Poorly designed, time-consuming electronic health record user interfaces are a common and longstanding complaint among doctors and nurses.

Interfaces that are not intuitive or that require too much effort to accomplish necessary recordkeeping can push clinicians – many of whom already are charting at home after hours – too far. It’s just more stress on top of existing burnout, especially during the pandemic.

In this seventh feature story in the Healthcare IT News Burnout in the Age of COVID-19 series, usability experts from three top EHR vendors and one top technology design firm outline the user interface/user experience problems that physicians and nurses have encountered, solutions to these problems, and where EHR and health IT usability is headed in the future.

IT stressors that lead to clinician burnout

According to a recent New England Journal of Medicine study, 55% of clinicians suffer from burnout. On average, doctors spend more than 16 minutes per patient in the EHR with only 15 minutes allotted for most patient appointments.

The steady rise of burnout among clinicians is a crisis that is affecting the healthcare industry, said Eva Karp, RN-BC, senior vice president and chief clinical and patient-safety officer, at Cerner.

“Clinicians are experiencing an overwhelming feeling of frustration in their careers and a loss of professional fulfillment because of several factors ranging from loss of autonomy to decreased efficiency,” she said. “The global pandemic has also added significant pressures on health systems and clinicians.”

"The industry needs to continue to streamline physician documentation with voice-assisted technology and other intelligent solutions."

Eva Karp, RN-BC, Cerner

There are many contributing factors to the burnout epidemic, such as increased regulation, inadequate training, changing reimbursement models, work-life balance pressures, financial obligations, organizations’ lack of health IT governance and use of the EHR, she said.

“A 2019 study by Reaction Data shows that despite the frustration technology has imposed upon the medical profession, EHRs contribute about 10-20% of the burnout problem, though some research and opinion pieces estimate EHR-related burnout to be higher,” she said. “Nonetheless, it is a significant issue that is impacting healthcare professionals today.”

Clinician burnout concerns that EHRs can address though improvements include issues with usability, cognitive load, payer and reimbursement burdens, health system operations, interoperability, and regulatory and quality documentation requirements, she added.

Regulation, education, litigation

Dr. Jackie Gerhart, who works in clinical informatics at Epic, said there are several factors that play a role in IT-related clinician burnout. These factors include government regulations, medical education, litigation, EHR design, health system practices and individual clinicians, she said.

“Regulations should encourage clinicians to document only what is medically necessary,” she contended. “Providers in the U.S. write notes that are three to four times longer than notes in other countries, in part because of older regulations that were made for a paper world. Health systems often have conservative interpretations of these regulations, so they encourage clinicians to duplicate information in the note that can easily be found elsewhere in the EHR.”

"Regulations should encourage clinicians to document only what is medically necessary. Providers in the U.S. write notes that are three to four times longer than notes in other countries."

Dr. Jackie Gerhart, Epic

There are strides in this area, though, she noted, with CMS’ 2021 coding guidelines, which are giving providers new opportunities to reduce note bloat.

The other factors Gerhart points to include the following:

• In medical school, clinicians often are trained to document details in the note that have already been recorded elsewhere in the EHR.
• Health systems and clinicians often are concerned about litigation, so they practice “defensive medicine” – meaning they write down every detail in case they need to defend their medical decisions in response to a lawsuit.
• Epic historically has received a lot of design input from experienced users who ask for advanced features. Epic needs to focus more on everyday users.
• Health systems need to keep up with the latest releases and continuously reevaluate their workflows to ensure their clinicians can take advantage of the latest best practices.
• The KLAS Arch Collaborative, which collected insights from more than 120,000 clinicians across more than 200 organizations, found there are two major factors that drive clinician happiness. The first is personalization – adjusting settings so the EHR matches the clinician’s individual preferences – and the second is good training.

Worsening the clinician experience

The most commonly cited clinician IT stressors: EHRs do not always map to the clinician’s mental model; technology tends to drive the conversation and journey, though it’s not designed for that role; and there is not enough time left after all of the required documentation to actually connect with patients in a meaningful way, said Amy Heymans, founder and chief experience officer at Mad*Pow, a design agency that works to improve the experiences people have with technology, services and organizations.

Technology often worsens the clinician’s experience with the patient as opposed to improving it, she added.

“The flow of EHR systems doesn’t map to the workflow of the clinician, causing frustration and wasting time for everyone involved,” she said. “It takes the clinician out of their rhythm and forces them to do things out of the order that is logical to them. The technology is dictating how they do their job, and often it’s counterintuitive and counterproductive.”

"The flow of EHR systems doesn’t map to the workflow of the clinician, causing frustration and wasting time for everyone involved."

Amy Heymans, Mad*Pow

EHR technology oftentimes forces clinicians go through multiple steps for a task that a clinician would expect to happen more fluidly as they have come to expect using other applications and technologies, she observed. A good example of this is issuing no defaulting known data or learning patterns, which leads to repetitive work that could be avoided, she said.

“Another major stressor for clinicians is the amount of time it takes to document patient visits, and the concern that it takes away from patient care,” she said. “Clinicians have to choose whether to document information in real time, making it difficult to connect on a personal level with patients when the clinician is focusing on the screen. The other option is to wait until after the appointment to document, but that can lead to omissions or mistakes, and with tight appointment schedules, time to do so is extremely limited.”

EHRs drive the flow of patient care

Engineers built EHRs to add greater utility and enhance productivity in the healthcare environment, Heymans noted.

“EHRs store and aggregate data that helps clinicians to see trends or secure a quick summary of things,” she said. “However, EHR systems have ended up driving the flow of patient care, and the human-to-human experience can end up feeling like a more transactional and technology-driven experience. Generally, clinicians go into health to be with people, not to be data entry professionals.”

Some of the blame for the dysfunctional relationship clinicians have with technology centers on the health system’s customization of the EHR, which can introduce usability issues, she contended.

“EHRs were created as databases to store critical health information so that it can be accessed in real time by anyone permissioned to do so, which reduces errors in patient care,” she explained. “Unfortunately, though, they have ended up becoming the backbone of the clinician and patient experience, and they have not been designed as a helpful guide along a journey, but rather a window into data.”

The average medical appointment time is seven minutes, she said. It’s hard for clinicians to follow up with patients because they are on such a tight schedule.

“This is a key factor in clinician burnout – the number of patients that need to be seen in order to pay the bills, in addition to the constant connection that technology requires. Both result in limited time with patients,” she said. “Ideally, the EHR should be making it easier for doctors to spend more time with patients [so] that the limited time they have is even more effective. Unfortunately, at this point, EHRs have not fully realized that promise.”

Human-centered design

For years, Allscripts has been performing what is called “human-centered design,” with a focus on safety, which includes a focus on physician burnout.

“Burnout, of course, is caused by many factors and is not limited to HIT,” said Paul Minton, vice president and chief product officer for hospital and health systems at Allscripts. “Successfully addressing it will require a ‘systems approach’ that involves different groups making significant contributions through thoughtful, multifaceted responses to the problem.”

That said, Allscripts has performed its own field research with its hospital and physician clients and has found strong ties between physician fatigue and the products they use.

"We have released features like the tracking-board hover, which provides up-to-the-second results and significantly reduces the action required to review those results."

Paul Minton, Allscripts

“For example, signing in requires multiple attempts throughout the patient charting and ordering process,” Minton said. “Some features are ‘hidden’ and require a practitioner to remember where the items are placed in the system. We also witnessed that the detailed charting tasks required for each patient demands hours of cognitive load after hours, leaving little time for family and the opportunity to recharge.”

Allscripts is focusing on reducing the complexity of this specific piece of healthcare delivery by improving ease of use in its new releases to deliver safer solutions for physicians and patients they serve, he added.

Progress on usability

While there are many issues with EHR and health IT usability, there also are many solutions. EHR makers and IT designers have been at work solving the problems clinicians have faced.

Heymans of Mad*Pow said in some instances there is a feedback loop where doctors can evaluate EHRs and then are able to say, “This doesn’t make sense,” or “This could be better.”

“That feedback can be taken into consideration as a team of people evaluate the feasibility of changes,” she said. “Changes have to work across an organization, not just with one specialty group, as workflows can differ from one group to the next. The process for customizing EHRs across an organization has to include all stakeholders and not be designed according to the preferences of a limited set of clinicians.”

If there is a way for clinicians to flag a usability concern, then a team can evaluate whether it’s a global issue that could be addressed across the board or altered based on preference so that different clinicians can turn a feature on or off based on their needs, she said.

“By approaching it this way, organizations can improve the usability of EHRs over time via a ‘test and learn’ methodology,” she explained. “An EHR system is not ‘set it and forget it’ technology. It has to be experienced, tested and evaluated by the users. The voice of the end user has to factor into how the tool is customized or adjusted.

“Productive improvements can be implemented by gathering feedback through the screens as clinicians use the technology,” she added. “Or it can be facilitated procedurally through observations by usability professionals shadowing clinicians as they perform their duties.”

Unfortunately, health systems do not always have the bandwidth or resources to do this, she added. That said, health systems that do have the resources to research, observe and then customize their EHR are able to reduce stressors and improve the clinician and patient experience, she said.

Reducing duplicate documentation

Over the past five years, Allscripts has released specific capabilities developed to reduce the stress and burnout associated with using an EHR. Through its human-centered design research and design process, it has delivered usability improvements in clinical documentation that focused on reducing the amount of duplicate documentation that clinicians have experienced by creating smarter sharing features that take advantage of the multidisciplinary nature of modern healthcare, said Minton of Allscripts.

“Essentially, [we are] using the collected information from all sources to ease the documentation burden,” he explained. “Smart Pump integration is an example of a two-for-one solution that not only eliminates manual documentation but enhances patient safety. We have released features like the tracking-board hover, which provides up-to-the-second results and significantly reduces the action required to review those results.”

The EHR vendor also has made it easier to use community data via CCD-A, he added, by capturing it the same way all data is used in the EHR, thus reducing the cognitive burden of multiple workflows for data input.

Efficient tools, machine learning

Gerhart of Epic said that the company works to design software that clinicians like to use that makes them more efficient and that helps them care for patients.

“For example, Chart Search lets clinicians search for all pieces of patient history related to a specific condition like diabetes, and Express Lane allows clinicians to quickly complete documentation for routine visits,” she said. “Machine learning also is helping clinicians work more efficiently. For example, the software now keeps track of which tools a clinician uses most and makes them easy to find.”

Data-driven solutions and interoperability are important to EHR usability moving forward at Cerner, Karp said.

“At the recent Cerner Health Conference, our CEO Brent Shafer shared Cerner’s commitment to innovating new tools and EHR enhancements to increase clinician satisfaction and return the joy of practicing medicine,” she recalled. “In the past year, Cerner has saved clinicians over 35,000 hours of documenting.”

The company works to innovate data-driven solutions to further reduce the documentation burden and provide clinical, financial, and operational insights for clients, and to support better patient care and outcomes, she added.

“Cerner client Banner Health recently cut half a million EHR alerts to improve clinician experience,” she said. “Reducing alerts helps support patient safety while addressing alert fatigue among pharmacists and providers. And at Lakeland Regional Health, Cerner teams worked with LRH providers to achieve an average 6% reduction in adjusted time per patient.”

These examples demonstrate how intelligently designed technology can help address the issue of clinician burnout, she contended.

On another note, interoperability is key in providing a more complete picture and insights into patient care, she said.

“We recently announced Cerner Unite, a portfolio of solutions that enable and improve on the ability to access and exchange data between our client and any organization with whom they need to share data,” she explained.

“This automates data integration, adds intelligence to ease the workflow burden, reduces data hunting time, and enhances data quality and usability. We’re taking interoperability beyond connectivity to true usability – creating a single, longitudinal record that’s more inclusive than ever – spanning all systems across any care venue.”

Voice technology

One technology that has been helping physicians and nurses better use EHRs is voice. It eases the data-entry burden.

"Clinicians can now use Epic’s voice assistant to complete documentation and take action with their voice, like ‘Order a CBC’ or ‘Call the patient’s PCP,’" said Gerhart of Epic. “When providers are getting ready for a visit, they can use the voice assistant to get up to speed on the patient’s story. They can request information like, ‘Who is my next patient?’ or ‘Show me the last lipid panel.’“

Natural language understanding is a related technology that can help reduce clinician burnout caused by poor health IT usability.

“We continue to design capabilities that reduce the workload on clinicians and put the burden on technology,” said Minton of Allscripts. “In the upcoming release of our Sunrise electronic health record, we are focusing on our physicians and simplifying the data input process by using smart technology like natural language understanding to create narrative documentation, so users can shift away from the manual process they are following today.”

Specifically, Allscripts is shooting to make it easier to add “problems” and “health issues” via deep data analysis of the collected information that already resides in the EHR.

“We are focusing on clinician collaboration by integrating Microsoft Teams capabilities into the EHR,” Minton explained. “Making it natural and easy to collaborate on results, progress and critical issues within the EHR saves clinicians time, and that time can be used to help patients get better faster. The more collaboration tools we can build will ensure clinicians do not feel like they are alone with the full burden of patient care, which can be shared with insights from other clinicians.”

From the patient perspective

Heymans of Mad*Pow believes that EHR designers need to in part look at things from a patient experience perspective.

“Patient experience and clinician experience are interconnected,” she observed. “Their experiences intertwine and there are dependencies and ramifications. If the patient arrives agitated because they had to pay for parking, wait a long time in the waiting room, or [is] anxious and confused about their care, they are going to go into their appointment feeling flustered, nervous, frustrated or mad.”

This will impact their overall experience and probably the experience of the clinician as well, she added.

“The more that healthcare organizations can improve the patient experience so that the patient comes into an appointment feeling calm and prepared, the greater the chance that the experience will be positive for both them and for their healthcare provider,” she said.

“Healthcare organizations are doing some of this by using patient portals to convey important information to patients, from directions on how to reach a facility to suggestions to write down questions or observations prior to a medical appointment.”

Conversely, if a clinician is stressed and overburdened coming into an appointment, then it could result in a poor patient experience, she said.

“Clinicians can be negatively impacted by the state of technology when they feel that they are not up-to-date on the patient’s status, or when that patient comes to an appointment with self-reported data or biometrics data,” she said. “There is often not a clear way for clinicians to capture and analyze this data on an ongoing basis to shift the relationship to one that is proactive in looking after the wellbeing of the patient over time.”

Where usability is headed

EHR vendors have been making progress in making their critical products more user friendly. Physicians and nurses certainly are having a much easier time managing health IT compared with 10 or even five years ago. Now the big question here is: Where is EHR usability headed? The experts have a variety of outlooks.

“We have invested in an extensive human-centered design effort that is re-thinking the paradigms on how an EHR should be designed,” said Minton of Allscripts. “We are excited to focus on physicians and their workflow, focusing on just-in-time information, the basic tasks necessary for patient care, and quieting the regulatory noise so they can focus on the patient. Simple is the new feature, recognizing that every click counts, every moment saved is another moment for patient interaction.”

Based on its experience working with clients over the years, Allscripts says what tomorrow needs is clean and simple design, he said, given what it has learned regarding how its clinician users are actually treating their patients in all settings of care.

“Design based on the human experience is what is needed as we go forward,” he stated. “We also need to invest in our clinicians and make sure they have adequate training to get the most out of the experience. The ARCH Collaborate project has shown that adequate EHR training is also key to their level of success, and thus the level of burnout, so while we will design for ease of use, it will be paired with training that produces the best possible outcomes for our clinicians and their patients.”

A health research database

Epic is looking in another direction.

“Today, it can take years for medical discoveries to make their way into clinical practice,” Gerhart said. “The Epic community has come together to create Cosmos, a health research database of over 80 million patient records with a goal of 200 million. In the future, Cosmos will help clinicians make key clinical decisions – such as which medication to prescribe or whether to perform surgery – by looking at the millions of patients and interactions in Cosmos and showing what’s worked best for similar patients.”

With ambient voice technology, documentation for clinic visits will be completed without the clinician needing to touch a mouse or keyboard, she added. The voice assistant will listen to the conversation between the clinician and the patient and write the note, she explained.

Relationships physicians wish to build with patients

When it comes to the future of EHR usability, it’s not about the EHRs, or at least, it’s not about the technology itself: It’s about the kind of experience doctors want to provide to their patients, said Heymans of Mad*Pow.

“What kind of relationships do they want to build?” she asked. “How do they want to support their patients while patients are in the office or when they are home? To improve EHRs, we need to consider the relationship we want to design, one that builds trust, and design the technology to support that relationship.”

Achieving this kind of change can feel like trying to make a sharp turn on a cruise ship, she offered. Healthcare needs to rethink how things are getting accomplished, but that doesn’t mean stakeholders cannot use the infrastructure that’s already in place, she said.

“Another really important need for the future: EHRs and health systems need to truly fulfill the promise of interoperability,” she stated. “Part of the reason for mandating the use of EHRs was for interoperability. EHRs were supposed to make it possible for patients to go from one doctor to another, inside the same health system, or outside to a different one, and still carry their health data with them.”

This is not happening unless patients live in a state with a strong health information exchange, she remarked.

“Widespread, patients in the U.S. still don’t have access to their health information,” she said. “They can log into a portal to look at it, but can’t seamlessly move it from one doctor to another or store it locally for themselves or upload information to it, or make a correction to the data. In a world where the Internet and technology have transformed the way the world communicates, moving patient health records still often involves faxing, a nearly obsolete technology.

“We must always strive to put the data and the power to access it in the hands of the patient, enabling them to share it easily with whomever they want, whenever they want,” she continued. “That hasn’t happened yet, but it’s a huge opportunity for disruption in the direction of reducing a huge stressor for clinicians and patients alike.”

AI, voice and interoperability

As healthcare enters a new age with artificial intelligence, machine learning and other advanced technologies, Cerner will continue to develop new ways to reduce clinician burnout and further leverage patient data to gain powerful insights that impact patient care, Karp said. These technologies will augment a clinician's decision-making process and save them time to put back into direct patient-interaction, she contended.

“The industry needs to continue to streamline physician documentation with voice-assisted technology and other intelligent solutions,” she said. “The development of technologies that [allow] clinicians to interact with the EHR by just using their voice can save significant time and reduce administrative burden by replacing manual data documentation.”

Advancing interoperability and data sharing also is essential to easing the clinician burden, she insisted. With greater interoperability, clinicians would be able to more quickly exchange and use patient information to make care decisions, she said.

“Perhaps a bit more obvious of an answer, but we need to continue to focus on adequate training for clinicians. This includes working with health systems to ensure they have an appropriate health IT governance in place or help them develop one,” said Karp.

“We remain committed to giving more time back to doctors and nurses. By putting critical information at the fingertips of clinicians, researchers and communities, data insights are helping resolve many issues healthcare and other industries are facing in unprecedented times.”

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.