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Reducing Electronic Health Record Fatigue

Julian A. Romero

Hahn School of Nursing, University of San Diego

HCIN 615: Advanced Health Care Analysis

Dr. Wendy Cole

04/24/2022
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Reducing Electronic Health Record Fatigue

An electronic health record (EHR) is a digital record that houses patient information and

has a variety of other functions that can gather data and drive patient care outcomes

(HealthIT.gov, 2019). The EHR system contains medical history, tracks treatment, manages

clinical orders, contains radiology imaging, and provides other features that are important in

providing healthcare for an individual (HealthIT.gov, 2019). Clinical decision support tools are

also available within an EHR for providers to make decisions regarding treatment plans or care

for a patient (HealthIT.gov, 2019).

EHRs are commonly used in the United States’ health care system. EHR adoption by

healthcare organizations has doubled since 2008 (HealthIT.gov, 2021). In 2017, about 9 in 10

office-based physicians adopted some type of EHR and about 4 in 5 utilized certified EHRs

(HealthIT.gov, 2021). EHRs are useful in automating and streamlining provider workflows, and

health information exchange between different organizations has become more available with the

advancement of health IT (HealthIT.gov, 2019).

With the adoption and common use of EHRs in the United States’ healthcare industry, it

has been discovered that provider alert fatigue can lead to a variety of issues if there is not a

proper user-centered design and ease in the usability of the system (Khairat et. al, 2020). When

provider burnout or fatigue happens, there is an inefficient use of the EHR, less time spent with

patients, higher rate of medical errors, and emotional distress (Khairat et. al, 2020).

It is important for organizations to ensure that the EHR is efficient and designed to fit the

needs of the providers at their organization. A well-designed EHR and workflow will ensure that

providers can balance the needs of their patient while ensuring accuracy in their documentation,

therefore, reducing the chance of medical errors and keeping provider satisfaction at work high.
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This paper will include a review of current research related to EHR provider fatigue,

highlighting causes of fatigue, and exploring the detrimental effects of EHR fatigue on patient

safety. By using research that has been conducted on EHR provider fatigue, the goal will be to

identify ways to ensure that all necessary user-center designs and workflows will be in place to

ensure the least amount of EHR fatigue by providers.

Literature Review

Reducing EHR Fatigue

EHR fatigue has been studied numerous times because it has a major impact on an entire

healthcare organization. It affects patient safety, provider and staff efficiency, quality of care,

and job satisfaction. EHRs were implemented to optimize patient care and data storage so it’s

important to have an EHR system that’s well designed to ensure that adoption and satisfaction of

the system is kept at a high level.

Highlighting key words in a search for scholarly articles that included: EHR Fatigue and

EHR Patient Safety provided an ample number of results to start a literature review on this topic.

It is important to review separate areas of EHR fatigue that include EHR design, efficiency of

use, patient safety, and alert fatigue. These are important topics to review because they address

the separate issues regarding EHR fatigue as whole.

EHR Entry and Design

Manual text and number entry is a ubiquitous task that is performed when utilizing the

EHR and is a necessary task in a controlled industry like healthcare (Thimbleby et. al, 2015).

While text and number entry may be a simple task, it is something that requires accuracy for the

safety of patients. Unnoticed errors can lead to wrong medication being ordered, orders not being

submitted, or insufficient data collected to pass to another healthcare provider.

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The Monte Carlo method can analyze the reliability of different number entry systems

like an EHR and enables designers to evaluate normal and unexpected user error when using an

EHR (Thimbleby et. al, 2015). After evaluation using this method, it enables designers to design

the EHR systems in a way to avoid user error (Thimbleby et. al, 2015).

Entry errors can go unnoticed by users, designers, and manufacturers solely because they

are unaware of any design issues causing this (Thimbeby et. al, 2015). Users of a poorly

designed system tend to get the blame for any errors that occur when documenting. In addition,

widely used systems don’t work the same for all organizations, so it’s important to make a user-

based design based off a specific organization a goal (Thimbleby et. al, 2015).

The delete key is an essential tool when entering information into the EHR, but can cause

errors if decimal places are overlooked and deleted or if it is pressed too many times (Thimbleby

et. al, 2015). To fix this, there can be designs put in place to curb the overuse of the delete key or

guards put in place to ensure that the user really wants to delete what they are typing. This can be

in the form of a force click release to ensure that the user wants to delete something which is

especially useful in touch screen technology (Thimbleby et. al, 2015). A guard can also be put in

place for repetitive characters ensuring that an extra zero wouldn’t accidentally be typed in

(Thimbleby et. al, 2015).

EHR Alert Fatigue

Clinical decision support tools built into an EHR include the use of alerts that can notify a

provider of things like medication allergies, incorrect ordering, drug combination reactions, and

overdue orders. In an environment like an emergency room (ER) or an intensive care unit (ICU),

there is more complexity surrounding the situation and care of patients. With a higher likelihood

of critical alerts that can show in an EHR regarding patients in these environments, alert fatigue
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can be a barrier to patient safety (Kizzier-Carnahan et. al, 2016). Passive alerts are an area of

EHR fatigue that has not been studied that much, though passive alerts are extremely important

for patient safety and care.

A review was conducted of EHR databases consisting of 100 consecutive ICU patient

records assessing values that flagged as abnormal or “panic” level, and using data that

determined the top 10 frequently used screens in an EHR that providers used while preparing for

rounds (Kizzier-Carnahan et. al, 2016). From this review, it was possible to see the number of

times an abnormal value or “panic” level value would be expected to be reviewed by a provider

(Kizzier-Carnahan et. al, 2016). There were 165.3 passive alerts per patient per day with

laboratory alerts consisting of 71% of the alerts, with the remaining consisting of vitals and

medications (Kizzier-Carnahan et. al, 2016).

With so many alerts in a fast-paced environment like an ICU or ER, providers can

become desensitized to them with alarm or alerts being ignored (Kizzier-Carnahan et. al, 2016).

A study of Computerized Provider Order Entry suggests that 52% - 98% of medication alerts are

overridden (Kizzier-Carnahan et. al, 2016). This can lead to patient safety issues and needs to be

addressed within the design of the EHR.

A customizable EHR alert threshold can be a solution for providers, so they feel that they

are getting the information that they need and do not overlook anything due to the large number

of passive alerts (Kizzier-Carnahan et. al, 2016). It’s important to reduce overall clinician alert

burden and modify an existing EHR to reduce the number of alerts that may cause alert fatigue

(Kizzier-Carnahan et. al, 2016).

EHR Efficiency
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EHRs were intended to help alleviate some of the manual workload that providers need to

do when documenting for patients, though EHR fatigue is still common. It is important to ensure

that the systems are as efficient as possible. Efficiency is related to the number of mouse clicks,

time, and EHR screens that someone may use in a healthcare organization (Khairat et. al, 2020).

Fatigue happens in short continuous periods of EHR and where there are more clicks, more

screens to navigate and more time spent on the EHR leads to less efficiency in the workflow

process for a provider (Kizzier-Carnahan et. al, 2016).

Poor EHR design exacerbates the issue with efficiency and usability (Kizzier-Carnahan

et. al, 2016). Achieving a user-centered design can lead to more efficient use of the EHR system

(Kizzier-Carnahan et. al, 2016). Working with clinical staff to understand needs specific to the

organization and implementing design changes can be effective at streamlining the workflow

process reducing clicks and screen usage, leading to more time spent with patients (Kizzier-

Carnahan et. al, 2016).

Patient Safety

Alerts from the EHR system are necessary to notify providers of abnormal test results,

and follow-ups (Singh et. al 2014). Fatigue can lead to missed results, follow-up failures, and

patient safety errors (Singh et. al 2014). Factors from the EHR workflow, user behaviors, and

organizational characteristics have effect on the way that results are read and interpreted (Singh

et. al 2014).

A survey sent out to primary care providers was conducted to analyze sociotechnical

aspects of their EHR use and missed test result experience (Singh et. al 2014). Over half of the

respondents reported that the current EHR made it possible for providers to miss results (Singh

et. al 2014). Roughly 87% say that the number of alerts they receive are excessive and roughly
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70% reported receiving more alerts than they can effectively manage (Singh et. al 2014). A third

of respondents reported personally missing results that caused a delay in care (Singh et. al 2014).

A delay in care and missed results impact a patient directly and could cause serious harm to the

health of a patient.

Ensuring that alert overload is managed and address within an organization, improving

EHR usability, and hands-off care is reduced will increase the accuracy and efficient use of EHR

leading to better patient outcomes.

Project Design

An efficient way of collecting data on the effects that EHR alert fatigue has on providers

can be done by developing surveys which are completed by providers and hospital staff that

utilize the EHR on a day-to-day basis. The qualitative data that surveys produce using a Likert

scale can measure the impact that the EHR has on the quality of care, workload, alert fatigue,

workflows, job satisfaction, and patient safety which is necessary to make informed decisions on

the utility of the current EHR. In addition, an observational study utilizing metrics in relation to

data that is gathered can provide insight on how EHR fatigue affects providers.

To gather successful information while utilizing surveys as an evaluation method, it is

important to identify inclusion and exclusion criteria. Two separate studies evaluated the effects

that EHR use has on physicians with one focusing more on information overload and missed

results (Singh et. al 2014), and the other focusing on effects of workload, work complexity, and

repeated alerts resulting in alert fatigue (Ancker et. al, 2017).

In a cross-sectional study evaluated by Hardeep Singh, surveyed Veterans Association

(VA) primary care providers (PCPs) and excluded trainees and subspecialists. The content of the

survey that was sent out to the VA PCPs was developed from an 8-dimension sociotechnical
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model (Singh et. al, 2014). The survey represented multifaceted EHR-based test result

notifications, and the survey gathered data regarding provider perceptions, ease of use, content of

alerts, user-interface, and social factors (Singh et. al, 2014).

A study by Jessica Ancker surveyed data on family practice physicians at a hospital who

met criteria for being an “eligible provider” and interacted with a patient at least once between a

specified timeframe. Exclusions included physicians within the organization that were not family

practice (Ancker, et. al, 2017). To find if physicians were desensitized to alerts, a dataset

consisting of best practice advisory (BPA) alerts and drug to drug interaction (DDI) alerts from

separate clinical encounters with patients were analyzed (Ancker et. al, 2017). Novel metrics

were created to fulfill the purpose of the study and the metrics were used to gauge whether the

physicians were desensitized from the large number of alerts they received (Ancker et. al, 2017).

Methods

Both the survey and observational method provides insight on EHR burnout and fatigue.

Survey use gives complex qualitative data that can be used to make corrective actions on the

functionality of the EHR with questions addressing multiple issues. Observational studies can

analyze large amounts of data and analyze an issue on a larger scale where a macro approach to

an issue can be addressed.

After analyzing results from either method, implementing large scale and continuous

improvements on an EHR can be costly and time consuming. It will cost to update and change

EHRs, implement new EHRs, and pay for training or retraining on current EHR systems. If there

is a large-scale change on an organization’s EHR, training an implementation can be introduced

using a phased approach where only certain providers or specialty areas are trained at a time
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which will reduce the amount of time that providers are spent away from patient care and in a

learning environment.

Evaluation

Evaluating and interpreting survey results received from EHR users is an important step

in understanding the user-interface issues and addressing concerns that users have. Surveys

administered using a Likert scale will allow qualitative data to be quantifiable and allowing

trends to be identified in certain questions.

Statistical analysis can be done from data that is received to relate significant predictors

for a question that is trying to be answered. In the study completed by Hardeep Singh, primary

outcomes related to missed test results were categorized and defined as two items that included:

Outcome 1, potential for missed results due to the EHR support tool and Outcome 2, provider

missed abnormal lab or imaging in the past year (Sing et. al, 2014). Variable related to the

outcomes in bivariate analysis was used in multivariable regression analysis (Sing et. al, 2014).

A hypothesis can be used as a base for evaluation of the survey results. Desensitization of

EHR alerts over time was a hypothesis included in the study by Jessica Ancker. This hypothesis

stated that the likelihood of a provider accepting an alert was at its highest when the EHR is first

introduced and would decrease over time (Ancker et al. 2017). By assessing the bivariate and

multivariable relationships that were observed in the data that was observed, a conclusion was

drawn that clinicians were less likely to accept alerts the more often they received them (Ancker,

et. al, 2017).

Conclusion

EHR fatigue is a known problem that has negative effects on an entire healthcare

organization. With an increased patient workload that many healthcare providers experience, the
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amount of time it takes to document in the EHR, submit orders, and utilize the EHR in day-to-

day work while balancing time with patients can lead to EHR fatigue and errors. Errors in

documentation or missing alerts can lead to patient harm, disciplinary action on the employee,

and risk for a healthcare organization.

By using different methods to analyze EHR use by clinicians and non-clinicians, a

healthcare organization can ensure that the system has an appropriate user-interface and works

well for employees. By evaluating the results of the responses or collected data corrective

changes can be implemented. When user concerns are addressed and fixed, it will lead to

increased job satisfaction, less burnout, higher utilization and accuracy of the EHR, and better

patient outcomes.
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References

What is an electronic health record (EHR)? | HealthIT.gov. (2019, September 10).

HealthIT.Gov. Retrieved February 27, 2022, from https://www.healthit.gov/faq/what-

electronic-health-record-ehr

Office-based Physician Electronic Health Record Adoption | HealthIT.gov. (2021, August 6).

HealthIT.Gov. Retrieved February 27, 2022, from

https://www.healthit.gov/data/quickstats/office-based-physician-electronic-health-record-

adoption

Khairat, S., Coleman, C., Ottmar, P., Jayachander, D. I., Bice, T., & Carson, S. S. (2020).

Association of Electronic Health Record Use With Physician Fatigue and Efficiency.

JAMA Network Open, 3(6), e207385.

https://doi.org/10.1001/jamanetworkopen.2020.7385

Thimbleby, H., Oladimeji, P., & Cairns, P. (2015). Unreliable numbers: error and harm induced

by bad design can be reduced by better design. Journal of The Royal Society Interface,

12(110), 20150685. https://doi.org/10.1098/rsif.2015.0685

Kizzier-Carnahan, V., Artis, K. A., Mohan, V., & Gold, J. A. (2016). Frequency of Passive EHR

Alerts in the ICU: Another Form of Alert Fatigue? Journal of Patient Safety, 15(3), 246–

250. https://doi.org/10.1097/pts.0000000000000270

Khairat, S., Coleman, C., Ottmar, P., Jayachander, D. I., Bice, T., & Carson, S. S. (2020b).

Association of Electronic Health Record Use With Physician Fatigue and Efficiency.

JAMA Network Open, 3(6), e207385.

https://doi.org/10.1001/jamanetworkopen.2020.7385
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Singh, H., Spitzmueller, C., Petersen, N. J., Sawhney, M. K., & Sittig, D. F. (2013). Information

Overload and Missed Test Results in Electronic Health Record–Based Settings. JAMA

Internal Medicine, 173(8), 702. https://doi.org/10.1001/2013.jamainternmed.61

Ancker, J. S., Edwards, A., Nosal, S., Hauser, D., Mauer, E., & Kaushal, R. (2017). Effects of

workload, work complexity, and repeated alerts on alert fatigue in a clinical decision

support system. BMC Medical Informatics and Decision Making, 17(1).

https://doi.org/10.1186/s12911-017-0430-8