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The 3 Eras of Clinician Burnout and How EHRs Can Mitigate It

Health IT professionals dove into the history of medical documentation, EHRs and how EHR vendors, clinicians, and health IT professionals can use history to help decrease clinician burnout in the future.

An increased emphasis on clinician burnout by way of health IT professionals, clinicians, and EHR vendors can help mitigate clinician burnout in the future, according to an article published in the Journal of the American Medical Informatics Association (JAMIA).

From the age of antiquity to now, medical documentation has been a primary source of clinician burnout. While EHRs have documentation benefits, it is the leading cause of clinician burnout.  

“We now have unprecedented opportunities in health care, with the promise of new cures, improved equity, greater sensitivity to social and behavioral determinants of health, and data-driven precision medicine all on the horizon,” explained the authors. “EHRs have succeeded in making many aspects of care safer and more reliable. Unfortunately, current limitations in EHR usability and problems with clinician burnout distract from these successes.”


The Era of Enlightenment ranged from the age of antiquity to the 1990s. Researchers defined this era as “recognizing, over centuries, the power of observation, documentation, and scientific inquiry to combat disease, resulting in awareness of opportunities.”

The authors went back to the initial transition from oral to written medical education, dating back to Hippocrates between 460 to 370 BCE when his disciples reported on individual patient knowledge of diseases and medical history.

By the medieval period, there was a standardized way to medically document a patient’s diagnosis. Documentation progressed and by the 18th and 19th centuries, providers delivered more complex healthcare and clinical documentation, which led to new disease and healthcare questions.

Fast forward to the 20th century, providers filled out patient charts by hand. By the 1960s, the first electronic documentation systems appeared.

“As summarized in the Institute of Medicine report The Computer-Based Patient Record: An Essential Technology for Health Care (CPR Report), paper records suffered from problems with legibility, record loss, missing data, and volatility,” explained the authors.

“Physicians, pharmacists, researchers, and nurses were among those often overlooking valuable clinical data because of the paper chart’s organization. The report stressed that a focus on data sources rather than patients (eg, physicians, nurses, monitors) limited the usefulness of the chart as a tool of clinical decision-making and research.”

But while clinicians saw the benefits of EHRs, increased documentation time demand and clinician burnout increased.

“The result decoupled the process of clinical record keeping from patient care,” the authors wrote. “Combined with a shift toward lengthier documentation attributable to requirements in billing and defensive documentation due to legal concerns, updating patient charts began to feel irrelevant to clinical needs, which was ‘off-putting’ to physicians.”


The authors described the 1990s to the present as the Era of Entanglement. The authors defined this current era as “using a combination of technology adoption, incentives and penalties to promote rapid, multifaceted, auditable process and outcomes improvement, resulting in burnout.”

With clinician burnout at the forefront, health IT professionals, health systems, and EHR developers are trying to combat clinician burnout by EHR optimization and integrating safety options into health IT.

Furthermore, the federal government stepped in with recommendations to form the Office of the National Coordinator for Health Information Technology (ONC). This led to the creation of several incentive programs.

“Meaningful use of the EHR was double-edged sword—incentivizing the rapid adoption of EHR technology while also creating, through EHR certification mandates, an environment in which newly required features were entangled into an already complex and highly-regulated industry,” the authors wrote.

“Pressure to conform to new requirements and implementation timelines forced many successful homegrown EHRs to be replaced with commercial EHR products.”

The authors noted that once pay-for-performance programs emerged, screening test performance documentation became increasingly important for clinicians. Thus, EHR click numbers increased and clinician burden followed.

“These numerous causes resulted in widespread misalignment of the technology and the typical clinical workflow,” the authors explained. “Our path forward begins with untangling the myriad roles being played by physicians, patients, and data in our healthcare system.”


The authors said the Era of Engagement will come around 2030. They said it is “empowering the change necessary to deliver equitable and health-preserving care across populations with frictionless data transfer from sources to stakeholders.”

In order to mitigate clinician burden, the authors pointed at EHR design and implementation types.

“Communication by groups such as American Medical Informatics Association and the Blue Ridge Academic Health Group will lead to further understanding by all stakeholders of the role that informaticians, policymakers, and clinical care teams must play in aligning needs with workable solutions,” wrote the authors.

Furthermore, the authors recommend increasing EHR audit logs, decreasing the focus on finance, abandoning complex incentive models, increasing transparency, and both learning from data and applying that data to what users learn.

With an increased focus on clinician burnout, the future holds the potential to decrease clinician burnout from EHRs and boost patient care.

“Perhaps the only constant in the history of medical records is their dynamism—in time, the frustration at clinical alerts or mandated points of data entry will give way to new successes and challenges,” concluded the authors. “Just as the limitations of paper records once motivated the adoption of electronic systems, today’s imposition of data entry onto clinicians has given discussions about the limitations of our EHRs a deep urgency.”

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