EHRs, VBC, and COVID: a perfect storm for burnout?

Clinicians were pointing to EHR inefficiencies and value-based care (VBC) as contributors to burnout long before COVID hit, but the pandemic has dramatically exacerbated the underlying issues facing the healthcare workforce, according to a new study conducted by a team from George Mason University. 

In a series of semi-structured interviews with physicians and nurse practitioners working in primary care, the researchers identified several major themes contributing to feelings of burnout, stress, depression, including inefficient technology, increased demands on time due to value-based care, and the ongoing impact of traumas associated with the pandemic. 

“Anxiety, COVID, burnout and now depression,” said one physician of her experiences over the past several years of her career. “It’s not a doctor’s natural inclination… [to say to yourself] ‘you’re burned out.’ I think it’s really the events over the last three years, since COVID that tipped me over the edge. I personally developed clinical depression about a year and a half ago, the first time in my life, and it sort of spiked again this summer, and that is the result of burnout.” 

The EHR as a primary factor in burnout 

Dissatisfaction with EHRs has been well documented over the past twenty years of digital transformation. To their credit, EHR vendors have been working steadily with end-users to streamline workflows and implement assistive functions, including the latest generation of artificial intelligence and machine learning tools. 

But despite these efforts, recent events may be accelerating, rather than reducing, the burnout potential associated with technology tools. Clinicians working a typical eight-hour day seeing patients still spend more than five hours in their EHR, a recent JAMIA study pointed out, clearly illustrating the challenges of balancing patient care with administrative tasks. 

When asked about the role of the EHR in burnout, the majority of clinicians aged 55 and older agreed that their digital systems actively contributed to mental fatigue, stress, and frustration. Younger clinicians were more likely to view EHRs as a “double-edged sword,” says the study, with positive traits that are nonetheless paired with significant downsides.  

During the interviews, respondents used phrases like “death by a thousand clicks” to describe their interactions, and complained that “terrible” user interfaces resulted in highly inefficient workflows. 

Increased demands on a decreasing workforce 

Challenges with the technical use of the EHR are compounded by changing documentation requirements tied to VBC and other administrative issues, as well as patient communications prompted by the rise in consumerism, the interviews revealed.  

Some noted a rise in digital communications from patients, many of whom are also suffering from anxiety, depression, and pandemic-related health concerns, and said they felt obligated to answer whether or not the need was urgent.  

“I get a message about a paragraph long from a patient who has heartburn for two days and asked me what to do… you have to deal with these like constant bombardment, and that is my burnout,” admitted one provider. 

Most clinicians stated that they also perform at least some administrative work after hours, whether that’s answering patient queries or completing documentation in the EHR. 

“You kind of have to clean out that inbox, and you don’t get to it,” said one participant. “And that creates a layer on layer of stress in your mind, you know, like, okay, I’m not going to get to messages.” 

Another commented, “I have a colleague who comes in at seven, eight in the morning, and then doesn’t leave. He’s an extreme case because he doesn’t want to do any work at home. I don’t like to stay in the office that much; let me have the dinners with family. Yeah, but after dinner, then I’m doing the work.” 

With the “great resignation” tied to the COVID pandemic resulting in fewer primary care providers and support staff available to assist with patient communications and administrative work, the remaining workforce is struggling to keep up with shifting demands on their time and attention. 

Systemic solutions for the burnout epidemic 

Clinicians are problem-solvers by nature, and were quick to pair their complaints with potential solutions for helping themselves and their colleagues overcome the burdens of burnout. 

Change will have to take place at the systemic and organizational levels in order to be most effective, they agreed, but self-care will also play a part in helping individuals cope in the post-pandemic environment. 

Top suggestions included: 

• Implementing team-based care strategies to create a network of support and resources that spreads the load of patient care 
• Optimizing EHR functionality with “thoughtful design” that incorporates real-world user feedback and reduces the sense of “moral injury” associated with forcing users into convoluted, inefficient workflows 
• Reducing documentation needs by reexamining reimbursement and administrative processes and improving the interoperability of medical records 

Participants also pointed to organizational-level actions that can relieve burdens on physicians and other clinical staff, such as leveraging a third-party medical call center to address 90% of patient needs after hours and scheduling longer appointments for patients to ensure enough time to comprehensively address concerns. One practice has even hired nurse practitioners solely to cover other clinicians on their days off, making it more likely for staff to take time for themselves when necessary. 

The researchers conclude that the findings highlight the importance of taking a coordinated, system-level approach to addressing burnout, especially in light of the industry’s challenges after the pandemic. A combination of ongoing technical innovation, practice transformation activities, and the introduction of new administrative and reimbursement policies will be required to improve the mental health and experiences of the primary care workforce.  

Jennifer Bresnick is a journalist and freelance content creator with a decade of experience in the health IT industry.  Her work has focused on leveraging innovative technology tools to create value, improve health equity, and achieve the promises of the learning health system.  She can be reached at jennifer@inklesscreative.com.