Provider burnout is a phenomenon representing an increasing concern in healthcare with debate regarding the role that Electronic Health Records (EHRs) play given the changes in workflow EHR implementation often results in.
Dr. Christina Maslach Ph.D is a prominent social psychologist and one of the pioneer in the field for studying the burnout phenomenon. In 1996, she developed the Maslach Burnout Inventory, a tool to assess burnout based on several questionnaires. The essential concepts captured by the MBI collectively encompass the definition of provider burnout and include:
1)Emotional exhaustion or loss of passion for one's work,
2)Depersonalization and cynicism, resulting in treating patient's as objects,
3)Loss of personal fulfillment and the sense that one's work is meaningful.
Scope of Problem
Medscape conducts surveys and reports to assess the scope of the provider burnout phenomenon. In 2013, Medscape found in their annual Lifestyle report that the overall burnout rate among responding physicians was 40%. This has been trending upward over the last few years, with the most recent 2017 report demonstrating an overall burnout rate of about 51% among responding physicians.
Consequences of Provider Burnout
A number of studies have evaluated the impact of provider burnout and have found a general negative relationship between burnout and provider productivity as measured by number of sick days being taken, self-perceived work ability, intent to change jobs, and intent to continue practicing medicine. Further detrimental consequences even include provider depression and suicide as well as an increased rate of medical errors.
Relationship to Electronic Health Records
There is debate regarding the role of the implementation of Electronic Health Records on provider burnout. There is some studies suggesting increased provider frustration due to the perception of increased clerical burden associated with the use of EHRs. The Mayo Clinic published a 2016 study surveying 5000 providers and found that approximately 40% of providers reported dissatisfaction with the use of their EHR, and that 60% of providers disagreed that EHRs had improved their efficiency. Another concern regarding EHRs is described as "pajama time", a term which refers to the amount of time a provider spends doing administrative EHR work at home after work hours. A retrospective study of 142 Family Practice physicians published in the Annals of Family Medicine in 2017 found that providers spent an average of 86 minutes of "pajama time" a night.. This is concerning particularly when considering that a separate study looking at 24 primary care residency practices in the Southeast US found that providers who spent over 6 hours on EHR work beyond normal work hours were almost 3 times as likely to report burnout.
One of the speculations regarding why there may be a negative association between provider burnout and EHRs arises from the observation that, unlike in other industries where automation or digitalization of process makes work easier or alleviates a burden on a human, the electronic medical record has added work to a provider, often requiring them to act as coders in addition to their clinical duties. It should be noted that there is some evidence of improved provider satisfaction with EHR use, such as that found with more accurate provider handoffs when integrated with the EHR.  Indeed, EHRs that are better designed with provider clinical workflows in mind may contribute to decreased "pajama time". In addition, a growing importance is placed on developing team-based approaches to address the clerical and administrative burdens that contribute to "pajama time" and burnout risk. It is hoped that over time, effective solutions may contribute to improved work-life balance around the EHR and decreased provider frustration and burnout.
4. Dewa, C. S., Loong, D., Bonato, S., Thanh, N. X., & Jacobs, P. (2014). How does burnout affect physician productivity? A systematic literature review. BMC Health Services Research, 14, 325. doi:10.1186/1472-6963-14-325 [doi]
5. Dyrbye, L. N., Thomas, M. R., Massie, F. S., Power, D. V., Eacker, A., Harper, W., . . . Shanafelt, T. D. (2008). Burnout and suicidal ideation among U.S. medical students. Annals of Internal Medicine, 149(5), 334-341. doi:149/5/334 [pii]
6. Fahrenkopf, A. M., Sectish, T. C., Barger, L. K., Sharek, P. J., Lewin, D., Chiang, V. W., . . . Landrigan, C. P. (2008). Rates of medication errors among depressed and burnt out residents: Prospective cohort study. BMJ (Clinical Research Ed.), 336(7642), 488-491. doi:10.1136/bmj.39469.763218.BE [doi]
7. Shanafelt, T. D., Dyrbye, L. N., Sinsky, C., Hasan, O., Satele, D., Sloan, J., & West, C. P. (2016). Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clinic Proceedings, 91(7), 836-848. doi:10.1016/j.mayocp.2016.05.007 [doi]
8. Arndt B.G., Beasley J.W., Watkinson M.D., Temte J.L., Tuan W., Sinsky C.A., Gilchrist V.J. (2017). Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations.Ann Fam Med September/October 2017 vol. 15 no. 5 419-426. doi: 10.1370/afm.2121
10. Robertson, S. L., Robinson, M. D., & Reid, A. (2017). Electronic health record effects on work-life balance and burnout within the I3 population collaborative. Journal of Graduate Medical Education, 9(4), 479-484. doi:10.4300/JGME-D-16-00123.1 [doi]
12. Palma, J. P., Sharek, P. J., & Longhurst, C. A. (2011). Impact of electronic medical record integration of a handoff tool on sign-out in a newborn intensive care unit. Journal of Perinatology : Official Journal of the California Perinatal Association, 31(5), 311-317. doi:10.1038/jp.2010.202 [doi]
15. Contratto, E., Romp, K., Estrada, C. A., Agne, A., & Willett, L. L. (2017). Physician order entry clerical support improves physician satisfaction and productivity. Southern Medical Journal, 110(5), 363-368. doi:10.14423/SMJ.0000000000000645 [doi]
Submitted by Peter Nguyen, MD