1.1. Background

Satisfaction and burnout of healthcare professionals are urgent challenges currently facing the healthcare system in the United States, especially given the effects of the COVID-19 pandemic.¹ There are multiple contributors driving these issues, but documentation burden is commonly cited as a key factor.^2–4 Many clinicians report that electronic health records (EHRs), electronic prescribing, electronic patient portals, and computerized physician order entry (CPOE) lead to information overload, frequent interruptions/distractions, and a change in the content of professional work to tasks less connected to meaning and purpose.^{2, 5, 6} Greater time spent on administrative tasks is associated with decreased career satisfaction and increased burnout,⁵ and greater use of EHRs and CPOE is associated with increased burnout.⁵ EHR usability is generally poor, and physician assessment of poor EHR usability is strongly associated with burnout.⁷ In addition, clinical documentation requirements often cannot be completed during the work day,^8–10 and “work outside of work” is a strong driver of burnout.¹¹ Aside from burnout, documentation burden may affect patients’ outcomes. One study has shown that the total in-basket notifications and delivery of alerts over the weekend can impact the opening of time-sensitive EHR alerts, and another has suggested a role of health information technology in diagnostic delays.^{12, 13} Documentation burden on clinicians may be associated with reduced patient satisfaction.¹⁴ Numerous factors contribute to documentation burden, including regulatory demands, payor needs, organizational structure and needs,¹⁵ and possibly fear of litigation.^16–18

The 2009 enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act is often identified as the beginning of the modern era of clinical burdens associated with health information technology, including documentation burden.¹⁹ More recently, there have been calls to evaluate and address clinician burden associated with the EHR, including documentation burden. Although the adoption of EHRs in the United States has increased since the mid-2000s and burdens have been a concern for many years, clear definitions and measures for documentation burden are lacking.^{6, 20, 21} Documentation burden has been described largely in the context of time and effort associated with specific clinical documentation tasks.⁶ For example, a summary of organizational interventions targeting reduced job demands, improved job resources, and improved clinical workflows is provided by Sinsky and colleagues.¹¹ These include eliminating multiple unnecessary documentation requirements, aligning EHR functions with clinical workflows, reducing inbox message volume, streamlining documentation involving verbal orders, and reducing the work associated with prior authorization. Additional interventions include team support for documentation and shifting to annual prescription renewals from more frequent intervals.

Measures for these interventions are often simplistic, for example, the number of messages or time spent on documentation.⁶ Expanded and more granular measures have been introduced through the American Medical Association’s Joy in Medicine Health System Recognition Program.²² These include the Work Outside of Work metric based on time outside of patient scheduled hours, Time on Inbox, Time on Encounter Note Documentation, and Total EHR Time.

In part because established definitions and measures for documentation are not well developed, published literature applying these measures is limited and has not been systematically collated to date. Evidence for validity of documentation burden measures is often lacking or not reported clearly, scalability is not demonstrated, and key strengths and weaknesses are not well delineated.^{6, 23} These challenges and controversies collectively highlight the need for a summary of the literature across different clinical fields and types of health professionals to increase the understanding of how best to measure and report documentation burden. This understanding would then support the evaluation of interventions designed to minimize documentation burden to reduce burnout, promote job satisfaction, increase efficiency, and improve the quality of patient care.

1.2. Purpose of This Technical Brief

This Technical Brief will evaluate multiple aspects relating to measuring documentation burden with the aim of assessing the current documentation burden and measuring progress of interventions targeting mitigation of the burden. This work will be used by the American Medical Informatics Association (AMIA) in alignment with the 25x5 Task Force’s vision of a “U.S. healthcare workforce free of documentation burden and focused on patient care and improved patient outcomes.”⁴ The AMIA 25X5 Task Force Reducing Documentation Burden aims to reduce the existing burden to 25 percent by 2025. The Task Force is in a position to develop, collaborate, and disseminate potential incremental documentation burden strategies.

1.3. Guiding Questions

The purpose of this Technical Brief is to address the following Guiding Questions:

• Description/overview of measurements of documentation burden:

  1.

  What measures of documentation burden have been developed or used (including measures broadly – quantitative and qualitative)?

  1. For which settings, populations, and intended uses were the measures developed?
  2. How have these measures been applied?
  3. Is there published information available on validity of the measures?
  4. What are the key strengths and weaknesses of different measures that have been used?

  2.

  What are the different perspectives on the appropriateness of different measures of documentation burden that have been applied/proposed (e.g., scalability, resource intensiveness to collect, equitable across populations)?

  3.

  What are the perceptions of documentation burden based on clinical roles (e.g., physician, nurse, physician assistant) and patients/caregivers?

• Factors influencing documentation burden:

  4.

  What is the role of patients in documentation burden?

  5.

  What is the role of setting (i.e., rural vs. urban, hospital, outpatient, academic institution, etc.) in documentation burden?