3 Factors Leading to EHR Usability Issues, Clinician Burnout

Too many EHR alerts resulting in fatigue

While alerts can offer providers useful updates and reminders, EHR alert fatigue has been a problem for clinicians who are already struggling with EHR usability. Low-value EHR alerts or an abundance of alerts can hurt patient care and contribute to physician burnout.

Effective EHR alerts can enhance clinical efficiency by opening up communication through the EHR. However, clinician burnout is increasing due to a high number of EHR alerts from computerized physician order entry (CPOE) systems and clinical decision support (CDS) tools, according to a study published in the Journal of the American Medical Informatics Association (JAMIA).

Researchers found providers can improve clinician safety and care quality by reducing the number of EHR alerts for nuisance orders and fatal orders.

Ninety-six percent of hospitals that use CPOE systems also have clinical decision support (CDS) tools. CDS tools enable prescribers to access real-time patient data, ideally resulting in enhanced patient safety and medication accuracy. CDS can also alert the prescriber about potential patient warnings to prevent errors and additional adverse drug events from happening.

While both CDS and CPOE systems aim aid prescribers and lower patient harm, both have unintended consequences, such as alert fatigue, missed alerts, and ultimately clinician burnout.

Researchers at the University of Utah and Brigham and Women’s Hospital designed the CPOE Evaluation Tool to develop a “full demonstration of national safety standard for decision support,” which was administered by the Leapfrog Group through their annual hospital safety survey.

Respondents entered a minimum of 85 percent of their medication orders using CPOE, while also alerting 60 percent or more medication orders. Once entered into the system, the clinician recorded the decision support, such as pop-up alerts or “hard stops” that disallow the order from being entered.

Then, the fatal and nuisance medication orders are dispersed across pre-existing order categories. The tool gives provider feedback in real-time with an overall percentage score and an individual order category score.

Although there was a significant 8 percent overall increase in orders and provider feedback, researchers said alert improvement is still needed. Researchers noted too many alerts had been turned on and too many alerts are connected to alert fatigue and clinician burnout.

Human EHR scribe versus EHR-implemented scribe

EHR documentation records clinical information, such as provider notes in real-time during a consultation, assessment, imaging, or treatment, with an ultimate goal to share patient information among health providers.

While the transition from paper to EHR documentation allows users to take more accessible and legible notes, it is a primary cause of clinician burden.

Information overload or having a lot of non-clinical or irrelevant text can be a lot to pick through.

If a clinician can access a patient’s notes across her lifetime, regardless of clinical benefits, it makes it difficult on the clinician to retrieve key information.

“Whenever possible, usability and information design should be an essential part of the EHR certification process,” wrote authors of a 2020 JAMA Network Open study. “There should be a focus on graphical visualization of numerical data. Custom development of patient summaries for various provider types and care settings requires effort but can be valuable.”

To combat long hours in the EHR, health systems can implement a digital EHR scribe or employ a human scribe.

“EHR documentation is probably the single greatest burnout issue for our clinicians,” BJ Moore, CIO and executive vice president of Providence, said in an interview with EHRIntelligence. “We've done everything, including hire scribes to help with that process. It's something doctors just worked through and that, unfortunately, adds to their burnout.”

Currently, there isn’t a great answer whether virtual EHR scribes or human scribes are better for mitigating burnout.

Although a well-designed EHR scribe eases clinician burnout, developers are facing issues that make it tough to completely get rid of human scribes, who aren’t always reliable.

Medical offices would typically hire a medical student to shadow the clinician and type information into the EHR. But these student scribes don’t always know how to write proper progress notes, and most aren’t great at picking out the key parts of the conversation. If the scribe is not a fast typist or doesn’t have a good memory, the scribe could miss important information.

Healthcare organization leaders may look at the specific needs of their facilities and consult with boots-on-the-ground providers to assess which option is best.

“It is probably the single biggest complaint,” Moore said. “Not only does it burn out our clinicians, but it also impacts the quality of patient interaction. Instead of having face-to-face interaction with the patient, a lot of times the caregiver is on a keyboard looking over their shoulder as they enter this information in the medical record.”

Cluttered EHR interface, inability to navigate sufficiently

A cluttered interface or a complex medication list is the result of an EHR product that is not properly developed or optimized after implementation.

“Oftentimes when people think about usability, they think about design and then they think about the EHR vendor,” Raj Ratwani, PhD, director of MedStar Health Human Factors Center, said in an interview with EHRIntelligence.

“In reality, it's a very complex space. The products that are being used by frontline clinicians are shaped by the vendor. But they are also shaped by how that product is implemented at that provider site, how it's customized, and how it’s configured. All of those things shape usability.”

For example, a cluttered medication list can lead to clinician burden and even potentially fatal consequences for the patient.

Lack of data integrity, too, can be an issue. A Pew report outlined an EHR usability issue regarding weight data collection and how it impacted medication prescribing.

“In one case, a clinician entered a child’s weight in pounds when the EHR was configured for kilograms,” explained Ben Moscovitch, project director for Health Information Technology at Pew. “The misunderstanding effectively doubled the child’s actual weight, resulting in the patient later receiving twice the appropriate drug dose.”

Ensuring the EHR is properly set on the correct drug entry measurement could be the difference between life and death for a patient. If a decimal point is off, or the user was not properly trained, serious consequences could arise.  

This is an extreme, yet a real example of an EHR usability issue that impacts both parties.

EHR adoption is nearing 100 percent in most healthcare settings, and as adoption increases, it can negatively impact clinician satisfaction and user experience. Organization leadership may consider one or a combination of ways to enhance EHR usability, consulting with the providers who are in fact the EHR end users.