Wearable Sensors Confirm EHR Inbox Use, Clinician Burnout Link

Wearable heart rate sensors proved EHR inbox work outside work hours, EHR inbox management duration, and EHR workflow switching are three critical factors that directly associate with clinician burnout and stress, according to a study published in JMIR Publications.

This study builds on the growing literature about EHR use and clinician burden.

Past EHR inbox studies primarily focused on self-reported measures to describe the impact of EHR inbox volume and burnout. In this case, researchers aimed to collect EHR use and physiologic stress data through a wearable sensor. The sensor provided objective and continuous measures, EHR inbox work patterns, clinician daily physiologic stress patterns, and the association between inbox work patterns and clinician physiologic stress.

Researchers from Kaiser Permanente equipped 42 outpatient clinicians from five separate medical facilities with wearable device heart rate sensors and the associated mobile apps for seven days. The devices tracked physiological stress throughout the workday based on heart rate variability.

Research revealed clinicians spent 3.5 hours within the EHR per day and 1.08 hours in the EHR inbox. On average, 37 percent of the 1.08 inbox hours accounted for patient portal messages, 31 percent accounted for laboratory results, 20 percent were clinical requests, and 13 percent accounted for administrative requests.

The device showed clinicians work within the inbox outside work hours, inside work hours, and in a post-work session tacked on at the end of their days.

Stress patterns showed the first hour of work, early afternoon, and in the evening as the top three time periods when clinician stress levels increased. Stress levels started to decrease from the morning until the lunch hour, and then it rose again at the beginning of the afternoon clinical shift.  

Clinicians who primarily conducted inbox work outside of regular work hours endured the most prolonged average stress duration of 80 out of 243 total work minutes.

“I find when I sacrifice sleep to do more at home, I’m too tired during the day and I’m very inefficient at night,” said an anonymous physician respondent who indicated working late at night.

Inbox work duration, EHR window navigation rate, the amount of inbox work accomplished outside of work hours, inbox work batching, and the day of the week were also independently connected with daily stress duration, the study authors wrote.

“Physicians who did most of their inbox work outside of work hours were more likely to batch email and spend more time per message, whereas physicians who mostly do their inbox work within work hours were more likely to continually check their inbox throughout the workday, potentially in the short periods of time between patient appointments, and spent less time per message,” explained the study authors.

“The group that did most of their inbox work outside of work hours had the longest stress duration during work hours.”

A follow-up study indicated 60 percent of clinician work-related stress resulted from inbox management. Forty-three percent of clinician respondents said they found inbox management moderately stressful, 34 percent said it was very stressful, 14 percent said it was extremely stressful, and only 9 percent said it was not stressful.

The continuous time stamped stress measure to show patterns, the experience sampling measure to provide self-assessment three times per day, and the final clinician survey to reflect on overall inbox work stress added critical nuance to the assessment, the researchers said.

“Organizations seeking to reduce physician stress may consider system-based changes to reduce EHR window switching or inbox work duration or the incorporation of inbox management time into work hours,” concluded the study authors.