Practicing Clinicians' Recommendations to Reduce Burden from the Electronic Health Record Inbox: a Mixed-Methods Study

Abstract

Background: Workload from electronic health record (EHR) inbox notifications leads to information overload and contributes to job dissatisfaction and physician burnout. Better understanding of physicians' inbox requirements and workflows could optimize inbox designs, enhance efficiency, and reduce safety risks from information overload.

Design: We conducted a mixed-methods study to identify strategies to enhance EHR inbox design and workflow. First, we performed a secondary analysis of national survey data of all Department of Veterans Affairs (VA) primary care practitioners (PCP) to identify major themes in responses to a free-text question soliciting suggestions to improve EHR inbox design and workflows. We then conducted expert interviews of clinicians at five health care systems (1 VA and 4 non-VA settings using 4 different EHRs) to understand existing optimal strategies to improve efficiency and situational awareness related to EHR inbox use. Themes from survey data were cross-validated with interview findings.

Results: We analyzed responses from 2104 PCPs who completed the free-text inbox question (of 5001 PCPs who responded to survey) and used an inductive approach to identify five themes: (1) Inbox notification content should be actionable for patient care and relevant to recipient clinician, (2) Inboxes should reduce risk of losing messages, (3) Inbox functionality should be optimized to improve efficiency of processing notifications, (4) Team support should be leveraged to help with EHR inbox notification burden, (5) Sufficient time should be provided to all clinicians to process EHR inbox notifications. We subsequently interviewed 15 VA and non-VA clinicians and identified 11 unique strategies, each corresponding directly with one of these five themes.

Conclusion: Feedback from practicing end-user clinicians provides robust evidence to improve content and design of the EHR inbox and related clinical workflows and organizational policies. Several strategies we identified could improve clinicians' EHR efficiency and satisfaction as well as empower them to work with their local administrators, health IT personnel, and EHR developers to improve these systems.

Keywords: burnout; efficiency; electronic health records; health information technology; medical informatics; situational awareness.

Figure 1

Screenshot of VistA/CPRS inbox used at the Department of Veteran Affairs EHR.