Physician Burnout

At a recent Minnesota HIMSS meeting, one of the speakers said that blaming EHRs for burnout was scapegoating, and that physicians had experienced burn out and were committing suicide long before EHRs were in use.1 Reports in 2017, however, have shown the time spent on EHR documentation, clinician attitudes regarding documentation in EHRs and self-reported satisfaction among physicians with EHRs they use today. The results are grim – time spent on documentation is burdensome, physicians are not satisfied with EHRs and some even plan on leaving the practice of medicine for new careers.

Are EHRs the cause of physician burnout? Evidence points to some percentage of the blame being attributed to additional burdens of EHR documentation, with “pajama time” now a term used for physicians’ work at home in the evenings and on weekends. To study this phenomenon, 3 years’ worth of a single system’s family medicine physicians’ EHR event log data were analyzed.2 It found that these primary care physicians spent 5.9 hours/day on EHR documentation, of which 4.5 hours were during clinic hours and and 1.4 hours after clinic hours, as well as almost 2 hours EHR documentation time for each hour of direct patient care. Although surveys of physicians’ time spent on documentation had previously been reported, this is the first analysis of clinic physicians’ actual time spent on this activity, including a breakdown of the various tasks involved. Some specific issues addressed were time spent on order entry, time spent on billing, coding and system security and inefficiencies in communication mechanics. Addressing any of these require EHR system application changes, which need to be carefully and thoughtfully done to not cause even further disruption.

Why are these problems coming to light now? Federal legislation passed in 2009, along with other new regulatory and payment requirements, created a “perfect storm” of new requirements for EHR vendors and providers alike.3 Rapidly advancing deadlines with substantial rewards and penalties made it unlikely that better systems would become available soon. As a result, untested and unproven systems became widely implemented over a short period of time. The results were reflected in a 2016 survey showing that 70% of physicians thought EHRs reduced their productivity and 75% thought they increased their practice costs.4

Are there solutions? Some proposed solutions suggest better collaboration among multi-disciplinary teams and longitudinal care records could enable better, more efficient communication. They also call for more patient documentation to promote information accuracy and better feedback for physicians.5 These solutions will require some global changes to today’s “digital health records”.6 When looking to other industries, we should expect major changes like this to take place in the next 5 to 10 years.7

Other proposed solutions involve re-design of medical and healthcare delivery to include changes in data acquisition and management as well as diagnosis and decision-making. As one small example, computerized physician order entry (CPOE) has been especially burdensome to physicians with little evidence that it has improved patient safety.8 Allowing support staff to enter orders from written physician orders or checklists may reduce physician clerical work and result in no greater risk to patient safety. The American College of Physicians has also called for an effort to review and eliminate as many administrative tasks as possible to reduce the burden on physicians and patients. They recommend that not only should these administrative tasks be carefully vetted, and also call for a way for research and collaboration to reduce the burdens they impose while achieving better quality of care and patient safety.9

Artificial intelligence and “big data” are often cited as the answer to cutting costs by operationalizing diagnosis and treatment with algorithms and reducing errors with better clinical decision support. This assumes we have all the data needed and in one place so analysis is possible. Interoperability and data sharing have improved, but we are far from having the data available to deliver truly personalized medicine. Perhaps we have not yet learned all the lessons about the complexity of using genomic data for diagnosis and treatment prognostics, and a new science of “network medicine” is emerging that may give us better insights into how to incorporate environmental, social and behavioral data to help deliver the best diagnoses and treatment recommendations.10 That kind of rich data is not yet routinely collected, but is becoming more available as patients, clinicians and researchers begin to understand its importance in understanding how best to optimize health as well as prevent and treat diseases. Interoperability as we understand it today will move the ball, but we need to consider a much richer set of health-related data to both understand what interventions and treatments most effectively address problems and how to apply them to individual patients.

1 Agree or disagree – The use of Health Information Technology has led more to provider satisfaction than burnout. Presentation sponsored by Minnesota HIMSS, MMGMA and the University of Minnesota Carlson School of Management’s MILI Program (December 5, 2017). Program accessed at

2 Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations. Ann Family Med 15(5):419-26 (2017). Accessed at

3 Halamka JD, Tripathi M. The HITECH Era in Retrospect. N Engl J Med 377(10):907-9 (2017) Accessed at “Soon physicians were expected to provide high-quality care and empathetic care in a 12-minute visit while weaning themselves from paper-based workflows, entering numerous structured data elements required for meaningful use, rolling out new HIPAA privacy notices, implementing security protections for new electronic data, learning and incorporating new ICD-10 billing codes, and convincing their patients to use patient portals and secure e-mail, all while avoiding safety and malpractice issues.”

4 Aldinger K. Why are EHRs still so terrible? Medical Economics blog (October 23, 2017). Accessed at

5 Rotenstein LS, Huckman RS, Wagle NW. Making Patients and Doctors Happier – The Potential of Patient-Reported Outcomes. N Engl J Med 377(14):1309-12 (2017). Accessed at

6 Powell C. A Digital Transformation in Health. Microsoft eBook (2017). eBook can be accessed at

7 Perna G. What Will EHRs Look Like in Five Years? Physicians Practice (June 14, 2016). Accessed at

8 Wolfstadt JI, Gurwitz JH, Field TS, et al. The Effect of Computerized Physician Order Entry with Clinical Decision Support on the Rates of Adverse Drug Events: A Systematic Review. J Gen Intern Med 23(4):451-8 (2008). Accessed at

9 Erickson SM, Rockwern B, Koltov M, et al. Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians. Ann Intern Med 166(9):659-61 (2017). Accessed at

10 Greene JA, Loscalzo J. Putting the Patient Back Together – Social Medicine, Network Medicine, and the Limits of Reductionism. N Engl J Med 377(25):2493-9 (2017). Accessed at