Background Physician burnout has a direct impact on the delivery of high-quality health care, with health information technology tools such as electronic health records (EHRs) adding to the burden of practice inefficiencies. Objective The aim of this study was to determine the extent of burnout among physicians and learners (residents and fellows); identify significant EHR-related contributors of physician burnout; and explore the differences between physicians and learners with regard to EHR-related factors such as time spent in EHR, documentation styles, proficiency, training, and perceived usefulness. In addition, the study aimed to address gaps in the EHR-related burnout research methodologies by determining physicians’ patterns of EHR use through usage logs. Methods This study used a cross-sectional survey methodology and a review of administrative data for back-end log measures of survey respondents’ EHR use, which was conducted at a large Canadian academic mental health hospital. Chi-square and Fisher exact tests were used to examine the association of EHR-related factors with general physician burnout. The survey was sent out to 474 individuals between May and June 2019, including physicians (n=407), residents (n=53), and fellows (n=14), and we measured physician burnout and perceptions of EHR stressors (along with demographic and practice characteristics). Results Our survey included 208 respondents, including physicians (n=176) and learners (n=32). The response rate was 43.2% for physicians (full-time: 156/208, 75.0%; part-time: 20/199, 10.1%), and 48% (32/67) for learners. A total of 25.6% (45/176) of practicing physicians and 19% (6/32) of learners reported having one or more symptoms of burnout, and 74.5% (155/208) of all respondents who reported burnout symptoms identified the EHR as a contributor. Lower satisfaction and higher frustration with the EHRs were significantly associated with perceptions of EHR contributing toward burnout. Physicians’ and learners’ experiences with the EHR, gathered through open-ended survey responses, identified challenges around the intuitiveness and usability of the technology as well as workflow issues. Metrics gathered from back-end usage logs demonstrated a 13.6-min overestimation in time spent on EHRs per patient and a 5.63-hour overestimation of after-hours EHR time, when compared with self-reported survey data. Conclusions This study suggests that the use of EHRs is a perceived contributor to physician burnout. There should be a focus on combating physician burnout by reducing the unnecessary administrative burdens of EHRs through efficient implementation of systems and effective postimplementation strategies.

ABSTRACT

This case report describes an initiative implemented to improve physicians’ experience with Electronic Health Records (EHRs), and is one of several strategies within our organization developed to reduce physician burnout attributed to the EHR. The EHR SWAT Team—a 10-member team—with interdisciplinary representation from clinical informatics, pharmacy informatics, health information management, clinical applications, and project management, is a direct feedback channel for all physicians to express their EHR challenges and have their requests reviewed, prioritized, and fixed in a timely manner. Through in-person divisional meetings, we gathered 118 requests, 36.4% of which were related to re-education and 17% of which were quick fixes. Popular requests included keyword search functionality, minimizing freezing, auto-faxing and auto-save. Our brief evaluation of 46 physicians demonstrated that physicians were satisfied with the initiative, with 61.3% physicians reporting that it increased their proficiency in using EHR functionalities. Lessons learned from this initiative include the importance of buy-in from Information Technology (IT) and physician leadership, extensive physician engagement, and leveraging project management techniques for coordination. Next steps include measuring the impact of this SWAT initiative on EHR-related burnout through a post-intervention organizational wide survey and objective back-end usage logs.

The burden associated with using the electronic health record system continues to be a critical issue for physicians and is potentially contributing to physician burnout. At a large academic mental health hospital in Canada, we recently implemented a Physician Engagement Strategy focused on reducing the burden of electronic health record use through close collaboration with clinical leadership, information technology leadership, and physicians. Built on extensive stakeholder consultation, this strategy highlights initiatives that we have implemented (or will be implementing in the near future) under four components: engage, inspire, change, and measure. In this viewpoint paper, we share our process of developing and implementing the Physician Engagement Strategy and discuss the lessons learned and implications of this work.

Members of the matrix metalloproteinase family of enzymes degrade specific components of the extracellular matrix. MMP-9 is a type IV/V collagenase necessary for normal osteogenesis and is increased in inflammatory and neoplastic conditions. In such destructive diseases as emphysema and arthritis, and in epithelial cancers, MMP-9 is produced by cells of the monocyte lineage. Fetuin, a prominent serum glycoprotein, binds to and inactivates TGF-beta family members and through this mechanism regulates osteogenesis (Binkert et al., 1999, J Biol Chem 274:28514-28520.). We studied the effects of TGF-beta1 and fetuin on proMMP-9 release by the human monocyte line THP-1. Exogenous TGF-beta1 stimulated proMMP-9 release by THP-1 cells, with half-maximal stimulation at approximately 0.01 ng/ml TGF-beta1. Human fetuin (0.5-2 microM) partially inhibited this stimulation. Human fetuin alone stimulated THP-1 monocyte proMMP-9 release, with half maximal stimulation at approximately 0.25 microM fetuin. Neutralizing antibody specific for TGF-beta1 also stimulated proMMP-9 release, suggesting that endogenously-derived TGF-beta1 has an inhibitory effect. In freshly isolated human peripheral blood monocytes, fetuin stimulated proMMP-9 release with a dose-response curve similar to that observed in THP-1 cells. Human fetuin also activated proMMP-9 present in THP-1 conditioned medium. Taken together, these data suggest that under physiological conditions, fetuin facilitates matrix degradation by monocyte-derived MMP-9, both by opposing the autocrine inhibitory effect of endogenous TGF-beta1 on proMMP-9 release, and by activating proMMP-9 in the pericellular milieu. Conversely, fetuin may limit the stimulation of monocyte proMMP-9 release by high levels of exogenous TGF-beta1. Such modulation could prove important under pathological conditions where TGF-beta1 derived from paracrine sources is abundant, such as in epithelial malignancies.

Background Although EHR systems have become a critical part of clinical care, nurses are experiencing a growing burden due to documentation requirements, taking time away from other important clinical activities. There is a need to address the inefficiencies and challenges that nurses face when documenting in and using EHRs. The objective of this study is to engage nurses in generating ideas on how organizations can support and optimize nurses’ experiences with their EHR systems, thereby improving efficiency and reducing EHR-related burden. This work will ensure the identified solutions are grounded in nurses’ perspectives and experiences and will address their specific EHR-related needs. Methods This mixed methods study will consist of three phases. Phase 1 will evaluate the accuracy of the EHR system’s analytics platform in capturing how nurses utilize the system in real-time for tasks such as documentation, chart review, and medication reconciliation. Phase 2 consists of a retrospective analysis of the nursing-specific analytics platform and focus groups with nurses to understand and contextualize their usage patterns. These focus groups will also be used to identify areas for improvement in the utilization of the EHR. Phase 3 will include focus groups with nurses to generate and adapt potential interventions to address the areas for improvement and assess the perceived relevance, feasibility, and impact of the potential interventions. Discussion This work will generate insights on addressing nurses’ EHR-related burden and burnout. By understanding and contextualizing inefficiencies and current practices, opportunities to improve EHR systems for nursing professional practice will be identified. The study findings will inform the co-design and implementation of interventions that will support adoption and impact. Future work will include the evaluation of the developed interventions, and research on scaling and disseminating the interventions for use in different organizations, EHR systems, and jurisdictions in Canada.

Although electronic health record systems have been implemented in many health settings globally, how organizations can best implement these systems to improve medication safety in mental health contexts is not well documented in the literature. The purpose of this case report is to describe how a mental health hospital in Toronto, Canada, leveraged the process of obtaining Healthcare Information Management Systems Society (HIMSS) Stage 7 on the Electronic Medical Record Adoption Model to improve clinical care specific to medication safety in its inpatient settings. Examples of how the organization met several of these HIMSS criteria are described as they relate to utilizing data from the system to support clinician practice and/or decision-making for medication safety.

Summary This article describes the development and implementation of wellness initiatives within a large Canadian academic mental health hospital, based on the Mental Health Commission of Canada’s workplace standards for mental health. To support the implementation of an organizational framework for physician wellness, a needs assessment of Centre for Addiction and Mental Health physicians (N = 181) was conducted between 21 November and 5 December 2017, including measuring physician burnout rates using two items on the Maslach Burnout Inventory tool. Based on findings, and the organizational wellness framework, a multi-pronged wellness approach was developed, improving physician supports at the individual, team and organizational levels. Eighty-four survey responses (46% response rate) were gathered across eight clinical divisions, with 59% of respondents stating that they were negatively impacted by emotionally stressful events at work within the past year. Themes emerging from open-ended questions included the importance of a culture of safety and wellbeing, leadership accountability and availability of formal supports and processes. In response to survey findings, and our organizational framework, the following six initiatives were implemented: (i) a peer support program, (ii) an office of professionalism, (iii) individual and group mentorship opportunities, (iv) communities of practice, (v) enhanced training and leadership development opportunities, and (vi) efforts to optimize use of electronic health records to enhance efficiency of practice. It is possible to implement a multifaceted organizational approach to physician wellness, engaging physicians and continuously adapting in response to physician input. Future robust evaluation of these strategies can inform organizational roadmaps to improve physician wellness.