How Technology Causes Physician Burnout
It seemed like a good idea at the time. The promise of clinical information systems (CIS), including electronic health records (EHRs) and other digital solutions, included fewer mistakes than hand-written notes, better continuity of care due to access to patient records in different settings, and more efficient record keeping so that providers would have more time with patients. But, just as John Maynard Keynes predicted in 1930 that economic efficiencies would lead to fifteen-hour workweeks a century later, electronic medicine hasn’t lived up to its promise of increased efficiencies for providers.
To be clear, CISs improve some aspects of care. In my current role as a clinical ethicist covering a large geographical area, the rollout next year of electronic records will make it much easier to do my work. Right now, if I get consulted about a patient in a different town, I either have to get a physician or nurse to give me details from the paper chart, or I have to go read it myself. The likelihood that I’ll miss something important is higher compared to reading it myself.
However, as Atul Gawande details in a New Yorker article, CISs have led to all sorts of negative outcomes, especially for physicians, who now spend about twice as much time entering data as they do seeing patients.
I have also seen the downsides of CISs in other places I’ve worked. One issue is just how much information they produce. Whereas it’s pretty easy to flip through a paper chart to find the right info, an electronic version produces reams of data: vitals, the result of every lab test, and copies of previous notes that providers add to every new note. One gets adept at figuring out where the valuable info is, but it’s definitely not faster than a paper chart. Gawande reports the same finding:
Doctors’ handwritten notes were brief and to the point. With computers, however, the shortcut is to paste in whole blocks of information—an entire two-page imaging report, say—rather than selecting the relevant details. The next doctor must hunt through several pages to find what really matters.
A result of all of this computer time is physician burnout. Studies have found two related issues. The first is the amount of time physicians spend documenting (1, 2, 3). The second is the usability of CISs (4). The usability issues Gawande documents are not just annoying; they are serious contributors to physician burnout. Here’s the conclusion from one study:
The usability of current EHR systems received a grade of F by physician users when evaluated using a standardized metric of technology usability. A strong dose-response relationship between EHR usability and the odds of burnout was observed (4).
The costs of burnout are substantial. Substance abuse, suicidal ideation, and depression are high among physicians. Burnout also leads to poorer care, as medical errors increase and patient satisfaction decreases. One study found that burnout doubles the risk of medical error (5). Since studies have found that burnout rates are above 50 percent among practicing physicians and residents (6, 7), and that this is a problem in many countries (8, 9) this is an issue that demands immediate action.
Since there are many causes of burnout, addressing the problem requires many approaches. However, technology plays a big role in burnout, so it should be a key focus of any effort. There are two components.
Offloading clerical burdens. One of the effects of CISs is that physicians are required to do more of the input themselves. Assistants, who take on a lot of the clerical work for paper processes, are unable to complete the same tasks with electronic formats. This partly explains why electronic processes are so much more time intensive for clinicians. One study found that computerized physician order entry is associated with a 29 percent increase in burnout (10).
The solution is to improve work processes. This would be a no-brainer even if burnout wasn’t occurring: It’s much more cost-effective to have physicians focusing on treating patients—i.e., practicing the skill for which they’re highly paid and highly trained—while having others relieve the clerical burdens. Given the high rates of burnout, getting physicians away from the computer is a necessity. There are reasons to require that physicians do more of the input, including security and preventing errors, but these reasons don’t outweigh the costs.
Optimizing CISs. Even with fewer clerical burdens, physicians will still need to use the CIS. Designers of these systems need to invest more in making them as efficient as possible for physicians while still ensuring that processes are consistently followed. Once again, there’s a trade-off, this time between physician freedom and standard practice. For some physicians, any external control will be viewed as an affront, but most physicians recognize that technology has promise.
The techno-optimists will say that CIS design just need more time. Health IT has exploded, so it’s understandable that there are growing pains, and issues will be addressed. Unfortunately, this isn’t a necessary truth. Lots of systems get worse over time, especially when they scale. It’ll take focused attention and buy-in to address this problem.
