Influx of EHR In-Basket Messages Leads to Greater Burnout, Study Finds

July 3, 2019
It’s been widely-reported that the time physicians spend in the EHR is linked to higher levels of burnout

In-basket messages generated by the EHR accounted for almost half of the total weekly in-basket messages received per physician, and was thus associated with a higher probability of burnout, according to new Health Affairs research.

The study, conducted by leaders of the Palo Alto Medical Foundation, University of California San Diego, and elsewhere, examined physicians from Palo Alto Medical Foundation, a multispecialty healthcare delivery organization in California that was an early adopter of EHRs.

The research shows in-basket messages generated by the EHR system accounted for almost half (114) of the 243 weekly in-basket messages received per physician, on average—far exceeding the numbers received from their colleagues (53) and patients (30). In a survey, 36 percent of the physicians reported burnout symptoms, and 29 percent intended to reduce their clinical work time in the upcoming year.

The data also revealed that receiving more than the average number of system-generated in-basket messages was associated with 40 percent higher probability of burnout and 38 percent higher probability of intending to reduce clinical work time. Given that physicians’ perceptions of a positive work environment were associated with lower odds of burnout and intention to reduce clinical work time and with greater satisfaction with life, “Meaningful redesign of EHR in-basket workflow and a wellness-enhancing work environment are necessary to effectively improve physicians’ well-being,” the study’s authors concluded.

There has been no shortage of recent literature linking the time spent by physicians in the EHR to their reduced satisfaction with work—so much so that healthcare leaders have called burnout a public health crisis, while pointing to technology as a key factor.

In this study, just 12 percent of respondents deemed the statement “physicians are highly valued” to be completely true regarding conditions in their primary practice setting. Eighty-three percent reported having good or optimal control over their work schedule, and 60 percent reported having a calm to busy but reasonable primary work area. Overall, the average score on life satisfaction was 78.22 out of 100, according to the data.

Regarding in-basket messages specifically, and the 47 percent that were generated by the EHR each week on average, 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, while 53 percent were from other physicians or care team members, and 31 were from the physicians themselves (for example, reports of laboratory tests they had ordered).

Notably, 45 percent of physicians with burnout symptoms received greater-than-average numbers of weekly system-generated in-basket messages, whereas 29 percent of physicians with burnout symptoms received only average or less-than-average numbers of the messages. Also of note, female physicians had 1.4 times higher odds of burnout and 3 points lower satisfaction with life, compared to male physicians.

The researchers offered several suggestions for patient care organizations to help combat this issue, including conducting a closer examination of if physicians are the appropriate recipients of some system-generated messages. They added, “Payers and government regulators may need to be part of the solution in enabling physicians to practice at the top of their license. EHR design engineers also need to reconsider whether system-generated automatic messages are the best way to ensure quality of care. It may be time to examine whether every reminder to order routine chronic disease management lab tests (for example, periodic glycosylated hemoglobin A1c tests) must be signed and placed by a physician.”