JMIR Publications

ABSTRACT

Background:

Increased work through electronic health record (EHR) messaging is frequently cited as a factor in physician burnout. However, studies to date have relied on anecdotal or self-reported measures, which limit the ability to match EHR use patterns to continuous stress patterns throughout the day.

Objective:

(1) collect EHR use and physiologic stress data through unobtrusive means that provide objective and continuous measures; (2) cluster distinct patterns of EHR inbox work; (3) identify physicians’ daily physiologic stress patterns; and (4) evaluate the association between EHR inbox work patterns and physician physiologic stress.

Methods:

Physicians were recruited from five medical centers. Participants (n=47) were given wrist-worn devices with heart-rate sensors to wear for a week. The devices measured physiologic stress throughout the day based on heart-rate variability. Perceived stress was also measured by self-reports through experience sampling and a one-time survey. From EHR system logs, time attributed to different activities was quantified. Using a clustering algorithm, distinct inbox work patterns were identified and their associated stress measures were compared. The effects of EHR use on physician stress were examined with a Generalized Linear Mixed-Effect model.

Results:

Physicians spent on average 1.08 hours doing inbox work out of an average total EHR time of 3.5 hours. Patient messages accounted for most inbox time (37%, SD 11%). Three patterns of inbox work emerged: (1) inbox work mostly outside workhours; (2) inbox work mostly during workhours; (3) inbox work extending after-hours, but mostly contiguous to workhours. Across these three groups, physiologic stress patterns showed three periods where stress increases: the first hour of work, early afternoon, and in the evening. Physicians in group 1 had the longest average stress duration during workhours (80/243 mins of valid HRV data; p=.02) as measured by physiological sensors. Inbox work duration, the rate of EHR window switching (moving from one screen to another), the proportion of inbox work done outside of workhours, batching inbox work and day of the week were each independently associated with daily stress duration (Marginal R2=15%). Individual-level random effects were significant and explained most of the variation in stress (Conditional R2=98%).

Conclusions:

This study is among the first to demonstrate associations between electronic inbox work and physiological stress. We identified three potentially modifiable factors associated with stress: EHR window switching, inbox work duration, and inbox work outside workhours. Organizations seeking to reduce physician stress may consider system-based changes to reduce EHR window switching or inbox work duration, or to incorporate inbox management time in workhours.