Why automating data entry can counter physician burnout

Burnout, defined as physical and emotional exhaustion as a result of prolonged stress, has become shockingly prevalent among U.S. physicians. Doctors experiencing professional burnout not only put their own well-being at risk, but also that of their patients.

A number of studies have found that distressed healthcare providers make more mistakes on the job. Surgeons who feel burned out have a higher likelihood of reporting major medical errors, which are estimated to be the third-leading cause of death in the U.S. ahead of stroke and diabetes. Half of surveyed physicians believe that overwork, stress and fatigue among health professionals significantly contribute to medical errors.

In recent years, changes to the healthcare practice environment have caused the problem of burnout to worsen. According to a survey by the Mayo Clinic, over half of U.S. physicians experienced at least one symptom of professional burnout in 2014—an increase of almost 10% from just three years earlier.

The swelling proportion of exhausted, unhappy doctors can be blamed on a perfect storm that has rapidly expanded a typical physician's workload.

The size of their patient panels is rising because of the Affordable Care Act's insurance expansion. The nation continues to age with the number of Americans 65 and older growing at 10,000 per day. Demographers project the Medicare-eligible population will more than double by 2060. Older people require more care.

New government policies also put the pressure on doctors. Most recently, the Medicare Access and CHIP Reauthorization Act (MACRA) (PDF) of 2015 aims to eliminate independent fee-for-service medicine and introduces a program called the Merit-based Incentive Payment System (MIPS). Doctors are graded on quality of care, resource use, meaningful use of EHRs and clinical practice improvement activities. MIPS will then punish those who don't make the grade with fee cuts, adding another layer of stress for providers.

At the same time, the sweeping, systemwide transition from a paper-based medical record system to electronic medical records has saddled physicians with new and oftentimes confusing burdens.

A study published in July by the Mayo Clinic Proceedings explored the relationship between clerical tasks, the electronic practice environment and burnout. Doctors who used EHRs and computerized physician order entry (CPOE) had lower levels of satisfaction because of the amount of time spent on clerical tasks and reported higher rates of burnout.

“There are several broad categories of contributors to physician burnout, including greater work hours and effort, poor work efficiency and support, and loss of meaning in work,” said Dr. Colin P. West, professor of medicine, medical education and biostatistics at the Mayo Clinic, who co-authored the study. “Although the promise of the electronic medical record has been to allow more efficient, higher-quality care, often clerical tasks and electronic medical records negatively affect all of these contributors.”

But there's promise amid all this peril. As West and other experts point out, operational changes that deliver the promised benefits of electronic systems can help lift the burden off physicians. For instance, automation of routine tasks like prescription refill requests or pre-visit planning could counter burnout by giving doctors more time for direct patient care.

“We need to turn this around so that the EHRs and data collection systems help physicians and patients by organizing information so that direct patient care is more efficient, errors can be averted and quality of care can be optimized,” said West. “In short, we need the technology to support its users rather than the current norm of the users serving the technology.”

The adoption of EHRs and other electronic tools—originally touted as time-saving, streamlined methods to manage and share data—have levied an unintended tax on physicians' time. More documentation and other clerical tasks to meet legal and regulatory requirements have been dumped on physicians' plates, leaving less opportunity to interact with patients.

The extra time required for these routine tasks often crosses the borders of the office into the physician's home, disrupting work-life balance and personal relationships. Those who decide to leave their practices cause interruptions in care for patients, as well as increased costs to the medical system for recruitment and replacement.

“Because the physician role includes legal and regulatory authority, a lot of tasks that used to belong to the medical assistant, nurse, or resident—lab requests, lab results, prescription refills, patient calls—get lumped under the physician's control,” said Vic Arnold, managing director at Huron Healthcare. “Health systems spend a significant amount of time post-EHR implementation trying to filter out what the physician should really be touching.”

Despite the hassles around implementation, experts say technology in healthcare has the potential to save time, raise productivity and reduce errors. While the current transition period places a heavy burden on doctors, the hope is that eventually EHRs and other digital tools will serve clinicians in ways that are beneficial while offsetting the increasing demand for care.

In addition, if such tools can be implemented on a widespread scale, they could help relieve the looming problem of physician shortages that many are predicting for the future.

Linda V. Green, a professor of healthcare management at Columbia University, had seen reports predicting a shortage of primary care physicians due to expanding insurance coverage and an aging population. Most had been based on simple ratios, such as one physician per 2,500 patients. Finding the estimates quite superficial, Green decided to use her background in quantitative modeling and queuing systems to determine whether a shortage would indeed occur.

“The whole idea is to provide timely access to care, so that's the question to answer: Are there enough physicians to provide access to care in a timely fashion for those who are demanding it?” she said.

Green and her colleagues used data from the National Ambulatory Medical Care Survey and the Medical Expenditure Panel Survey to estimate patient demand probabilities.

Their analysis, published in 2013 by Health Affairs, showed that the use of primary care physician pools supported by non-physician professionals and EHRs can increase efficiency and the ability to handle larger patient panel sizes.

“There are so many factors that to me seem to indicate that we can reduce our dependency on physicians quite a bit and leverage other resources,” said Green. “Studies show that a significant proportion of primary care office visits can be handled by another person or another technology.”

For instance, a recent report by the National Institute of Standards and Technology looked at how human factors modeling methods can improve EHR workflow integration into the overall clinical workflow. The authors recommend EHR developers find ways to increase efficiency for bottleneck tasks such as drafting pre-populated orders to be formally executed later and the ability to document care with shorthand.

Operational changes involving EHR-based technology could offset the increased demand for care that looms around the corner. And after an initial learning curve, more health systems and private practices can begin to harness the power of this new electronic environment.

“A hundred or more years of paper-based process have moved into an electronic workflow, which has a huge impact on the physician,” said Arnold. “Success in this transition period means understanding the various wrinkles in the system and making sure all the plumbing is properly thought through.”

Next week in Part 2 of Automating Clinical Tasks, Scripps Health searches for a solution that will relieve physicians of the need to respond to routine prescription refill requests.

Meeri Kim is a freelance writer based in Los Angeles.