Dr Dominic Pimenta, Jasmine Balloch, and Dr Ellie Asgari from TORTUS explore the impact of clinical workload on NHS clinicians and how approaches to EHR systems could be improved
Burnout in the NHS workforce has reached fever-pitch: nearly two-thirds of junior doctors ‘are at high to moderate risk of burnout’ – a figure that grows even higher in fields such as primary care. (1)
Healthcare professionals experiencing burnout cite workforce shortages, high workloads and time pressures, as well as poor organisational support as the primary drivers of their symptoms; each has also been cited as influencing clinicians’ intention to leave the NHS. (2)
In April, working alongside clinical experts from within the NHS, colleagues at TORTUS published a narrative review paper in the JMIR Medical Informatics titled ‘Impact of Electronic Health Record Use on Cognitive Loads and Burnout Among Clinicians’. The paper identified multiple studies that show how clinicians’ interactions with electronic health record (EHR) systems are a contributor to so-called ‘cognitive overload’. This overload impacts performance and, over a sustained duration, can lead to burnout.
EHRs are vital tools in modern healthcare. They play a critical role in providing clinical teams with a comprehensive picture of a patient’s health history in a form that – compared to the paper records they replaced – is simple to access and straightforward
to update.
Yet, while burnout is driven by a number of factors for which there is no single remedy, addressing EHR challenges for clinicians may prove to be a cost-effective tactic for healthcare providers looking to support staff. With 87% of primary, secondary and community care staff using EHRs as part of their role, putting in place certain measures to reduce the frictions clinicians face when using these systems could potentially minimise burnout and improve workforce retention. (3)
How do EHRs contribute to burnout?
When clinicians’ ‘cognitive load’ – their capacity to process information – is overwhelmed, the resulting cognitive overload can impair decision-making, interfere with mental performance and elevate stress levels.
High workloads – marked by frequent interactions with patients and the need to absorb and process information quickly, often ahead of making critical decisions – put clinicians at high risk of experiencing cognitive overload.
Our review found that certain features of EHRs may add extraneous tasks to clinicians’ cognitive load, increasing the risk of load becoming overloaded. Poorly designed user interfaces, such as those requiring clinicians to comb through large amounts of data to identify relevant information or to navigate complex interfaces to bring together all required context, add an extra layer of complexity to their roles.
EHRs play an essential part in improving the quality of care and patient outcomes. But equally – as a result of features that have emerged – either to meet compliance requirements or as a result of poor design choices – that negatively affect the user experience for clinicians, these systems are not fulfilling their potential to relieve clinicians’ workload and spend more time with patients.
How can organisations improve clinicians’ interactions with their EHR systems?
Involve clinicians in EHR procurement and implementation: Many of the challenges clinicians experience with EHRs stem from an initial lack of involvement in the design and implementation of these systems. This leads to misalignment with clinical workflows or the presentation of irrelevant information. Organisations should, therefore, ensure that clinicians help to define the specific requirements of any new system prior to rollout and are involved in its implementation.
Minimise information overload and alert fatigue: Alert fatigue is common in EHR use. Large numbers of prompts or alerts demand that clinicians commit cognitive capacity to tasks other than those centred around their patients. Conversations between clinical, administrative, and compliance teams are essential to determine the appropriate governance of these alerts and the extent to which each is required.
Provide training on the use of EHRs: Navigating complex user interfaces while under considerable time pressures requires significant cognitive load, which may be even greater when the user is unfamiliar with the system. Providing training on how to use systems may help to improve clinicians’ confidence in using systems.
Streamline data entry and recall: Clinicians were often overwhelmed by the prompts they received when submitting data into their EHR system; equally, care decisions required clinicians to filter relevant and irrelevant information presented by their systems. By assisting clinicians in completing tasks through EPR modifications, such as through clinical assistants to support with data input or the use of clinical decision- support tools to identify relevant information, organisations could minimise the extraneous load on clinicians.
Generative AI could ensure these modifications reduce, rather than add to, cognitive overload. Since the technology entered the mainstream, its application as a clinical scribe – synthesising the outputs of patient consultations into a form that can be automatically entered into an EHR – has generated interest within the NHS and primary care. Likewise, the technology may also be helpful in streamlining the labelling of clinical data, for example, by assigning procedure codes to ensure accurate reimbursement for treatment.
Ultimately, the drivers of burnout are complex and wide-ranging. The pressures on the clinical workforce cannot be attributed solely to any one factor, including EHRs. These systems have had an overall positive impact on care outcomes since they were first rolled out and, in most cases, continue to do so.
Yet, with many of the factors driving burnout beyond the control of local or regional NHS employers, the cognitive overload stemming from EHR use is a critical area in which organisations could be doing more to support their staff, with the likely outcome of reducing burnout and retaining staff.
References
- ‘Shameful’ levels of burnout highlighted in GMC survey, says BMA https://www. bma.org.uk/bma-media-centre/shameful-levels-of-burnout-highlighted-in-gmc-survey-says-bma
- Weyman et al. 2023, Determining the relative salience of recognised push variables on health professional decisions to leave the UK National Health Service (NHS) using the method of paired comparisons https://bmjopen.bmj. com/content/13/8/e070016
- Health Foundation, 2024, Which technologies offer the biggest opportunities to save time in the NHS? https://www.health.org.uk/publications/long-reads/which-technologies-offer-the-biggest-opportunities-to-save-time-in-the-nhs#:~:text=The%20evidence%20on%20whether%20EHRs,44%25%20 found%20no%20time%20savings.
