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Clinician EHR Workload, Cognitive Efforts Double After EHR Adoption

Providers reported significant cognitive workload increases, such as higher levels of frustration and mental demands following EHR adoption.

Clinician workload and cognitive efforts doubled after the first six months of EHR adoption, according to a study published in Applied Ergonomics.

Clinicians also experienced increased EHR workload over 2.5 years following EHR implementation.

This adds to the evidence showing a connection between EHR usability and clinician burnout. EHR usability issues typically increase cognitive load and errors, leading to patient safety issues. An increase in cognitive load adds to EHR use, which then leads to clinician burnout.

Boosting EHR usability while decreasing task load, such as mental, physical, and temporal demand for a clinician, can allow practicing clinicians to reduce cognitive burden, which then allows for better patient care and improved decision making

Following an EHR implementation at Carle Health Systems in Illinois, the research team assessed the urgent care clinician team’s transition to its new EHR system.

“What we found surprised us a little,” Karen Dunn Lopez, the director of the Center for Nursing Classification and Clinical Effectiveness at the University of Iowa, said in a statement. “After two and a half years of continuous use, clinicians’ cognitive workload remained very high, and they still found the new EHR system more difficult to use than the prior paper- and computer-based hybrid system.”

Prior to the new implementation, clinicians utilized the computer system as a clinician note repository for scanned documents. The clinicians used paper records to write clinical notes, prescribing, and medical orders. Carle Health System utilized this hybrid workflow until an EHR vendor implemented the new system.

“Any time you change technology, you tend to change the whole work system to some extent. It’s important to take a user-centered approach to designing these systems and have users’ perspectives in mind so you can forecast how their work processes will change,” said Daniel Morrow, educational psychology professor at the University of Illinois Urbana-Champaign.

The research team surveyed study participants about their EHR workload use under the hybrid and current EHR systems across a three-year period. The survey asked participants to rate EHR workload tasks on a 100-point scale based on mental, physical, and temporal demands, along with frustration and effort levels.

Clinicians answered the survey right before the new EHR implementation, again at the six-month mark, and then finally at the 30-month mark following implementation. The research team also observed clinician workflow with the new EHR system.

The pre-implementation survey revealed similar scores for both provider and nurse respondents. However, the study revealed significant differences following implementation.

Providers reported significant cognitive workload increases, such as higher frustration levels and mental demands. However, nurses did not suffer the same consequences.

The research team said provider staff assumed some previous nurse tasks after implementation.

All provider scores increased except for physical activity. The research team hypothesized that cognitive load increased because providers utilized the EHR system during patient visits instead of after patient visits.

“Minor design flaws such as slow response times when clinicians clicked on buttons and nonstandard labeling of tools negatively impacted their perceptions of the system’s usability and caused mounting frustration during their workdays,” Morrow explained.

If the study continued past 30-months, the research team said EHR usability ratings may have reached pre-implementation levels since it was trending downward at that time.

The researchers said health care organizations “can’t say ‘mission accomplished’ and withdraw support quickly after adopting new EHR systems,” concluded Kayla Banks, vice president of women’s health and children’s services at Carle Health.

“There’s an ongoing need to modify workflows to accommodate increased workloads and look for iterative improvements. Nurses especially may be less likely to report that systems are not user-friendly or if their cognitive workload is significantly worsened.”

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