- A survey of 934 physicians with the Palo Alto Medical Foundation (PAMF) found they received an average of 243 electronic "in-basket" messages per week regarding their patients. Of those, nearly half were automatically generated by PAMF's EHR.
- According to the survey results, published Monday in Health Affairs, 36% of responding doctors reported symptoms of burnout, while 29% said they intended to reduce their clinical workload in the next year. Additionally, 42% of surveyed physicians received EHR-generated messages at higher-than-average volumes. Those doctors had a 40% greater likelihood of reporting symptoms of burnout and a 38% higher probability they wanted to cut their clinical work hours.
- The study's authors suggested shutting off automatic messaging to doctors when they're off work and altering EHR-related workflows so some tasks are delegated to other employees. They also urged EHR designers to rethink messaging algorithms, as "physicians might not be the most appropriate recipients of some system-generated messages."
When medical practices began deploying EHRs in the 1990s, the intent was to centralize patient medical histories to maximize efficiency and help avoid errors such as contraindicated medication orders. However, evidence continues to mount that physicians have had their workload divided between seeing patients and inputting data, a factor leading to costly burnouts.
At PAMF, a multi-specialty medical group affiliated with California hospital system Sutter Health, physicians received an average of 114 EHR-generated messages per week. But internal medicine and family practice doctors received more than 200 weekly messages — an inflow five times greater than some specialty physicians, and 2.5 times that of surgeons.
Many PAMF physicians compare the flow of EHR-generated messages to "a fire hose that is never turned off," Dominick Frosch, director of the organization's research institute and senior author of the Health Affairs study, told Healthcare Dive. "Messages accrue in their in-basket all day long. They go to bed and wake up, and there are even more messages. It feels very overwhelming." The study suggested message volume — not content — was more likely contributing to burnout.
The messages usually remind physicians to order lab tests, or authorize referrals to specialty care. The physicians received EHR-generated messages at nearly double the rate of communications from their own patients and other doctors. PAMF's internal medicine and family practice physicians received an outsized share of such messages.
EHR-generated messages often contain reminders for mundane tasks such as ordering periodic blood tests for diabetic patients. "If you have 400 patients with diabetes, that's 400 messages alone every few months," study lead author Ming Tai-Seale, a professor at the school of medicine at the University of California San Diego, told Healthcare Dive.
Respondents' deployment of coping mechanisms for such workloads is uneven at best. The survey found that while 70% of respondents exercised at least twice a week, just 36% slept seven or more hours a night and only 31% engaged in mindfulness activities once a week. Tai-Seale noted a previously established correlation between using electronic devices such as smartphones for too long and a lack of sleep. Although this was not explored specifically in the study, she said there was a possibility vigilance in responding to EHR messages (which PAMF's doctors can read on smartphones) was contributing to sleep loss.
The study authors suggested that "limiting desktop medicine work during evenings, weekends, and holidays, unless the physician is on call, could reduce burnout."
And while the authors also suggested some tasks be delegated to other clinicians like nurses, Tai-Seale observed many payers still require physicians to sign off on test orders. The study suggested that payers rethink some of those policies.
To help alleviate burnout, PAMF launched a pilot project in spring 2018 known as the Multi-disciplinary Inbox Support Team (MIST). Instead of doctors receiving EHR-generated messages automatically, they are first sent to a pool of pharmacists, nurses and medical assistants, who endeavor to handle the task independently. If pool staff determines that physician intervention is required, the message is routed to the appropriate doctor.
The MIST initiative, first deployed at a PAMF clinic in Santa Cruz, California, almost immediately reduced EHR-generated messages to physicians by 27%. The participating doctors "felt it provided substantial relief," Frosch said. MIST is currently being introduced to other PAMF sites, he added.