Interventions to Reduce Electronic Health Record-Related Burnout: A Systematic Review

Abstract

Background Electronic health records are a significant contributing factor in clinician burnout, which negatively impacts patient care.

Objectives To identify and appraise published solutions that aim to reduce EHR-related burnout in clinicians.

Methods A literature search strategy was developed following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Six databases were searched for articles published between January 1950 and March 2023. The inclusion criteria were peer-reviewed, full-text, English language articles that described interventions targeting EHR-related burnout in any type of clinician, with reported outcomes related to burnout, wellness, EHR satisfaction, or documentation workload. Studies describing interventions without an explicit focus on reducing burnout or enhancing EHR-related satisfaction were excluded.

Results We identified 44 articles describing interventions to reduce EHR-related burnout. These interventions included the use of scribes, EHR training, and EHR modifications. These interventions were generally well received by the clinicians and patients, with subjective improvements in documentation time and EHR satisfaction, although objective data were limited.

Conclusion The findings of this review underscore the potential benefits of interventions to reduce EHR-related burnout as well as the need for further research with more robust study designs involving randomized trials, control groups, longer study durations, and validated, objective outcome measurements.

 

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Keywords

electronic health records - burnout - documentation - workload

Background and Significance

Coronavirus disease 2019 (COVID-19) has led to a substantial increase in clinician burnout, characterized by emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment.[1] [2] [3] [4] An oft-noted contributor to clinician burnout is electronic health records (EHRs).[5] [6]

EHR-related burnout, or the exhaustion and dissatisfaction due to interactions with EHRs, encompasses challenges such as inconsistent user interface, high volume of inbox messages, excessive data entry requirements, and lack of interoperability.[7] [8] [9] This overwhelming documentation burden, where clinicians spend excessive time on data entry and record-keeping, can result in reduced job satisfaction and increased stress[10] [11] and ultimately affect the quality of patient care.[12] [13]

Measures to address EHR-related burnout can benefit both clinicians and patients in the long run.[14] Prior reviews have focused on understanding factors contributing to clinician burnout,[15] [16] and interventions on clinician burnout in general, such as shift length changes and stress management training.[17] [18] However, there is a paucity of literature to guide interventions specifically to reduce the EHR-related burnout.

 

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Objectives

The objective of this systematic review was to appraise the characteristics and outcomes of interventions aimed to reduce EHR-related burnout in clinicians.

 

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Methods

In consultation with a reference librarian, a literature search strategy was developed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA; [Table 1]).[19] We searched the following databases for studies published between January 1950 (i.e., prior to the first published reports of EHRs) to March 2023 that met our study criteria: PubMed, MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science.

Table 1 Search strategy

Database	Search query
PubMed	((((“Electronic Health Records”[MeSH Terms] OR “medical records systems, computerized”[MeSH Terms]) AND “english”[Language]) OR ((“electronic health record*”[Title/Abstract] OR “EHR”[Title/Abstract] OR “electronic medical record*”[Title/Abstract] OR “EMR”[Title/Abstract]) AND “english”[Language]) OR ((“electronic record”[Title/Abstract:∼2] OR “digital record”[Title/Abstract:∼2]) AND “english”[Language])) AND “english”[Language] AND ((((“burnout, psychological”[MeSH Terms] OR “burnout, professional”[MeSH Terms] OR “stress, psychological”[MeSH Terms] OR “Occupational Stress”[MeSH Terms] OR “stress, physiological”[MeSH Terms] OR “Workload”[MeSH Terms] OR “Job Satisfaction”[MeSH Terms] OR “Personal Satisfaction”[MeSH Terms] OR “Psychological Well-Being”[MeSH Terms]) AND “english”[Language]) OR ((“burnout”[Title/Abstract] OR “burn-out”[Title/Abstract] OR “burn-out”[Title/Abstract] OR “burned out”[Title/Abstract] OR “stress*”[Title/Abstract] OR “exhaust*”[Title/Abstract] OR “Workload”[Title/Abstract] OR “overwork”[Title/Abstract]) AND “english”[Language]) OR (“physicians/psychology”[MeSH Terms] AND “english”[Language])) AND “english”[Language])) AND (english[Filter])
MEDLINE	(((“Electronic Health Records” or “Medical Records Systems, Computerized”).sh.) or ((“electronic health record*” or “EHR” or “electronic medical record*” or “EMR”).ti. or (“electronic health record*” or “EHR” or “electronic medical record*” or “EMR”).ab.) or (((electronic or digital) adj2 record*).ti. or ((electronic or digital) adj2 record*).ab.)) and (((“Burnout, Psychological” or “Burnout, Professional” or “Stress, Psychological” or “Occupational Stress” or “Stress, Physiological” or “Workload” or “Job Satisfaction” or “Personal Satisfaction” or “Psychological Well-Being”).sh.) or ((burnout or “burn-out” or “burn out” or “burned outor stress*” or exhaust* or workload or overwork*).ab. or (burnout or “burn-out” or “burn out” or “burned outor stress*” or exhaust* or workload or overwork*).ti.) or (Physicians/px [Psychology]))
Embase	((('electronic medical record'/exp OR 'electronic medical record' OR 'electronic medical record system'/exp OR 'electronic medical record system' OR 'electronic health record'/exp OR 'electronic health record') OR ('electronic health record*':ti,ab,kw OR 'ehr':ti,ab,kw OR 'electronic medical record*':ti,ab,kw OR 'emr':ti,ab,kw) OR (((electronic OR digital) NEAR/2 record*):ti,ab,kw)) AND (('burnout'/exp OR 'professional burnout'/exp OR 'physiological stress'/exp OR 'mental stress'/exp OR 'wellbeing'/exp OR 'workload'/exp OR 'job satisfaction'/exp) OR (burnout:ti,ab,kw OR 'burn-out':ti,ab,kw OR 'burn out':ti,ab,kw OR 'burned outor stress*':ti,ab,kw OR exhaust*:ti,ab,kw OR workload:ti,ab,kw OR overwork*:ti,ab,kw)) AND [english]/lim) AND 'Article'/it
PsycINFO	((MA (“Electronic Health Records” or “Medical Records Systems, Computerized”) OR DE “Electronic Health Records” OR TI (“electronic health record*” or “EHR” or “electronic medical record*” or “EMR”) OR AB (“electronic health record*” or “EHR” or “electronic medical record*” or “EMR”)) OR (TI (((electronic or digital) N2 (record*))) OR AB (((electronic or digital) N2 (record*))))) AND (DE (Burnout OR Stress) OR MA (“Burnout, Psychological” or “Burnout, Professional” or “Stress, Psychological” or “Occupational Stress” or “Stress, Physiological” or “Workload” or “Job Satisfaction” or “Personal Satisfaction” or “Psychological Well-Being”) OR TI (burnout or “burn-out” or “burn out” or “burned outor stress*” or exhaust* or workload or overwork*) OR AB (burnout or “burn-out” or “burn out” or “burned outor stress*” or exhaust* or workload or overwork*))
CINAHL	(((MH “Electronic Health Records + ”)) OR (TI (electronic health record*” or “EHR” or “electronic medical record*” or “EMR”) OR AB (electronic health record*” or “EHR” or “electronic medical record*” or “EMR”)) OR (TI (((electronic or digital) N2 (record*))) OR AB (((electronic or digital) N2 (record*))))) AND (MH (Burnout OR “Professional Stress” OR “Stress, Occupational Stress” OR “Physiological Stress, Psychological”) OR TI (burnout or “burn-out” or “burn out” or “burned outor stress*” or exhaust* or workload or overwork*) OR AB (burnout or “burn-out” or “burn out” or “burned outor stress*” or exhaust* or workload or overwork*))
Web of Science	((“electronic health record*” (Topic)) OR (“electronic health record*” or “EHR” or “electronic medical record*” or “EMR” (Title) OR “electronic health record*” or “EHR” or “electronic medical record*” or “EMR” (Abstract)) OR (((electronic or digital) NEAR/2 (record*)) (Title) OR ((electronic or digital) NEAR/2 (record*)) (Abstract))) AND ((burnout (Topic)) OR (burnout or “burn-out” or “burn out” or “burned outor stress*” or exhaust* or workload or overwork* (Title) OR burnout or “burn-out” or “burn out” or “burned outor stress*” or exhaust* or workload or overwork* (Abstract))) and Article (Document Types) and English (Languages)

Notes: The search strategy used is shown for each database searched, which accommodated for both differences in search logic syntax as well as available keyword or index terms. Date of search: March 1, 2023.

The inclusion criteria were full-text articles published in an English language peer-reviewed journal describing an intervention intended to reduce EHR-related burnout in any type of clinician with reported outcomes on burnout or related to burnout, such as stress, job satisfaction, and documentation workload. To differentiate EHR-related burnout from general burnout, we only included studies describing interventions explicitly designed to alter the way clinicians interacted with EHRs. The exclusion criteria were studies describing EHR-related interventions without explicit intent to reduce burnout, stress, and documentation workload or improve EHR-related satisfaction. We also excluded studies that we considered “wrong study design” (i.e., abstracts, conference proceedings, nonpeer-reviewed manuscripts, and non-English studies without a translation).

The retrieved eligible studies were deduplicated using EndNote (Clarivate Analytics, Philadelphia, Pennsylvania, United States) and imported the studies into the systematic review software Covidence (Melbourne, Victoria, Australia) for screening, full-text review, and data extraction. The screening and selection process is displayed in a PRISMA flowchart ([Fig. 1]). Covidence was then used to conduct title/abstract screening, full-text review, and data extraction in Covidence. The authors developed a data template in Covidence to extract relevant information, including country, study design, setting, type of clinician, number of participants, intervention type, characteristics of the intervention, duration, objective, outcome measures, and outcomes of the study.

Fig. 1 PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

 

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Results

Study Characteristics

The initial search yielded 4,258 studies after deduplication; after title/abstract and full-text review, 44 studies met the eligibility criteria. The publication year of the articles ranged from 2010 to 2023. Most studies were based in the United States (93%), whereas others were based in Canada,[20] Taiwan,[21] and the United Kingdom[22] ([Table 2]). Most studies (95%) were prospective in study timing, whereas two studies (5%) were retrospective.[23] [24] The number of participants in the interventions ranged from 13 to 6,459, with a cumulative total of 14,429 participants across all studies. Most included studies were pre/poststudies (66%). Eight studies were case reports (18%),[20] [25] [26] [27] [28] [29] [30] [31] four were cohort studies (9%),[23] [32] [33] [34] two were randomized control trials (5%),[35] [36] and one was an observational study (2%).[24]

Table 2 Characteristics of included studies

Author year	Country	Study design	Setting	Type of clinician	Participants (n)
Bauer 2020	USA	Cohort study	Medical–surgical unit at a large tertiary care hospital	RNs and CNAs	49
Buivydaite 2022	UK	Pre/poststudy	Community-based adult mental health teams in the UK	Physicians, nurses, support and recovery workers, and therapists	71
Dastagir 2012	USA	Pre/poststudy	Kaiser Permanente Northwest (KPNW)	Physicians, NPs, PAs, dentists, podiatrists, mental health practitioners	155
Day 2019	USA	Case report	University of Missouri Health Care	Physicians	NR
Diangi 2019	USA	Pre/poststudy	Stanford Children's Health	Inpatient and ambulatory care providers	147
English 2022	USA	Pre/poststudy	University of Colorado Health	Physicians, APPs, speech, physical, occupational therapists	493
Gao 2020	USA	Cohort study	Large academic medical center's oncology practice	Physicians	33
Gidwani 2017	USA	RCT	Academic family medicine clinic	Physicians	4
Gordon 2022	USA	Pre/poststudy	Large ambulatory practice network	Physicians, apps, therapists, audiologists, pharmacists, and nurses	673
Hartman-Hall 2023	USA	Case report	Community teaching hospital	Resident physicians	24
Heckman 2020	USA	Case report	A large academic general internal medicine practice	Physicians	13
Hindman 2019	USA	Case report	Oncology Program at FirstHealth Moore Regional Hospital	Physicians	NR
Hsieh 2016	Taiwan	Pre/poststudy	A 50-bed surgical unit in an acute and tertiary medical center in Taiwan	Nurses	22
Imdieke 2017	USA	Pre/poststudy	A hospital-based, outpatient primary care clinic	Physicians, NPs, and MAs	7
Ip 2022	USA	Pre/poststudy	Radiology department of a tertiary care academic medical center	Physicians	36
Jhaveri 2022	USA	Pre/poststudy	A large academic pediatric primary care practice in central Pennsylvania	Physicians and NPs	6
Johnson 2021	USA	Pre/poststudy	Ascension St Vincent Family Medicine Residency Program	Resident physicians	26
Kadish 2018	USA	Pre/poststudy	Department of Medical Oncology, Dana-Farber Cancer Institute	Physicians, NPs, PAs	185
Koshy 2010	USA	RCT	Urological Institute of Northeastern New York	Physicians	5
Lam 2022	USA	Pre/poststudy	Outpatient academic dermatology clinic	Physicians and NPs	6
Lindsay 2022	USA	Pre/poststudy	Two medical units at a health system in the southeastern United States	Nurses	161
Lin 2021	USA	Case report	Stanford University School of Medicine	Physician	29
Livingston 2022	USA	Case report	Department of radiation oncology at a large academic institution	Physicians	6
Lourie 2021	USA	Pre/poststudy	Children's Hospital of Philadelphia (CHOP)	Physicians, APPs, psychologists	1010
Martel 2018	USA	Pre/poststudy	nine clinics in an academic, inner-city, hospital-based clinic system	Physicians, APPs	51
McCormick 2018	USA	Pre/poststudy	University of North Carolina Department of Urology	Physicians	6
Micek 2022	USA	Pre/poststudy	academic primary care practice	Physicians	38
Mishra 2018	USA	Pre/poststudy	2 medical center facilities in Kaiser Permanente Northern California (KPNC)	Physicians	18
Morawski 2017	USA	Pre/poststudy	Internal medicine practice	Physicians and PAs	23
O'Connor 2023	USA	Observational study	Primary medical centers of the Veterans Health Administration	Physicians, NPs, PAs	6,459
Pfoh 2022	USA	Pre/poststudy	Cleveland Clinic	Physicians and a NP	37
Platt 2019	USA	Pre/poststudy	Family Practice Group in Arlington, Massachusetts	Physicians	5
Pozdnyakova 2018	USA	Pre/poststudy	Academic general internal medicine clinic at the University of Chicago	Physicians	6
Raney 2020	USA	Pre/poststudy	St Jude Affiliate Network	Pediatric oncology providers	47
Robinson 2018	USA	Pre/poststudy	Kaiser Permanente Southern California Region	Physicians	3500
Sattler 2018	USA	Pre/poststudy	Academic family medicine practice	Physicians	4
Scott 2020	USA	Cohort study	Ohio State University Wexner Medical Center	Physicians, nurses, and other health care professionals	108
Sequeira 2021	Canada	Case report	A large academic mental health hospital located in Toronto, Ontario	Physicians	46
Sieja 2019	USA	Pre/poststudy	6 clinics in University of Colorado Health	Physicians, APs	220
Sieja 2021	USA	Pre/poststudy	One academic internal medicine practice	Physicians and APPs	26
Simpson 2021	USA	Pre/poststudy	A medical–surgical acute care unit at the University of Colorado Hospital	APPs	19
Stephens 2022	USA	Pre/poststudy	Primary care and medical specialty practices	Physicians	50
Stevens 2017	USA	Case report	Stanford Children's Health	Physicians and APPs	561
Tohmasi 2021	USA	Cohort study	General surgery residency at the University of California	Resident and attending physicians	44

Abbreviations: APP, advanced practice provider; CNA, certified nursing assistant; MA, medical assistants; NP, nurse practitioner; NR, not reported; PA, physician assistant; RN, registered nurse.

The type of clinician in the retrieved studies varied widely and included attending physicians (84%),[20] [22] [23] [24] [25] [26] [27] [28] [29] [30] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] advanced practice providers (APPs) such as nurse practitioners and physician assistants (30%),[22] [24] [31] [34] [37] [39] [40] [43] [44] [45] [46] [50] [51] [57] [58] [60] [61] [62] resident physicians (14%),[21] [30] [32] [33] [40] [63] nurses (14%), and other clinicians such as medical assistants, certified nursing assistants, psychologists, therapists, support and recovery workers, podiatrists, and mental health practitioners (14%; [Fig. 2]).[22] [32] [39] [40] [45] [60] Eighteen studies (41%) used interventions aimed at multiple categories of clinicians.

Fig. 2 Target clinicians in interventions to reduce EHR-related burnout. EHR, electronic health record.

The study setting in the retrieved articles included academic or research hospitals,[20] [21] [25] [30] [32] [33] [38] [39] [45] [46] [51] [57] [59] [62] [63] general internal medicine,[24] [26] [41] [48] [50] [53] [57] [60] oncology,[23] [27] [29] [43] [54] family medicine,[35] [52] [56] [61] urology,[36] [47] general surgery,[34] dermatology,[44] and radiology practices,[42] large health networks and systems,[28] [37] [40] [49] [55] and community hospitals.[22] [31]

 

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Outcome Measures

Fourteen studies measured the baseline burnout or wellness level of the participants as well as the outcomes of the interventions. These included the Mini-Z survey,[30] [38] [46] [48] Maslach Burnout Inventory,[50] [57] [61] Professional Fulfillment Index,[31] [48] [51] [59] American Medical Association Steps Forward Survey,[26] [48] Copenhagen Burnout Inventory,[44] and physician work–life study study,[45] and the Stanford Physician Wellness Survey.[42] [45]

For intervention satisfaction, written surveys[20] [21] [22] [23] [24] [25] [28] [29] [32] [33] [34] [35] [36] [37] [40] [41] [43] [47] [48] [49] [52] [53] [55] [56] [60] [63] was most often used, followed by Net Promoter Score (NPS),[39] [45] [57] [62] and the Technology Acceptance Model sub-survey.[45] The NPS represents the percentage of promoters (those who are likely to recommend the service) minus the percentage of detractors (those who are unlikely to recommend a service).

To measure EHR proficiency, studies used EHR metrics such as total time spent in the EHR,[21] [29] [58] [60] [63] and the User Settings Achievement Level and proficiency score.[40]

 

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Types of Interventions

Interventions to reduce EHR-related clinician burnout were in three broad groups: (1) employment of scribes (48%),[23] [26] [27] [28] [31] [34] [35] [36] [41] [44] [46] [47] [48] [49] [50] [51] [52] [53] [56] [59] [60] (2) EHR training (36%),[20] [25] [29] [30] [33] [37] [38] [39] [40] [42] [43] [45] [55] [57] [58] [61] and (3) EHR modifications (25%)[20] [21] [22] [24] [32] [39] [54] [57] [58] [62] [63] ([Table 3]). Four studies combined both EHR training and modifications into one intervention (9%; [Fig. 3]).[20] [39] [57] [58]

Fig. 3 Interventions to reduce EHR-related burnout in clinicians. EHR, electronic health record.

Table 3 Intervention characteristics, objectives, outcome measures, and outcomes of included studies

Author year	Intervention type	Duration of intervention	Objective	Outcome measures	Outcomes
Bauer 2020	EHR modifications	3 wk	To investigate the impact of data entry automation technology on cost, quality, performance, and job satisfaction in a hospital nursing unit	Survey	The initiative reduced data errors from to zero, increased direct patient care time for nurses, and improved nurses' job satisfaction
Buivydaite 2022	EHR modifications	10 wk	To enhance the user-friendliness of EHR evaluation documents in a UK clinical setting	Usability testing, clinician experience survey, proportion of completed EHR assessment forms	Clinicians required less time to fill out the forms and duplicate patient data and expressed satisfaction with the improved usability changes
Dastagir 2012	EHR training	3 d	To evaluate an EHR training program's effectiveness in improving provider's EHR proficiency, job satisfaction, and work–life balance	Online questionnaire	The training program enhanced clinician's self-perceived comfort and efficiency in utilizing an EHR and improved their job satisfaction and perception of work–life balance
Day 2019	EHR training	NR	To describe an “EMR happy hour” designed to alleviate the burden of documentation by facilitating peer-to-peer sharing of best practices	Interviews	Participants appreciated the peer support that reduced feelings of isolation and allowed them to learn alongside others sharing similar experiences.
Diangi 2019	EHR training	20 mo	To improve provider EHR work satisfaction and decrease documentation time through personalized, on-site EHR training	Self-reported clinician metric, Mini-Z burnout survey	Although EHR training enhanced providers' satisfaction on EHR workload, it did not result in a significant decrease in either self-reported or calculated EHR usage time
English 2022	EHR training; EHR modifications	5 mo	To assess the effects of an EHR training and optimization program on provider and staff burnout and EHR experience	Net Promoter Score	Providers experienced a significant increase in EHR satisfaction and subjective EHR proficiency and efficiency
Gao 2020	In-person scribes	24 mo	To assess the impact of scribes on clinic workflow, physician satisfaction, and quality of life in outpatient oncology clinics	Physician surveys, patient visit duration times	Physicians utilizing scribes experienced a significant decrease in duration of patient visit and time spent on chart completion
Gidwani 2017	In-person scribes	52 wk	To assess the impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency	Physician and patient satisfaction survey	Scribes positively influenced physician satisfaction and increased the proportion of closed charts within 48 hours, with no significant impact on patient satisfaction
Gordon 2022	EHR training	26 mo	To describe an EHR training program designed to enhance physician education after the implementation of a new EHR at Mayo Clinic	User Settings Achievement Level, proficiency score	Significant improvements were observed in user confidence, configuration outcomes, and proficiency scores
Hartman-Hall 2023	In-person scribes	6 mo	To assess the impact of medical scribes on the time resident physicians in inpatient medicine teams spend on various tasks	Professional fulfillment inventory	Residents allocated a higher percentage of time to direct patient care when assisted by a scribe, although there were no significant improvements in burnout or fulfillment
Heckman 2020	In-person scribes	16 wk	To assess the effect of medical scribes on patient and provider satisfaction and provider productivity	American Medical Association Steps Forward Survey, wRVU	Physicians utilizing scribes completed significantly more visits per hour and reported improved perception of the documentation burden
Hindman 2019	In-person scribes	NR	To describe the utilization of scribes within the oncology program at FirstHealth Moore Regional Hospital	Interviews	Physician interviews revealed a generally positive perception of scribes, citing increased opportunities for direct patient interaction and the ability to allocate more time to patient care
Hsieh 2016	EHR modifications	NR	To assess nurse satisfaction and time spent on progress note documentation after revising the EHR templates	Time documentation, staff satisfaction survey	Documentation time after revising the focus template decreased by 60% and EHR satisfaction improved
Imdieke 2017	In-person scribes	2 mo	To evaluate the impact of scribes in an ambulatory primary care clinic on the duration of documentation times	Survey	Implementing medical scribes led to a reduction in provider documentation times by more than 50%
Ip 2022	EHR training	2 y	To compare the self-reported levels of burnout in radiologists after departmental well-being initiatives including EHR training	Stanford Physician Wellness Survey	Despite the wellness initiatives, radiologists reported no change in burnout levels across, which may be attributed to the growing patient volume and low participation rates
Jhaveri 2022	In-person scribes	3 mo	To assess the impact of medical scribes on the time required to complete clinical notes and clinician satisfaction	EHR time data, survey	Medical scribes led to a reduction in the time spent on charting and time taken to finalize clinic notes
Johnson 2021	EHR training	5 mo	To assess the effect of EHR training on the wellness and productivity of family medicine residents	Modified Maslach Burnout Inventory	Residents reported subjective improvement in EHR efficiency, although most objective efficiency metrics showed a statistically nonsignificant decline
Kadish 2018	EHR training	NR	To examine whether a personalized EHR training could decrease the time spent using the EHR and enhance clinician confidence levels	Survey	Personalized training increased clinician confidence across all activities and decreased time spent in the EHR in some activities, although not statistically significant
Koshy 2010	In-person scribes	10 mo	To assess the impact of scribes on physicians' work burden in an academic urology program	Survey	Physicians were significantly more satisfied with office hours when a scribe was present, and patients were accepting of having a scribe in the examination room
Lam 2022	In-person scribes	9 mo	To evaluate the influence of a scribe on physician and patient satisfaction in an academic dermatology clinic	Copenhagen Burnout Inventory	Physicians felt improved work satisfaction and decreased active documentation time by more than 50%, resulting in an increased number of patients seen
Lindsay 2022	EHR modifications	14 mo	To improve efficiency and reduce unnecessary duplication in nursing documentation by reconfiguring the EHR workflow	Survey	The initiative enhanced the user-friendliness and effectiveness of the EHR, which reduced time spent on documentation, redundancy, and excessive clicking
Lin 2021	In-person scribes	5 y	To describe a postbaccalaureate premedical program that incorporates a scribing experience	Timestamp Data, survey, video motion-time recording	Mentors and mentees reported high levels of satisfaction, where faculty members reported that scribes improved their joy of practice
Livingston 2022	EHR training	NR	To describe a personalized training program for radiology oncologists aimed at enhancing documentation efficiency	EHR performance data, survey	Physicians felt more efficient in their EHR after training and spent less time on communication and documentation metrics
Lourie 2021	EHR training	NR	To deliver personalized EHR training to address providers' concerns related to documentation burden	Physician work–life study Single Item Burnout Survey, Stanford WellMD EHR questions sub-survey, Technology Acceptance Model sub-survey, Net Promoter Score	Following the training, providers demonstrated a 26% increase in their average knowledge of EHR functionality, 17% reduction in after-hours EHR usage, and reported less burnout
Martel 2018	In-person scribes	2 y	To implement a medical scribe program to enhance provider satisfaction, standardize documentation practices, and increase revenue	Mini-Z work–life assessment	Providers reported a significant improvement in documentation time and increased satisfaction with their clinic responsibilities
McCormick 2018	In-person scribes	3 mo	To assess the impact of medical scribes in an academic urology clinic on productivity, revenue, and patient/provider satisfaction	Survey	Scribes resulted in increased efficiency and job satisfaction for physicians, enabling them to see a mean of 2.15 more patients per session, while patient satisfaction remained unaffected
Micek 2022	Virtual scribes	1 y	To evaluate a remote scribe pilot program in an academic primary care practice	Survey	Compared with controls, physicians paired with scribes reported higher Mini-Z wellness metrics and lower total EHR time
Mishra 2018	In-person scribes	12 mo	To assess how medical scribes affects the workflow of primary care physicians and patient experience	Survey	Compared with baseline, physicians reported less after-hours EHR documentation and higher face-to-face time with patients when paired with scribes
Morawski 2017	In-person scribes	NR	To document the impact of scribes on clinical productivity and experiences of physicians and patients	Maslach Burnout Inventory	Providers reported a reduction in the need for documentation, an increase in the average number of patients seen per week, and higher scores in the MBI subcategories
O'Connor 2023	EHR modifications	NR	To assess provider burnout after implementing an initiative to decrease low-value notifications	Annual workforce survey	Inbox notifications per provider decreased by an average of 5.9%, although burnout was not significantly associated with these changes
Pfoh 2022	In-person scribes	6 mo	To understand how scribes impacted provider efficiency and satisfaction	Modified Professional Fulfillment Index	Most clinicians endorsed that working with a scribe and felt more satisfied with work and spent less time charting on clinic days
Platt 2019	In-person scribes	1.5 y	To investigate the impact of medical scribes on patient and physician and quality measure documentation in a family medicine setting	Health care effectiveness data and information set, survey	Documentation quality improved and physicians felt that they were spending less time on documentation with reduced levels of stress with scribes
Pozdnyakova 2018	In-person scribes	2 mo	To investigate the effect of scribes on physician and patient satisfaction at an academic general internal medicine clinic	Survey	Physician burnout remained low but unchanged while mean time spent documenting after clinic significantly decreased with scribes
Raney 2020	EHR modifications	3 mo	To address low compliance with complete oral chemotherapy documentation with a long-term goal to decrease provider burnout	Mini Z 2.0 survey	Standardization of the documentation and weekly training improved the compliance rate from 13 to 87%, leading to less redundant e-mail exchanges among the staff
Robinson 2018	EHR training	2 y	To describe an educational intervention aimed to manage physicians' EHR in-basket workload and physician burnout	Survey, EHR performance data	Most physicians reported significant improvements in various aspects of documentation and a reduction in medical errors
Sattler 2018	In-person scribes	12 mo	To describe the use of scribes in a family medicine practice using an ethnographic approach	Survey	Physicians felt that scribes brought joy of practice and improved quality of care and patient experience
Scott 2020	EHR training	21 mo	To improve provider satisfaction with the EHR through a provider EHR efficiency program	Survey	Providers were satisfied with the initiative and felt that the training was informative, well-executed, organized, and beneficial
Sequeira 2021	EHR training; modifications	7 mo	To describe the use of an interdisciplinary EHR “SWAT” team that fixes EHR-related requests in a timely manner	Survey	A total of 118 requests were gathered and physicians reported that the SWAT team increased their EHR proficiency
Sieja 2019	EHR training; modifications	2 wk	To evaluate a novel clinic-focused Sprint process to optimize EHR efficiency	Maslach Burnout Inventory, Net Promoter Score	Clinician satisfaction with the EHR increased by 27 points and exhaustion measure of burnout decreased, although statistically nonsignificant
Sieja 2021	EHR training; modifications	2 wk	To report the effect of Sprint EHR training and optimization on clinician time spent in the EHR	EHR usage data	The intervention led a 6-h decrease in documentation time per day at a clinic level that was sustained over 6 mo
Simpson 2021	EHR modifications	2 wk	To describe a 2-wk EHR optimization sprint intended to reduce EHR burden on inpatient clinicians	Maslach Burnout Inventory, Net Promoter Score	EHR Net Promoter Score increased by 54 points and clinicians reported a subjective decrease in documentation time although user log data did not show a significant decrease
Stephens 2022	virtual scribes	1.5 y	To evaluate a synchronous virtual scribe model and its impact on clinician perceptions of burnout in an outpatient setting	Professional Fulfillment Index	Burnout levels trended upward during this study, although there was a 50% of the participants dropped out during the study
Stevens 2017	EHR training	1 y	To describe an EHR training program designed to improve EHR efficiency and satisfaction	Mini-Z burnout survey	Survey results revealed qualitative improvement clinicians' efficiency and satisfaction with the EHR
Tohmasi 2021	In-person scribes	4 y	To assess the impact of outpatient scribes at an academic general surgery residency program	Survey	Majority of residents and faculty reported that scribes decrease the daily workload of trainees, improved the quality of their surgical education, and enhanced resident well-being

Abbreviations: EHR, electronic health record; EMR, electronic medical record; NR, not reported; MBI, Maslach Burnout Inventory.

 

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Scribes

The most common intervention to reduce EHR-related clinician burnout was the use of scribes. Most used in-person scribes,[23] [26] [27] [28] [31] [34] [35] [36] [41] [44] [46] [47] [49] [50] [51] [52] [53] [56] [60] whereas two studies described the use of virtual scribes.[48] [59] All studies described the use of scribes by physicians, although four studies also included APPs.[44] [46] [50] [51]

In-person scribe programs involved a scribe accompanying the clinician into the patient room and documenting the patient encounter in real time.[56] [60] For virtual scribe programs, a scribe working in a remote location would listen to the patient interaction and enter clinical information into the EHR real time or asynchronously.[48] [59] The clinicians used desktop, mobile phones, smart watch, or tablets to communicate with the scribe. The adoption of virtual scribes was driven by their suitability for practices in remote geographical areas where the cost of hiring physical scribes may be prohibitive.[59]

Studies used varying methods to train and hire the scribes. Some institutions partnered with a scribe company that provided scribes who were already trained and certified.[35] [44] [47] [48] [49] [50] [51] [53] [56] [59] [60] Other studies trained the scribes in-house,[46] utilizing premedical students,[28] [36] [52] externs,[31] or certified medical assistant or licensed practical nurses.[27]

Five studies emphasized the importance of developing a strong working relationship between the clinicians and scribes. In two studies, clinicians implemented a transition period of 1 to 2 months for quality control by providing feedback and specialty-specific training.[44] [59] In other cases, a scribe was consistently paired with the same clinician to ensure a deeper understanding of the clinician's documentation preferences.[27] [48] [50]

Clinicians generally expressed positive sentiments regarding the use of scribes, although the impact of scribes has shown mixed results. Postintervention surveys frequently revealed a downward trend in burnout metrics and an upward trend in wellness metrics.[48] [50] [59] Clinicians reported feeling less mentally burdened,[34] [56] experiencing increased joy in their practice,[28] [35] and having more time to focus on communication with their patients.[46] [49] [53] Contrastingly, studies conducted in an academic general internal medicine and dermatology clinic found that physician burnout was already low at baseline and remained unchanged after implementing scribes.[44] [53]

Additionally, two studies reported a decrease in documentation time with the implementation of scribes.[48] [51] Time logs have revealed significant reductions in time spent on the EHR, such as a 50% decrease in overall documentation time,[41] a reduction of 3 minutes and 28 seconds per patient,[60] and a reduction of 53.4 minutes in postclinic documentation time.[53]

Studies also noted an unexpected increase in clinic productivity after hiring scribes. A prospective study on use of in-person scribes in an outpatient dermatology clinic reported a 29% increase in patients seen, translating into 2.5 patients per half-day session.[44] Similarly, a study based in a general internal medicine practice found that clinicians with scribes completed more visits per hour and generated more work Relative Value Units per hour.[26]

In general, the scribe program was well-received by patients.[26] [36] [44] [47] [52] In fact, some patients felt that physicians were more attentive during visits with the scribe present.[52] [53] Studies conducted in an academic setting noted that patients are accustomed to having additional individuals, such as medical students and residents, present during their appointments, which may contribute to their accepting attitude toward the presence of a scribe.[36] [44]

Several studies have highlighted certain challenges associated with the use of scribes. One notable issue was the dropout of some participants from the program due to dissatisfaction or scribe turnover.[48] Additionally, some clinicians expressed concerns regarding minor inaccuracies in the notes generated by the scribes.[56]

Six studies emphasized that cost served as a barrier to the adoption of scribes, prompting researchers to adopt various financing models.[27] [28] [46] [48] [53] [59] In two studies, the institution covered a portion of the expenses associated with hiring scribes, whereas the remaining cost was paid by either the individual departments[46] or participating physicians.[59] In the latter study, approximately half of the physicians dropped out of the study within the first year, likely due to the costs involved and the need for continuous quality assurance. In other studies, clinicians opted to increase the number of patients they saw at the clinic to offset the costs.[27] [48] [53] In one study, a tuition-based scribe fellowship program supplied scribes to the hospital, which alleviated the financial burden on the hospital and the physicians.[28]

 

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Electronic Health Record Training

EHR training emerged as a prevalent intervention to mitigate EHR-related burnout.[20] [25] [29] [30] [33] [37] [38] [39] [40] [42] [43] [45] [55] [57] [58] [61] In contrast to scribe programs (which are typically geared toward physicians), EHR training was often used for clinicians for various levels of training across specialties such as physicians, nurses, and APPs.

The training sessions covered a range of topics aimed at enhancing EHR satisfaction and efficiency. These topics encompassed instructions on utilizing standardized templates effectively,[25] [29] leveraging voice recognition tools,[29] managing inbox communication,[29] accessing personalized guides,[29] [40] [45] [55] and utilizing specialty-specific lists of smart tools.[55]

In the majority of EHR trainings, a combination of brief didactic sessions[40] [61] and longer individualized sessions[20] [29] [43] [61] were used. This blended approach allowed for both general knowledge transfer and personalized instruction. Alternatively, two studies opted for a more intensive training program that spanned 2 to 3 days.[40] [55]

The EHR training team varied in size from 4 to 20 people. Teams were often interdisciplinary, including roles such as chief medical information officers,[20] project manager,[20] [39] clinical informaticians,[20] [39] [45] [58] EHR analysts and trainers,[33] [39] [45] [58] and a training coordinator.[30] [38]

Seven studies describing EHR training emphasized the importance of individualization in their approaches.[30] [37] [42] [45] [55] [58] [61] To tailor the learning experience for clinicians, individualized learning plans were developed based on three key inputs. These plans typically involved a need assessment survey, vendor-generated EHR report, and an observation session, in which an informatician shadowed the provider during clinical care.[38] [43]

Researchers employed various strategies to promote participation in their studies. Two studies used protected time and leveraged existing timeslots during divisional meetings.[20] [29] Other studies provided nominal financial incentive for all departments with a high participation rate.[30] [38] In two cases, participants had the opportunity to earn continuing medical education (CME) hours and quality improvement maintenance of certification credits.[33] [40]

EHR training studies reported qualitative improvements in clinicians' efficiency and satisfaction with EHR. Participants often reported a subjective increase in EHR proficiency,[37] [38] [40] [43] [45] [61] which was sustained at 6-month postintervention in one study.[40] Other studies found that participants felt less feelings of burnout after the training.[39] [45] [58] [61]

The impact of training on the time spent on documentation varied among the studies. Four studies reported a decrease in documentation time,[29] [37] [43] [45] ranging from 8.9[29] to 20 minutes saved per day.[58] Conversely, other studies found no notable change in documentation time.[38] Interestingly, Johnson and Roth noted that while subjective EHR proficiency increased, quantitative efficiency metrics worsened, although statistically nonsignificant, which could possibly be attributed to the placebo effect.[61]

Even if EHR training does not result in statistically significant changes in EHR log data, improved perceptions of the EHR are still noteworthy. Such improvements suggest that EHR training can have a positive impact on clinician burnout by streamlining the management of EHR limitations and reducing user frustration.

 

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Electronic Health Record Modifications

Implementing EHR enhancements emerged as another strategy to mitigate EHR-related burnout.[20] [21] [22] [24] [32] [39] [54] [57] [58] [62] [63] Some interventions focused on individual modifications such as creating a data entry automation technology,[32] revising EHR forms and workflow,[21] [22] [54] [63] and decreasing low-value inbox notifications.[24] In other cases, an EHR “Sprint” or “SWAT” team were established to resolve EHR-related requests in a timely manner.[20] [39] [57] [58] Common requests included keyword search functionality, minimizing freezing, and autofaxing.

Various positive outcomes have been associated with modifications in the EHR, such as an increase in subjective EHR usability and satisfaction.[21] [32] Additionally, researchers have noted a decrease in the time spent on documentation,[32] with reductions ranging from 18.5[63] to 60%.[21] EHR modifications have also been linked to higher documentation completion rates[22] [54] and an improvement in the quality of documentation, leading to a decrease in data errors to nearly 0%.[32]

Despite these benefits, EHR modifications did not consistently result in a significant reduction in burnout. For instance, an observational study that aimed to reduce low-priority notifications within the Veterans Health Administration found that although the initiative decreased daily inbox notifications by 5.9%, it did not result in a significant change in physician burnout.[24] Similarly, a 2-week sprint program at the University of Colorado Health did not yield significant changes in the metrics of emotional thriving, emotional recovery, and emotional exhaustion.[62] These findings suggest that while EHR enhancements can improve various aspects of the health care workflow, they may not directly address the usability defects of the EHR itself contributing to clinician burnout.

 

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Discussion

We conducted a systematic review of 44 studies describing interventions aimed at reducing EHR-related burnout. These interventions, including scribe utilization, EHR training, and EHR modifications, were implemented in diverse academic, research, and subspecialty clinics catering to clinicians from various backgrounds. The review highlights the significant burden of EHR-related burnout experienced by clinicians across different fields and the growing interest in addressing this issue. Subjective findings indicate potential benefits for participants, such as reduced documentation time and increased EHR satisfaction, while objective data remain contradictory or limited. Nonetheless, the study emphasizes the potential of these interventions to reduce burnout and emphasizes the need for further research to establish stronger evidence.

The literature suggests that the three primary intervention types—scribe employment, EHR training, and EHR modifications—may address specific aspects of EHRs and their impact on clinicians' workload and burnout. For instance, the employment of scribes may alleviate EHR-related burnout by reducing the documentation burden on clinicians by capturing patient information more efficiently, allowing clinicians to focus more on patient care.[59] [64] EHR training can help improve clinicians' proficiency in using EHRs, leading to reduced frustration and stress.[39] [65] Additionally, EHR modifications, by streamlining EHR systems to better align with the workflow, may reduce the time and effort required for data entry, mitigating sources of frustration associated with EHR usage.[66]

We identified several gaps in the literature on interventions intended to reduce EHR-related burnout in clinicians. First, there is a lack of standardized assessment to measure EHR proficiency, satisfaction, and clinician burnout, making it difficult to distinguish between perceived and objective improvements postintervention.[67] [68] Some studies used surveys that were not pretested or validated, whereas other studies modified the surveys during the intervention, making it difficult to compare results. Other limitations were related to study design such as small sample size, low participation and response rate, high attrition rate, lack of control groups, and short duration of the intervention.[69] Enrollment was also disrupted by the COVID-19 pandemic, rotating nature of residency programs, and rolling enrollment policies. As a result, it is hard to determine the scalability or generalizability of such interventions.

This review included articles identified in six literature sources. The databases included in this study reflected broad coverage of literature (Ovid MEDLINE and Embase), psychological and mental health research (PsycINFO), as well as allied health and nursing (CINAHL), as well as search tools that complemented the search interfaces for each of the literature databases (PubMed and Web of Science). To bolster the evidence base for interventions targeting EHR-related burnout, future studies should employ stronger research designs, including randomized trials, control groups, longer study durations, and validated, objective outcome measurements.[69] Further research is needed to answer several key questions such as investigating the sustained impact of interventions on EHR time and clinician wellness, assessing variations in effectiveness across clinical settings (academic, research, and subspecialty clinics), and validating subjective findings with more objective and quantifiable data. A thorough cost–benefit analysis can also help clinicians understand the economic feasibility and potential savings associated with these interventions.

It is important to note that this study did not include studies published in gray literature or in languages other than English. By not incorporating these types of studies, we may have missed some important findings from operational settings not reported in peer-reviewed literature.

 

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Conclusion

There were three main types of interventions that hold promise in reducing EHR-related burnout among clinicians: employment of scribes, EHR training, and EHR modifications. Our findings suggests that while interventions often yield positive outcomes such as increased EHR satisfaction and reduced documentation time, addressing the burnout directly requires a more comprehensive approach. Factors contributing to burnout extend beyond EHR systems and encompass workload, organizational culture, and work–life balance. Therefore, although interventions may positively impact certain aspects of clinicians' experience, they may not directly translate into a reduction in burnout. Long-term, large-scale studies with robust study designs need to be conducted to gain a better understanding of the sustained effects of interventions and their impact on burnout.

 

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Clinical Relevance Statement

The review's findings suggest promising interventions, such as employing scribes, providing EHR training, and implementing EHR modifications, for reducing EHR-related burnout among clinicians. Researchers, policy makers, and administrators should adopt a comprehensive approach to address the multifaceted nature of burnout, which include factors beyond EHR systems, such as workload, organizational culture, and work–life balance.

 

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Multiple-Choice Questions

1. What intervention is mostly geared toward physicians?

   • Scribes

   • EHR training

   • EHR modifications

   • All of the above

   Correct Answer: The correct answer is option a. Scribes were primarily utilized to support physicians, whereas EHR training and EHR modifications were implemented to support clinicians from diverse backgrounds and varying levels of training.

2. What is one of the methods researchers used to promote participation in EHR training?

   • Making participation mandatory

   • Awarding CME hours

   • Offering social activities as part of the training

   • Providing fee merchandise and food

   Correct Answer: The correct answer is option b. Researchers adopted various approaches to encourage clinicians to participate in EHR training such as using protected time, offered financial incentives, awarding CME hours and quality improvement maintenance of certification credits.

 

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Conflict of Interest

None declared.

Acknowledgment

We thank Andrew Creamer from Brown University for drafting and conducting the search strategy for this project.

Protection of Human and Animal Subjects

Human and/or animal subjects were not included in the project.

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Publication History

Received: 10 August 2023

Accepted: 02 November 2023

Accepted Manuscript online:
03 November 2023

Article published online:
03 January 2024