separate.’”

Here are some results of a response by participants to a questionnaire:

•       22% indicated sufficient time for documentation.

•       56% agreed with “I feel a great deal of stress because of my job.”

•       42% reported “poor” or “marginal” control of workload.

•       90% reported satisfactory or better proficiency with EHR.

•       56% felt that amount of time spent on EHR at home was “excessive” or “moderately high.”

“What surprised us is that people can really see the potential for the technology to be helpful, but they believe it is not implemented well,” Kroth said. “They talk about how difficult it is for data to transfer between institutions, for instance.”

Although physicians can see the clear value in having structured data, the increase in documentation requirements is a death by a thousand cuts, he said. “Everyone agrees that medication reconciliation is a good thing to do, so they made it a requirement for Meaningful Use and MACRA. Then all the vendors had to create a way for physicians to document it,” Kroth explained. “With our EHR vendor, you have to go through a few screen transitions and it is a little awkward to do, but that would be OK. The problem is that there are dozens of things like this. It seems like there is no one keeping track of the cumulative effect of that. When someone proposes a new regulation to require recording something, there doesn’t seem to be an accounting done as to what the burden will be on physicians.”

Researchers also have found that how much control physicians have over work processes matters a lot. “Does the institution work with physicians?” Kroth asked. “How much do they involve them in process design? MACRA is going to be driving a lot of the requirements impacting how physicians practice and the amount of support they need. There is no one magic bullet, but we are gathering lots of interesting comments.”

These surveys and focus groups are being done in fairly large primary care settings in urban areas. But what about small practices in rural areas? “We think these problems are probably much worse in rural areas where you don’t have as much specialty support,” he said.