In late 2014, Bodenheimer and Sinsky wrote a perspective adding the goal of improving the work life of healthcare providers to Berwick’s Triple Aim (improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of health care). The authors quoted a 2011 survey stating that 87 percent of physicians named paperwork and administration as the leading cause of work-related stress and burnout.
A 2013 survey of 30 physician practices found that electronic medical records (EMRs) worsen professional satisfaction with time-consuming data entry and interference with patient care. Emergency room physicians spend 44 percent of their day doing data entry and only 28 percent of their day with patients.
In 2001, Maslach and her colleagues defined burnout (also called depressive anxiety syndrome) as a psychological syndrome in response to chronic interpersonal stressors on the job. Three key dimensions of this response are:
- An overwhelming exhaustion
- Feelings of cynicism and detachment from the job
- A sense of ineffectiveness and lack of accomplishment
The research group developed the Maslach Burnout Inventory to assess burnout. The authors go on to define a model that includes six work life areas that can affect burnout: workload, control, reward, community, fairness and values. The authors emphasize that these six elements are not a checklist, but a framework to understand how an individual views their work; subsequently, those elements may contribute to their specific risk for burnout.
So what can we do about burnout?
Burnout can be framed as the interaction of individual factors, situational factors, and organizational factors. Maslach et al. believe situational and organizational factors play a larger role in burnout than individual factors. Tactics to address individual factors (e.g., developing effective coping skills, deep relaxation) may not reduce the risk of burnout, as workers have much less control over stressors than in other aspects of their life. While it appears that people can learn new coping skills, it is less clear that people can apply these coping skills to work or reducing the risk of burnout.
To that end, Maslach et al. suggest employing a combination of organizational and individual tactics to address burnout. The authors believe leveraging other work life elements besides workload (i.e., control, reward, community, fairness and values) may help employees better reduce the risk of burnout.
Burnout in healthcare
The Society of General Internal Medicine held a symposium addressing the issue at their Annual Meeting in April 2013. The presenters published a manuscript in the Journal of General Internal Medicine in January 2014 describing a conceptual model of how interventions might prevent stress, burnout and turnover:
Linzer et al. suggest that burnout is a long-term stress reaction, and so institutions can measure progress toward burnout and intervene. The authors go on to list 10 steps to prevent burnout in general medicine:
- Make clinician satisfaction and well-being quality indicators
- Incorporate mindfulness and teamwork into practice
- Decrease stress from EMRs
- Allocate needed resources to primary care clinics to reduce healthcare disparities
- Hire physician floats to cover predictable life events
- Promote physician control of the work environment
- Maintain manageable primary care practice sizes and enhanced staffing ratios
- Preserve physician “career fit” with protected time for meaningful activities
- Promote part-time careers and job sharing
- Make self-care a part of medical professionalism
- Interventions to reduce burnout
In 2014, West et al. published their findings after randomizing 74 Mayo Clinic physicians to either one hour of protected time every other week for nine months. The curriculum included multiple modules including meaning in work, personal and professional balance, medical mistakes, community, caring for patients and other topics relevant to the work experiences of practicing physicians. The physicians randomized to the small-group curriculum demonstrated small improvements in empowerment, engagement at work, and rate of high depersonalization. The intervention did show small, but no statistically significant differences in stress, depression, overall quality of life, job satisfaction, mental and physical well-being, fatigue or empathy.
In that same year, Linzer et al. published a paper recruiting 166 primary care clinicians in 34 primary care clinics in a cluster randomized control trial with the clinic as the unit of randomization to either site-level interventions to improve work/life and clinician outcomes or usual care. The interventions were grouped into three categories:
- Improving communication especially among clinicians and staff
- Changes in workflow
- Targeted quality improvement
Overall, the intervention clinics noticed improvements in burnout and satisfaction with no statistically significant differences in stress or intent to leave. In the discussion section, the authors stated their strongest intervention was workflow modification, followed by communication improvement, especially among staff and clinicians.
Developing EMR interventions to address clinician burnout
Babbott et al. reviewed data from the Minimizing Error, Maximizing Outcome (MEMO) between 2001 and 2005 to determine relationships among number of EMR features available, organizational characteristics and physician stress, burnout, job satisfaction and intent to leave the practice. The researchers identified 15 EMR features that I group into the following categories:
- Chart review (display lab results, patient notes, radiology reports, and consult notes from other services)
- Data reconciliation (medication and problem lists)
- Orders (prescriptions, tests, and images)
- Decision support (prevention reminders, warnings about drug interactions and patient allergies, and obtain treatment alternatives/guidelines)
- Communication (with other physicians and patients)
The authors found physicians using an EMR with a moderate number of functions had more stress and less job satisfaction than those using an EMR with a low number of functions. In addition, time pressure was more related to adverse physician outcomes for physicians using an EMR with a high number of functions. Babbott et al. hypothesize that EMRs may not match workplace process and flow, challenging physicians as they try to complete their tasks with the patient present.
Thinking back to Maslach’s worklife elements, hospital and medical center leadership could engage physicians differently to increase their engagement with the EMR. To address control, invite physicians to engage with EMR design and prioritization sessions to influence how the clinical system can better serve the physicians’ needs. To address reward, educate physicians on how the EMR can help improve patient care independent of externally reported quality measures could improve intrinsic satisfaction with physicians’ performing their work. To address values, connect the physicians’ own sense of why they became doctors with the understanding of how EMRs can help them achieve those goals.
From an educational perspective, physician EMR training could include specific modules to address physicians’ intrinsic drive to deliver excellent care while helping them to appreciate the tools that exist to better engage patients with their health care (e.g., decision support tools, patient portal). Clinic, hospital, and health system leadership could consider mandatory training with re-credentialing cycles to verify that physician users are familiar with the most efficient techniques to complete specific tasks. Physicians who demonstrate increased stress could be referred to EMR educational teams for additional training to see if learning new EMR skills could reduce the risk of burnout.
From an optimization perspective, clinical and information technology leadership could prioritize those EMR enhancements that facilitate each healthcare team member’s ability to complete their tasks. Ideally, the tasks should be designed to be performed in front of a patient to increase transparency and reduce the total time required to complete the work. Physicians should be invited to provide input into what new functions or enhancements should be requested from the organization’s EMR vendor.
From a design perspective, EMR vendors or health information technology startups should consider opportunities to address workflow challenges in chart review, data reconciliation, ordering, decision support and communication. Reducing the cognitive burden required to complete specific tasks should simultaneously improve the physician’s performance of those tasks and allow that user to better focus on the patient’s specific complaint.
Moving the health care system from the Triple Aim to the Quadruple Aim will require a reorganization of how the industry prioritizes its work. Physicians could adopt tactics to increase their resilience toward work stress, but recognize that those strategies would be more likely to success in organizations that address situational and organizational factors. Clinics, hospitals and health systems could implement specific educational and optimization strategies to better engage physicians with EMR education and improvements, respectively. Finally, EMR vendors and health information technology startups could consider designing software changes that reduce the steps physicians perform to complete specific tasks to reduce the physicians’ perception of overload.