Extra hours spent working on EHRs may contribute to the increase in physician burnout in the United States.
Courtesy of pandpstock001\GettyImages


Published 3/1/2018
Nicholas Colyvas, MD; Marianna Babiolakis, BA

The EHR Era: Workload Reduction Strategies

The introduction of electronic health records (EHR) has imposed new workloads and workflows on physicians and orthopaedic practices.

Although EHRs offer benefits including centralized and consolidated medical information, electronic prescriptions, and enhanced legibility, interoperability of these systems remains problematic.

Many clinicians have found that the largely regulatory- and reimbursement-driven documentation requirements offset the advantages of EHR. As a result, in many cases, EHR adoption has increased workloads for physicians and other providers.

Work-life balance and burnout
To accommodate necessary EHR work, physicians must now find extra time in their day. As they struggle to maintain the equilibrium between paperwork and patients, many providers find themselves completing "paperwork" outside of the clinical setting. A recent study on the allocation of time found that physicians spend 86 minutes of "pajama time" (time at home) with their EHR nightly.

These extra hours spent working on EHRs may contribute to the increase in physician burnout in the United States. In one survey, more than half of responding physicians reported symptoms of burnout. According to a 2016 Insights Report by NEJM Catalyst, 80 percent of physician burnout is attributed to workflow difficulties.

Physicians have responded in various ways to reduce workload and readdress the balance. The Catalyst report, for example, suggested improving EHR-user interface, increasing machine learning for coding purposes, customizing EHRs, and applying more team-based care. The use of scribes or mid-level providers to meet documentation requirements, thus freeing the physician to spend more time with patients face-to-face, predates EHRs. Scribes also improve satisfaction and medical chart accuracy and quality.

This method can both reduce a physician's daily workload, and benefit the scribes themselves, especially those who are aspiring medical professionals. Patient interactions enable scribes to gain daily hands-on experience in clinical settings. But to practices that operate on already thin margins, the added costs and management of hiring scribes can present significant challenges. Quality, consistency, and availability are other challenging issues.

The scribe industry has grown significantly since the adoption of EHRs. Practices can now outsource the training and hiring of scribes to companies established to meet this need. Although outsourcing may lead to improvements in quality control, availability, and human resource management, while also reducing training requirements, it is still an added cost. Offsetting this cost is the fact that scribes may make the practice more efficient and enable physicians to see more patients.

Enter technology
Technologic solutions have also been proposed to reduce the time physicians must spend at a keyboard. The ideal goal would be to create a keyboardless encounter. These technologies include variants of the classic dictation model (the tape recorder), as well as innovative information-capture models, such as Google Glass.

As part of a study on multiple speaker automatic speech recognition capabilities, Google Brain (Mountain View, Calif.) and Stanford University examined whether the technology could differentiate among individuals, filter out noise, and transcribe doctor-patient conversations. Although the word error rate was about 20 percent, the study authors concluded that the technology could be practical for transcribing medical conversations.

The potential to incorporate the translation services of Google Translate would be a value-added benefit, if it can be done seamlessly. This technology is in the early stages of development, but is limited by its inability to capture the video portion of the encounter.

With both video and audio capture, Augmedix (San Francisco) is attempting to "rehumanize" physician-patient encounters, using Google Glass systems. The system even enables physicians to transmit the encounter electronically in real time, enabling consultation with other physicians. However, the physician must wear the Google Glasses whenever seeing patients.

Robin Healthcare (Berkeley, Calif.) uses a propriety device installed in the workspace that seamlessly captures video and audio of the encounter. Multiple devices can be installed to capture all phases of the visit, without requiring the provider to wear or control anything. Such a technology could also capture encounter components such as pre-physician history gathering and X-ray or ultrasound room conversations.

These systems, however, still require the services of a "remote scribe." They must also address inherent HIPAA (Health Insurance Portability and Accountability Act) and confidentiality concerns, and they all require use of additional resources. The associated cost of such systems must be balanced against the finances of the overall practice and the level of patient care achieved.

Future directions
Advances in machine learning and artificial intelligence could make these systems true advances rather than technology-aided modifications of a tried and trusted model. Although a totally "scribeless" encounter is still some time away, a day may come when encounter documentation automation significantly reduces or eliminates the human factor.

In addition to finding ways to address the current excessive workload demands, some work is being done to reduce this burden. Many initiatives have been implemented to improve physician-patient interactions while operating the EHR. The Centers for Medicare & Medicaid Services recently launched the "Patient over Paperwork" initiative to review and revise regulations imposed on physicians. This initiative was triggered by an American Hospital Association report, which stated that providers spend approximately $39 billion annually on administrative efforts related to regulatory compliance.

Among the unintended consequences of adopting EHRs are the increased workload burden and negative workflow changes on physicians and practices, potentially degrading the doctor-patient relationship and fueling physician burnout.

To address this problem, a number of solutions are being developed, offering varying degrees of benefit and cost. Technology is playing an increasing role in addressing the problem, with the eventual promise of an inexpensive but effective, comprehensive, and accurate documentation of patient-physician encounters.

Nicholas Colyvas, MD, is an orthopaedic sports surgeon at Golden Gate Sports Medicine and Orthopedic Surgery in San Francisco. He is an assistant clinical professor of Orthopaedic Surgery in the Sports Medicine Section at The University of California, San Francisco. Dr. Colyvas serves on the AAOS Practice Management and the Health Care Systems Committees and is chairman of the Healthcare Systems Committee for the California Orthopaedic Association.

Marianna Babiolakis, BA, is currently a medical school candidate fulfilling a scribe internship with Dr. Colyvas at Golden Gate Sports Medicine in San Francisco.


  1. Arndt BG, Beasley JW, Watkinson MD, et al: Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations. Ann Fam Med 2017;15:419-426. (www.annfammed.org/content/15/5/419.full)
  2. Shanafelt TD, Hasan O, Dyrbye LN, et al: Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General U.S. Working Population Between 2011 and 2014. Mayo Clinic Proc 2017;90:1600-1613. (www.mayoclinicproceedings.org/article/S0025-6196%2815%2900716-8/abstract)
  3. Swensen S, Shanafelt T, Mohta NS:  Leadership Survey: Why Physician Burnout Is Endemic, and How Health Care Must Respond. NEJM Catalyst Insights Report, Dec. 8, 2016 (https://catalyst.nejm.org/physician-burnout-endemic-healthcare-respond/)
  4. Gidwani R, Nguyen C, Kofoed A, et al. Impact of Scribes on Physician Satisfaction, Patient Satisfaction, and Charting Efficiency: A Randomized Controlled Trial. Ann Fam Med 2017;15:427-433 (www.annfammed.org/content/15/5/427.full www.annfammed.org/content/15/5/427.full)
  5. Chiu C-C, Tripathi A, Chou K, et al. Speech recognition for medical conversations. Cornell University Library. (https://arxiv.org/abs/1711.07274)
  6. Dickson V. CMS wants docs to spend more time on patients, less on paperwork. Mod Healthcare Oct. 26, 2017 (www.modernhealthcare.com/article/20171026/NEWS/171029903)
  7. New Report Shows Regulatory Burden Overwhelming Providers, Diverting Clinicians From Patient Care. American Hospital Association. (https://www.aha.org/press-releases/2017-10-25-new-report-shows-regulatory-burden-overwhelming-providers-diverting)