Physician Burnout and EMR - it's not about the Progress Note

Posted by Dike Drummond MD

EMR-EHR-Electronic-medical-records-physician-burnoutNew Study proves EMR is the Kraken of physician stressors - a multi-armed nightmare of overwhelm - where the Progress Note is the least of our worries.

The modern Electronic Medical Record is so much more than just a method to create a digital Progress Note. Yes, indeed. That is just the start of its contributions to the quality of your daily practice experience

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Your EMR's ability to send out multiple arms of stress into your work day ... each one sucking time and attention away from actually taking care of patients ... is so perfectly toxic to the practice of medicine, that a horror metaphor from the high seas is appropriate here. 

kraken-emr-electronic-medical-records-physician-burnout-in-basket-overload-opt240WEMR is the Kraken of physician stressors

You remember the Kraken; that ship-eating massive squid monster that would crunch your three masted schooner like a bag of potato chips and tear you limb from limb with the eagle beak hiding in the place where its legs all meet -  YUCK and OUCH !! 

Why a Kraken? Eight separate arms, any one of which can wrap around your throat and choke you out of your practice day. You can chop off seven and he/she/it can still wrap you up and take you down.

One of the arms of the EMR Kraken is the perfect click storm you must wade through just to document a simple Progress Note. This one task is onerous enough all by itself now that it is digital.

But the Progress Note doesn't seem to be the worst stressor for doctors.

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In a new study of EMR stress on 934 doctors at the Palo Alto Medical Foundation, researchers found:

"...we did not observe that the amount of time physicians spent in EHR progress notes was significantly associated with burnout."

emr-physician-burnout-in-basket-overloadWHAT ??

Well if the major stressor from EMR isn't the Progress Note, what the heck is blowing up our days? (you will nod your head, when you hear their findings)

"45 percent of physicians with burnout symptoms received greater-than
average numbers of weekly system-generated in-basket messages."

And what was the source of these messages?
... wait for it ...

"Almost half of all weekly in-basket messages came from EHR algorithms, and they were significantly associated with physicians having burnout symptoms and intending to reduce their clinical work hours. These are new findings that deserve careful consideration."

"The average number of weekly in-basket messages was 243, of which 114 (47%) were generated by the EHR system. These included pending orders automatically sent to physicians according to algorithm-driven health maintenance reminders, requests for prior authorization, patient reminders, and many more. Only 30 messages per week were directly from patients."

That's right, it's the In Basket - driven by your EMR

  • The In Basket is the arm of the Kraken that sneaks up on you from behind
  • There is a pipeline from your EMR into your In Basket. EMR drives two sources of overload for the price of one.

That's not all;

There are specialty differences in the severity of In Basket overload

"The finding that family physicians and internists receive disproportionately high numbers of system-generated messages (greater than 2.5 times the volume of surgeons, 4.0 times that of nonprocedural evaluation and management–oriented specialists, and 5.0 times that of nonsurgical proceduralists) also calls for our attention."

So family docs and internists, if you are feeling the In Basket is a massive drain, you are absolutely spot on. And your EMR is driving the majority of the items in the basket.

Their Recommendations?

Get ready for the DUH of the Day, because they really go out on a limb here:

"Physicians might not be the most appropriate recipients of some system-generated messages."

Our Recommendations?

We recommend you build and deploy a System-Wide Burnout Prevention Strategy and hard wire EMR stress reduction and Team Based Care protocols into your entire organization.

The time for more studies is LONG PASSED.
Any CMO could have discovered this In Basket overwhelm with a single provider survey asking, "What are the top three stressors in your practice day?" Let's GET BUSY Making a Difference!

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This In Basket - EMR connection is not something new - except to the academics

Even though the researchers state, " ... these are new findings" - that is a bunch of Hooey! This may be the first time an academic has made a valid statistical connection between the In Basket and burnout - and had their paper published - but anyone who has seen patients and used an EMR in the last five years is well aware of this EMR to In Basket pipeline.

In our work as coaches to burned out physicians, we have known the Progress Note is not the #1 EMR stressor for years. This awareness comes from working with our clients to get them a scribe and listening to them say -- down the road when the scribe is fully integrated into the practice -- "my scribe is awesome with the Progress Note and that is not enough."


Don't Wait for the Research, Help Your People NOW!

A single survey by any CMO could have discovered this connection within weeks of your first EMR implementation. All you have ever had to do is ask them, "What are the three biggest stressors in your day?"

  • The In Basket would have been up near the top of that list.
  • Pieces of the In Basket would have made any organizations G.R.O.S.S. Project List.
  • This should have been just a simple staffing issue. If you increase the workload with EMR, we simply need more hands on deck.

If you want specific, targeted suggestions on how to get started in Your Organization
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the-kraken-emr-ehr-electronic-medical-records-physician-burnout-physician-stress_opt240WRemember, the Kraken has six more arms!

In addition to In Basket, don't forget the relatively new developments of 24/7 patient access to the physician through

  • Text messaging
  • Email ... always the email
  • And always-open patient portals

All of these sources of daily distraction must be dealt with in order to free up the doctor to see patients and minimize their risk of burnout.

A couple of additional study findings of interest:

1) Which EMR was this?

The Palo Alto Medical Foundation has been an EPIC shop since 1999. So we must presume that this study is looking at one of the finest implementations of EPIC in the world. (yet this is what they found)

2) How to get the doctors to respond to the survey

This study backs up findings from several previous physician survey driven projects. If you want to get the doctors to return your survey, it really helps to bribe them!

The study authors got a 72% response rate to the survey by giving everyone a $10 gift card. Take note: bribes work with physicians and it does not have to be a lot of money.

3) We get a peek into the Palo Alto Medical Foundation physician demographics. How do these numbers compare to your organization?

-- 55% are female
-- 56% are over age 45
-- A staggering 71% do not work full time
-- 32% also occupy a leadership role in the organization



What is the biggest EMR stress in your day?
What role do things like the following play in your personal stress levels?

  • Progress notes
  • In Basket
  • Text and email messages
  • Patient portal access


This blog post is based on the article:
"Physicians’ Well-Being Linked To In-Basket Messages Generated By Algorithms In Electronic Health Records"
Health Affairs Vol. 38, No. 7: July 2019
Ming Tai-Seale, et al

Here is a ful PDF article download:

Tags: EMR, stop physician burnout