Association of Electronic Health Record Design and Use Factors With Clinician Stress and Burnout

IMPORTANCE Many believe a major cause of the epidemic of clinician burnout is poorly designed electronic health records (EHRs). OBJECTIVES TodeterminewhichEHRdesignandusefactorsareassociatedwithclinicianstressand burnout and to identify other sources that contribute to this problem. DESIGN, SETTING, AND PARTICIPANTS This survey study of 282 ambulatory primary care and subspecialty clinicians from 3 institutions measured stress and burnout, opinions on EHR design and use factors, and helpful coping strategies. Linear and logistic regressions were used to estimate associations of work conditions with stress on a continuous scale and burnout as a binary outcome from an ordered categorical scale. The survey was conducted between August 2016 and July 2017, with data analyzed from January 2019 to May 2019.


Introduction
The adoption of the electronic health record (EHR) has occurred alongside the dramatic and troubling rise in clinician stress and burnout. [1][2][3] This association has fueled the debate over the extent to which EHRs are associated with the epidemic of clinician stress and burnout. Technostress (ie, the stress related to technological tools in numerous industries) is real, 4 but the degree to which it is a factor in medicine is largely unknown.
The introduction of EHRs has resulted in shifting many clerical tasks to clinicians (eg, billing, coding, and quality control) as well as creating new tasks to be performed during clinical encounters (eg, data entry, computerized decision support, computerized order entry, and electronic prescribing). These new tasks have increased the cognitive and physical load on the clinician in many ways. 5,6 For example, e-prescribing, which has benefits, has also created an additional burden by requiring clinicians to know where to route prescriptions at the time they prescribe. This may be a relatively small burden, but repeated multiple times per day and added to the myriad other tasks shifted to clinicians, these technology-enabled tasks have considerably increased clinician workload.
In fact, an entirely new medical scribe industry has arisen in order to ameliorate the additional workload. 7 We designed this study (Minimizing Stress, Maximizing Success of the Electronic Health Record) to identify the relative contribution of aggregated EHR burdens compared with other burdens (ie, workplace chaos, control of workload) associated with clinician stress and burnout. This work is based on a conceptual framework derived from prior work ( Figure). 8 Our hypothesis was that EHR-associated stress adds to overall stress and could lead to burnout-which may play a role in the quality of patient care. In this study, we aim to understand which EHR design and use factors are associated with stress and burnout. The potentially challenging EHR design and use factors included in the survey instrument were identified through physician focus groups conducted in the first phase of the study. 9 The design and use factors studied were intentionally limited to those over which clinicians and their institutions might have some control. This in no way minimizes other societal factors, such as governmental regulation and malpractice, that could be associated with clinician stress and burnout. [10][11][12] This survey phase of our study quantifies the association of these EHR design and use factors with clinician stress and burnout to address the following questions: (1) what specific EHR design and use factors are most strongly associated with clinician stress and burnout? (2) What amount of overall stress and burnout is associated with EHRs? And, (3) what coping strategies or organizational solutions did respondents feel are important in addressing stress and burnout?

Identification of Challenging EHR Design and Use Factors
The methods for this study have been previously reported. 9 In brief, physician focus groups at 3 institutions (Stanford Hospital and Clinics, Stanford, California; University of New Mexico, Albuquerque; and Centura Health Physician Group, Westminster, Colorado) identified EHR design and use factors that were perceived as successful and those that were associated with user stress, burnout, or unintended physical symptoms. We also identified commonly used coping strategies by the clinicians.

Survey and Sampling
The EHR design and use factors identified in prior clinician focus groups informed the design of the survey instrument, which is freely available. 13 The instrument included questions from previously validated instruments to measure stress, burnout, and other challenges identified by Motowidlo,14 the Physician Worklife Survey, 15  The survey's design attempted to determine the following: (1) perceived EHR successes, (2) EHR design and use factors associated with clinician stress and burnout, (3) perceived adverse personal outcomes (eg pain or anxiety), (4) things that could improve the EHR experience (eg, greater staff support, scribes, or fewer clicks per task), and (5) coping strategies (eg, exercise or setting boundaries). We sampled clinicians (physicians and advanced practice clinicians, including nurse practitioners and physician assistants) at 3 institutions from 5 disciplines: general internal medicine, medical subspecialties, general pediatrics, pediatric subspecialties, and family medicine.
We excluded residents, as we thought they could have dissimilar experiences of stress and burnout than practicing clinicians. We determined respondent stress levels using the 4-item validated measures from Motowidlo, 14 a continuous measure that ranges from 4 to 20, and burnout using the single-item validated measure from the Physician Worklife Study, in which a score of 3 or more indicates burnout. 21 While a binary approach to burnout has been controversial, 22,23 this measure has been used and validated in many settings and among thousands of respondents for 20 years, and it is associated with adverse work conditions and adverse clinician outcomes, such as intent to leave the practice. We ran additional analyses using the 5-choice measure of burnout as an ordered categorical (as opposed to binary) outcome and found no substantive differences between the 2 methods.

Statistical Analysis
Answers to survey questions were analyzed as standard summary statistics. We reported continuous variables as mean and SD and categorical variables as number of respondents and percentages of total sample.
Linear regression was used to determine the association of focus group-identified variables (eg, work conditions, EHR design and use factors, and coping strategies) with clinician-reported stress, which we scored according to the Motowidlo 4-item measure, 14 and burnout. β was used to estimate the magnitude and direction of association, and it was calculated using the least-square estimation technique. We used logistic regression with stepwise selection, which is a combination of the forward and backward selection techniques, to estimate the association of focus group-identified variables with the odds of clinician-reported burnout, which we measured as a binary outcome based on a single question (with burnout representing endorsement of any choice with the word burnout in it). 14 We used construct variables created to summarize the associations of variables within the same domain with stress and burnout. (These showed that the models were well calibrated.) Finally, we performed a statistical factor analysis using the varimax rotation method on 9 EHR design and use items to summarize the association of EHRs with stress and burnout. We used SAS version 9.4 (SAS Institute, Inc) for all analyses. Statistical significance was set at P < .05, and all tests were 2-tailed. definitely likely to leave their practices within 2 years (Table 1).

Association of EHR Use and Design Factors With Stress and Burnout
The EHR design and use factors significantly associated with high clinician stress were information overload (β = 0.37; P < .001), slow system response times (β = 0.42; P < .001), excessive data entry

Other Factors Associated With Stress and Burnout
Factors not related to EHRs associated with high levels of variance in stress were office atmospheres  (Table 3), these variables, along with the EHR design and use factors listed in

Factor Analysis of EHR Stress Items
We performed a statistical factor analysis using the varimax rotation method on the 9 EHR design and use factors listed in Table 2. We found that the first 2 statistical factors from the factor analysis accounted for 52.2% of the variability in EHR design and use items. We characterize these 2 factors as follows: (1) interference with patient care (eg, note bloat, interference with patient-clinician relationships, and notes geared toward billing) and (2) inefficient systems (eg, slow system response times, inability to navigate the system quickly, and excessive data entry). Thus, more than half of the variance in EHR issues associated with clinician stress and burnout stemmed from interference with patient care and inefficient EHR systems.

Discussion
In this cross-sectional survey of 282 clinicians from 3 health systems, we identified 7 EHR design and use factors associated with high stress and burnout. These were information overload, slow system response times, excessive data entry, inability to navigate the system quickly, note bloat, interference with the patient-clinician relationship, fear of missing something, and notes geared toward billing. While previous studies have identified several of these EHR design and use items as challenging to clinicians, 9,24,25 we believe this study is the first to show an association between these factors and objectively validated stress and burnout scales.
In this study, 45.0% of participants described symptoms of burnout, consistent with the findings of the national survey by Shanafelt et al 2 in which 44% of physicians reported at least 1 symptom of burnout. The amounts of variation in stress and burnout associated with the EHR design and use factors listed in Table 2 were 12.5% and 6.8%, respectively. Thus, other sources of burnout aside from the EHR (such as lack of control of workload, chaotic environments, lack of attention to work-life balance, and ineffective teamwork) will also need to be addressed as medical practices seek to reduce burnout. Information overload may be associated with EHR design in which too much clinically unnecessary information is displayed. The aviation industry has a user interface design philosophy called quiet dark, where information is not displayed until something goes wrong or needs the pilot's attention. 28 In other words, the default state of all indicator lights is off during normal conditions.
Applying this philosophy to EHR design could potentially reduce the amount of unnecessary data displayed based on particular users' need and context, reducing the information overload problem.
Arguably, the current state of EHR design is loud bright, where virtually all information, normal or otherwise, appears in relatively the same manner regardless of its importance to the clinician or patient. Although abnormal results from laboratory tests are highlighted, all normal values are typically displayed and occupy the same amount of space and are given the same prominence as abnormal results. Given the proliferation of standardized templates as a time-saving tool for data entry, the amount of unnecessary, repetitive, normal information (ie, note bloat) is increasing vs a design where an economy of information relevant to the patient's current needs and context is used. 29 The data entry problem has created the scribe movement and produced promising results, at least in terms of clinician and patient satisfaction. 30 However, scribes only help with data entry during office visits and not with EHR tasks at other times and in other venues. A more comprehensive approach is to use specially trained medical assistants (MAs) to relieve the clinician from clinic tasks (eg, responding to routine in-basket messages, refilling some prescriptions per protocol, completing paperwork). Before the clinician meets the patient, the MA completes prework (eg, medication reconciliation, review of systems, documentation of chief concern, and any protocolized clinical measurements, such as peak flows or pulse oximetry). The MA scribes during the clinician encounter, and after the clinician leaves the room, the MA can review the plan of care, deliver patient education, process referral requests, and schedule follow-up appointments. 31 Some of the troublesome EHR design and use factors, such as the inability to navigate the system quickly, are attributable to computer-human interaction problems. In fact, most of the current EHR user interface designs are still based on 2-dimensional paper metaphors (eg, tabs, flowsheets, tables, and forms) and do not take advantage of the potential of graphics capabilities now in the most basic computers. 32 More research to determine what display metaphors beyond paper are most efficient could help. Complaints of interference with the patient-clinician relationship is evidence that clinicians are troubled by their excessive focus on the screen rather than the patient.
While most studies have shown the presence of the EHR in the exam room does not adversely affect patient satisfaction, 9,33,34 clinicians feel that EHRs requiring clinically irrelevant data entry take away from their relationships with their patients. 35 Our study shows that this is significantly associated with clinician stress and burnout.
The proportion of clinicians reporting pain (47.5%) and posture issues (51.1%) attributed to EHR use was high. Ergonomics are rarely addressed in most clinical settings. Clinicians often must work at several workstations, with different heights and seat structures. Collaboration with employee health groups skilled at ergonomics could potentially have a substantive effect on the health outcomes of our clinician workforce. 36 This is an area ripe for further quality improvement studies.
Coping strategies clinicians suggested to reduce EHR-associated stress included exercise (used by 68.1% of our sample), verbally discussing issues with other clinicians (68.8%), and setting boundaries for work while at home (57.1%). Setting boundaries, exercise, and taking breaks were significantly associated with reductions in overall stress and burnout and may be useful components to incorporate into stress reduction interventions. It is not clear how many of these strategies clinicians actually used or how effective they were at using them.

Strengths and Limitations
The strengths of this study include surveying a diverse group of clinicians, including academic, community-based, and rural institutions and practices, physicians and advanced practice clinicians, and a mix of specialists and nonspecialty ambulatory care clinicians. In addition, the list of the EHR design and use factors the clinicians rated in the survey was defined by clinicians in multi-institutional focus groups. 9 The survey response rate (44.1%) was reasonable for large clinician-based studies with no financial incentive. The design of the instrument included questions previously validated in studies of physicians about stress and burnout.
This study has limitations, including its cross-sectional nature and the use of self-reported metrics. One needs to consider response bias, given the 44.1% response rate. The relatively modest sample size limits validity. As respondents came from only 3 institutions, these results may not be more widely generalizable. The mapping of the paper instrument's Likert scales to the REDCap slider bars scale may have introduced some bias. Despite using validated instruments to measure burnout and stress, the survey relied on the respondents' own definitions. Self-reported metrics may underrepresent the numbers at risk. As Knox et al 37 found, a self-defined, single-item burnout measure identified significantly fewer physicians most at risk of burning out compared with the Maslach Burnout Inventory. All respondents were grouped together for this analysis, which does not account for possible intragroup differences, such as between physicians and advanced practice clinicians. 37

Conclusions
Stress and burnout associated with EHRs is prevalent and may be at least partly remediable at the local level. The issues identified in our list of EHR-associated challenges may provide designers, government regulators, and clinical leaders with targets for improvement of EHR design. Other work conditions are associated with stress and burnout in clinicians and deserve equal attention.