Clinician Burnout: Causes, Consequences and Strategies

Constance McLaughlin, MBA, BSN, RN-BC, Anup D. Salgia, DO, FACEP

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Table of contents

Executive summary ..................................................................................................................... 3

Introduction ................................................................................................................................. 3

What is burnout? ......................................................................................................................... 4

Impact of clinician burnout .......................................................................................................... 5

Contributors to burnout ............................................................................................................... 6

Beating burnout ........................................................................................................................... 9

Strategies to reduce burnout related to technology ................................................................... 12

How is Cerner helping ............................................................................................................... 14

Improving the clinician workflow ................................................................................................ 14

Leadership education tools ....................................................................................................... 16

Professional fulfillment and improved wellness ......................................................................... 17

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Executive summary

Burnout levels among physicians, nurses and ancillary health care professionals have hit an all-time high with little sign

of retreating. There are many contributing factors to the burnout epidemic, such as increased regulation, greater burden

in meeting quality measures and clinically irrelevant reporting, work-life balance pressures, financial obligations and

medical record and coding requirements through the electronic health record (EHR). The COVID-19 pandemic of 2020

has thrown medicine into a crisis, exacerbating burnout in a workforce weakened by illness and exhaustion. A recent

study by Reaction Data (2019) shows that despite the frustration technology has imposed upon the medical profession,

EHRs contribute about 10%-20% of the burnout problem, though some research and opinion pieces estimate EHR-

related burnout to be higher. Nonetheless, it is a significant issue that is impacting health care professions today.

Introduction

Meet Jaime. She has worked as a nurse practitioner for 12 years, dedicating her work to the health of others. Working in

the hospital and clinic over the years has been both challenging and joyous, but over the past year, her patient workload

has been quite heavy. Lately, she experiences a new, unexplained anxiety before her shifts start. Added stressors with

payment reform and mandates with electronic documentation and charge submissions don’t make it easier.

Jamie is reminded to attest online for her MIPS program, but the website is still down. She is starting to feel a bit

indifferent to it all; co-workers seem detached and management appears to be at odds with one another and the clinical

staff. Jamie still loves caring for patients, but other distractions seem to add a level of complexity; she’s thinking that,

perhaps, a change in jobs may be something to consider — perhaps even going part-time. During a recent routine

doctor’s visit, she was diagnosed with hypertension, noticeable weight gain and a reported lack of energy. She knows

there is something wrong but can’t quite put her finger on it.

Dr. Danielle Ofri at Bellevue Hospital, in her provocative New York Times opinion piece, "The Business of Health Care

Depends on Exploiting Doctors and Nurses" notes, “In a factory, if 30 percent more items were suddenly dropped onto an

assembly line, the process would grind to a halt. Imagine a plumber or a lawyer doing 30 percent more work without

billing for it. But in health care there is a wondrous elasticity — you can keep adding work and magically it all somehow

gets done. The nurse won’t take a lunch break if the ward is short of staff members. The doctor will 'squeeze in' the extra

patients.” Dr. Ofri goes on to write “…by far the biggest culprit of the mushrooming workload is the electronic medical

record, or EMR. It has burrowed its tentacles into every aspect of the health care system. There are many salutary

aspects of the EMR, and no one wants to go back to the old days of chasing down lost charts and deciphering

inscrutable handwriting. But the data entry is mind-numbing and voluminous.” Similarly, Atul Gawande, MD noted in his

op-ed in the New Yorker that he “feel[s] that a system that promised to increase my mastery over my work has, instead,

increased my work’s mastery over me.”

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What is burnout?

More than half of U.S. doctors and nurses experience symptoms of burnout. Unfortunately, many have either chosen to

ignore them, have misinterpreted them or decided to leave or reduce their clinical practice because of them. Recent data

show that over 50% of providers and about one-third of nurses suffer from burnout. About 43% of nurses reported signs

of emotional exhaustion — an early indicator of burnout [1].

In 1974, clinical psychologist Herbert Freudenberger identified the presence of emotional and physical exhaustion along

with emotional detachment in his co- workers [2]. He referred to this experience as “burnout.” Since then the topic has

been researched extensively and more notably by Christine Maslach. In 1981, Maslach published a methodology to

understand the variables causing burnout syndrome [3]. Current research validates this, evidenced by epidemic

proportions of burnout among clinicians, resulting in overwhelming feelings of frustration in their careers and a loss of

professional fulfillment stemming from factors ranging from loss of autonomy to decreased efficiency.

In 2013, The U.S. National Institute for Occupational Safety and Health recognized job stress as “the harmful physical

and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs

of the worker.”[4] Stressors that contribute to burnout are individually felt and can be caused by under-staffed shifts

resulting in excessive workloads, personal challenges or emotional exhaustion from caring for patients [5].

Similarly, in 2019, the World Health Organization (WHO) officially recognized occupational burnout as a disease by

assigning it an ICD-11 diagnostic code. Accordingly, the WHO notes that burnout is characterized by 1) feelings of

energy depletion or exhaustion; 2) increased mental distance from one’s job, or feelings of negativism or cynicism

related to one's job; and 3) reduced professional efficacy [6].

Several investigations suggest that an increased burden placed on nurses in the form of increased workload, sparse

staffing models and unrealistic management expectations [7,8] are strong predictors of physical and emotional burnout.

This forecasts poor patient outcomes, workplace and patient safety concerns, increased errors and an uptick in hospital-

acquired infections.

Clinicians feel the effects of burnout yet remain in their respective professions, conceding that physical and emotional

stress are a predictable and acceptable part of a professional clinician’s job. Suboptimal physical ergonomics and the

strain of compartmentalizing emotions in order to provide compassionate and competent care for high-acuity patients

(and their families) are equally draining. Constant interruptions, persistent heightened mental alertness and shift work can

negatively alter decision-making abilities affecting patient care, general wellness and personal relationships. Finally, the

stigma associated with asking for help can be viewed as weakness. The threat of jeopardizing licensure deters nurses

and physicians from seeking professional help with stress, anxiety and depression.

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.

Impact of clinician burnout

A report from the National Academy of Sciences, Engineering and

Medicine points out that the stability of a clinician’s well-being holds

consequences for clinicians themselves, their patients, health care

organizations and society as a whole [9]. Over time, continuous

exposure to stressors like increased workload, increased patient

complexity and misalignment of organizational and personal values can

lead to overall poor health. Chronic health conditions like hypertension,

high cholesterol, cardiovascular disease, insomnia, anxiety and

depression can result from burnout if unchecked.

Burnout leads to job dissatisfaction and has the potential to increase

adverse patient outcomes. Resulting feelings of disengagement,

physical and emotional exhaustion, loss of control, decreased

productivity and cynicism can be transferred to other co-workers, teams, units and patients, ultimately affecting the

organization’s very culture.

With patient safety initiatives at the forefront of modern health care delivery, clear evidence shows that disproportionately

higher staffing ratios and dissatisfactory work environments are highly correlated to poor patient outcomes, reduced

patient satisfaction and shorter tenure of the clinical workforce [7]. Lower staff-to-patient ratios results in lower burnout

rates, less chance for error and decreased incidences of hospital-acquired infections [10]. Lighter staff workloads also

afford more time and attention to the patient and lift the burden of feeling mentally and physically stretched.

A California study showed that each

additional patient per nurse was associated

with a 7% increase in the likelihood of

patient morbidity within 30 days of admission

and a 7% increase in the odds of failure-to-

rescue (not recognizing an emergency until

it is too late) [7]. Studies also suggest that

care organizations consider the cost of

staffing and hospital-acquired infections

versus the cost of losing physicians and

nurses (to burnout).

There are two distinct

advantages to staff retention:

morbidity reduction and cost

savings [8,11]. Figure 1

illustrates personal and

professional impacts of burnout.

Figure 1: Personal and Professional Repercussions of Burnout Adapted from Mayo Clin Proc. 2017;92(1):129-146

Stress and eventual burnout

leave the health care worker with

feelings of disengagement,

physical and emotional

exhaustion, loss of control,

decreased productivity and

cynicism. This negativity can be

transferred to other co-workers,

teams, units and patients,

ultimately affecting the

organization’s very culture.

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Burnout among physicians results in emotional exhaustion, depersonalization (viewing/treating people like they are

objects), a diminished sense of personal success, substance abuse, depression, post-traumatic stress disorder (PTSD)

and suicidality [12,13] (Fig. 1). Physician suicide rates are more than twice that of the U.S. population [14]. Female

physicians reported higher burnout rates than male physicians (39% vs 28%) and lower rates of professional fulfillment

(37% vs 51%). Emotional exhaustion is at the core of physician burnout. Physicians working in outpatient settings like

primary care and emergency medicine experience higher burnout compared to those working in inpatient facilities [15].

Impairment in judgement is highly associated in physicians who experience tiredness, exhaustion, fatigue, inattention

and irritability [16,17]. Burnout may also put a physician at increased risk of motor vehicle accidents and near-miss

events, even after adjusting for fatigue [18]. Psychologically, physician burnout might contribute to increased incidence of

stress, disruptive behavior, mood disorders and depression [19-21]. The presence of any of these conditions can

severely impact a physician’s well-being, disrupting their personal life and decreasing professional effectiveness. This

creates a slippery slope as it increases the odds of substance abuse and increased alcohol abuse/dependence,

especially in surgeons [22]. Though the consequences of nurse burnout are less defined, the findings from physician

studies should be cause for alarm among nurses.

Contributors to burnout

Peripheral stressors compound the prevalence of burnout. Workload affected by staffing levels, patient complexity and

increased patient volume as increased numbers of baby boomers utilize the health care system all play a role in burnout.

Organizational culture, inadequate leadership support, low employee engagement, financial pressures of school and

personal debt pile on to the problem. The nature of this highly charged subject brings with it much emotion.

Psychologists believe that humans tend to imitate and respond to others’ emotions [23]. Negative emotions are thought

to be transferred easier and imitated at a higher rate than otherwise neutral or positive feelings, leading us to conclude

that strong, negative emotions around clinician burnout and the reasons therein can spread from unit to unit or within

other business units like financial offices or clinics threatening an organization’s culture – a phenomenon referred to as

burnout contagion [24,25]. The National Academy of Medicine’s committee on System Approaches to Improve Patient

Care by Supporting Clinician Well-Being recommends that organizations take a systems approach to begin proactive

changes within the organization versus the individual level.

Public health crisis: COVID-19 pandemic

The COVID-19 pandemic has thrust front-line doctors and nurses into a chaotic public health crisis that is likely to be a

defining time in their careers. A report by the International Council of Nurses found that over 90,000 nurses worldwide

have been infected by COVID-19. The same report projects that over 200,000 health care workers have been infected.

Those who have died number in the thousands. Not all who have contracted COVID-19 have fully recovered, as a small

subset of these health care workers have experienced some type of post-recovery disability. It is unknown if these

disabilities are permanent or short-term. The pandemic has exacerbated the common contributors of burnout, and yet

has introduced new stressors. Wearing physically restrictive personal protective equipment for unusually long periods of

time, and the unabating threat of becoming infected or bringing it home to their loved ones, add to the pressures of the

job. Additionally, post-traumatic stress disorder (PTSD) has been reported to be 10%-20% higher among emergency

care workers and as high as 30% among ICU workers. Management of critical medical situations, caring for severely

traumatized people, frequent witnessing of death and trauma, operating in crowded settings and interrupted circadian

rhythms due to shift work are all reported as contributors to PTSD in this pandemic.

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Aging populations and health care workforce

Projections from a 2019 report by the American Association of Medical Colleges predicts a severe shortage of

physicians up to 121,000 by 2031 [26]. As the baby boomer generation ages into retirement, their demands on the

medical system will outstrip the supply physicians. The study goes on to note that 30% of U.S. doctors are over the age

of 65, nearing retirement themselves, compounding the problem. Similarly, The U.S. Bureau of Labor Statistics predicts

1.2 million nursing vacancies between 2014 & 2022 and estimates the need to add 200,000+ RNs each year to fill

vacancies due to attrition, accepting non-clinical roles and those retiring [27-31]. As it stands, 50% of the current nursing

workforce is 50 years of age or older [32].

Experience gap among providers

Amid an aging clinical workforce, a decrease in nursing school applicants is a

concern. The AACN suggests that nursing schools have too few seats to address

the shortage due to fewer teaching faculty and facilities. As fewer people pursue

careers in nursing, a tsunami of retiring nurses is exacerbating the shortage.

An experience gap among nurses is another issue that negatively impacts

nursing. As newer nurses simply do not possess the same experience the retiring

workforce holds, this creates a substantial gap in the quality of care. Training time

among newer nurses has shortened, yet the care complexities of the aging

population has intensified. The Advisory Board Executive Nursing Center recently

published the "Experience-Complexity Gap” citing another dimension to the

shortage [33]. Their findings emphasize the importance of precepting early-career

nurses more effectively. The development of standardized preceptor programs

and redistributing and differentiating experienced nursing staff to ensure high-

quality preceptor programs can be an effective means of training novice nurses.

This experience gap has a significant impact on the quality of care, noting that

novice nurses recognize signs/symptoms in deteriorating patients less effectively. In addition, the experience gap can

contribute to a rise in the number of medication errors. A report by HealthAffairs estimates in 2015 showed health care

lost 1.7 million years of clinical experience when nearly 60,000 nurses retired – a staggering number that ultimately

affects staffing, retention, workload and attitudes within the profession, contributing to work stress and eventual burnout

[34].

Technology

The Health Information Technology for Economic & Clinical Health (HITECH) act of 2009 was passed to promote the

adoption of electronic health records (EHR) to improve quality, safety and efficiency. This legislation outlined provisions

for data protection and security and gave the newly created Office of National Coordinator for Health Information

Technology (ONC) authority to set standards in EHR technologies and stimulate incentives through demonstrated

meaningful use of EHRs. As new rules were published, and the measures instituted by CMS & ONC became

increasingly complex, providers became increasingly pressured to meet Meaningful Use measures and adopt the

technology at a rapid pace.

Meeting the regulatory demands of technology adoption itself took a toll on clinicians’ experiences and the promises

technology would bring. Similarly, EHR vendors were required to hastily adapt solutions to pass regulatory muster.

Within a few years, physicians began blaming the EHR as a significant contributor to burnout [35]. Research, opinion

pieces and health care IT publications discuss how the EHR contributes to clinician burnout. The combination of growing

regulatory requirements, health care administrative goals, payor demands and the resulting mismatch in care processes

and application workflows created the perfect storm for EHR- related burnout.

A report by HealthAffairs

estimates in 2015,

Health care lost

1.7 million years of clinical

experience when nearly

60,000 nurses retired – a

staggering number that

ultimately affects staffing,

retention, workload, and

attitudes within the

profession contributing to

work stress and eventual

burnout [34].

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The use of the EHR is still largely manual and the amount of data collected can frequently be perceived to be not

necessarily relevant to patient care. Yet clinicians spend an average of 2-3 hours a day in extra screen time (all clinicians

combined). Christine Sinksy, MD, Vice President of Professional Satisfaction at the American Medical Association refers

to this as “work outside of work,” frequently called “pajama time.” [36]. A study by Hendrich, et al., reported that nurses

spend approximately 35% of their time documenting, 21% of their time coordinating patient care and only 19% on direct

patient care [37]. In general, the nursing profession lacks documentation standards, leading to excessive, unnecessary

documentation and administrative documentation that could be delegated to non-clinical staff. Similarly, physicians

spend up to 73% of their time on non-clinical tasks as newer technology forces more screen time in the form of inbox

communication, portal messaging with patients and other non-reimbursable tasks [38]..

After over a decade of inputting data into EHR systems, clinicians often find it

difficult to effectively extract data in the form of patient knowledge discovery,

adding to the frustration of working with EHRs. Clinicians are drowning in a sea of

patient data.

Surveys indicate that clinical, top-of-license care process workflows are disrupted

by technology in the form of alerts, errors and excessive documentation. The

Annual Physician Lifestyle Report (Medscape survey) indicates that, over the last

five years, the top three themes indicated as the most significant burnout causes

were excessive paperwork and charting, spending too much time at work and

increased use of the EHR [39]. Other important findings from the survey include a

lack of interoperability, redundant data gathering, unintuitive or non-user-friendly

systems and too much manual effort [1]. For example, the sending of Continuity

of Care Documents (CCDs) between physicians – if not automated, can lead to

an unmanageable administrative burden. Regulatory mandates, like this and

others, take doctors away from the patient-physician interaction. From a pure

clinician perspective, the same themes repeat in terms of not meeting the actual needs of the clinician: poor system

usability, non-integrated systems, poor interoperability, lack of documentation standards, limited functionality/missing

components and redundant data gathering (overlapping data collection with other clinical disciplines) [40,41].

Alert fatigue also plays a central role in burnout. The U.S. Agency for Healthcare Research and Quality (AHRQ) defines

alert fatigue as “workers (in the case of health care, clinicians) become desensitized to safety alerts, and as a result,

ignore or fail to respond appropriately to such warnings. This phenomenon occurs because of the sheer number of

alerts, and it is compounded by the fact that the vast majority of alerts generated by CPOE systems (and other health

care technologies) are clinically inconsequential, meaning that in most cases, clinicians should ignore them. The problem

is that clinicians then ignore both the bothersome, clinically meaningless alarms and the critical alerts that warn of

impending serious patient harm.” [42].

The medical field has seen many advancements, and the industry is just beginning to identify how technology could

invariably enhance medicine while reducing current clerical, manual aspects of the EHR. We are nearly fully digitized but

not yet transformed. As the industry grows by way of apps on FHIR®, artificial intelligence and virtual assistants,

business intelligence and natural language processing, vendors are beginning to standardize their code to enable better

communication and integration. Health care software vendors and third-party companies are developing ways to capture

conversations (between patient and provider) through natural language processing (NLP), to identify relevant information

related to the visit (pulling from all data in the record and the conversation) and to suggest tests/treatments all while

compiling a note without the provider touching a keyboard.

Historically, nurses have manually collected massive amounts of patient data which has swelled since the advent of

digitization. System customizations have gotten expansive to the point that some of the data collected is arguably not

clinically relevant and probably will never be consumed. Until recently, the nursing industry continued to function the

same as they had on paper [43]. Over the past few years, work efforts to review clinical documentation processes and

content have emerged. Nursing leaders are coming together to discuss standard content for nursing documentation that

will ensure relevant, timely data collection and pave the way for effective data sharing between clinical teams. Changes in

content and timing of collection will potentially show an increase in time efficiencies and more accurate documentation;

however, transformation has yet to be realized for nursing as well.

After over a decade of

inputting data into EHR

systems, clinicians often

find it difficult to

effectively extract data in

the form of patient

knowledge discovery,

adding to the frustration

of working with EHRs.

Clinicians are drowning

in a sea of patient data.

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In the era of health care reform and a focus on patient-centered care, patients expect safe, high-quality care. Health care

organizations’ focus on improving the ways in which clinicians can successfully carry out their responsibilities directly

affects patient satisfaction and may contribute to higher levels of patient safety and quality of care [44]. Cimiotti, et al.,

discovered a significant link between health care associated infection (a nursing sensitive indicator), workload,

leadership support and education. An emphasis on nurse engagement, professional development and appropriate

staffing mix may pave the way to increase nurse retention rates and help renew nurses’ sense of resilience.

Beating burnout

Engagement level and resilience plays a significant role in clinician retention. Research points to a combination of

individual programs and an organizational approach to creating less stressful work environments [45,46]. Focusing on

staff wellness and safety enhances health system improvements and performance.

Staff wellness proves to be most impactful when hospital leadership emphasizes their commitment to employee well-

being. Health care organizations may approach this concept by instituting practice models that encourage a professional

workplace environment, emulating top employers across the country [48,49]. Empowering clinicians by giving them a

seat at the table with regard to clinical practice decisions has shown to improve

commitment to their respective professions and place of employment. This

provides a renewed sense of professionalism and commitment to safety elicited

from evidence-based practice. This framework encourages interdisciplinary

collaboration and workforce engagement, which has been shown to increase

clinician and patient satisfaction, retention and improved safety. Simply put, a

healthy practice environment points to decreased burnout.

Resilience plays a key role in burnout and retention. Given the evidence, it is

imperative that health care leaders remove barriers, bolster communication and

provide ways for caregivers to identify and acknowledge clinicians’ basic and

psychological needs in the workplace [50]. Instituting and engaging employees

in individual wellness programs can help increase clinicians’ coping

mechanisms against the impacts of a stressful health care environment [51].

Wellness programs and educational offerings in communication skills, team

building and emotional intelligence provide support and a sense of

understanding. These types of programs can increase self-confidence and

provide a sense of personal achievement which aids in boosting coping

mechanisms [52,53]. According to the Institute for Healthcare Improvement,

“…health is more than the absence of disease, so too joy is more than the

absence of burnout.” [54].

The Stanford Medical Center WellMD program engages physicians in regular surveys and wellness programs.

Accordingly, the Stanford program “focuses on the need for professional fulfillment rather than simply the avoidance of

burnout.” Stanford recognizes that burnout is multidimensional and approaches it as such [47]. Even diet may play a role

in burnout. A new area under investigation at Stanford is the part diet plays in physician performance and how it may

impact burnout.

Empowering clinicians

by giving them a seat at

the table about clinical

practice decisions

improves commitment to

their respective

professions and place of

employment. This

provides a renewed

sense of

professionalism,

commitment to safety

and evidence-based

practice.

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.

The Mayo Clinic encourages physicians to form peer groups of 6-7 physicians and meet every two weeks during one

hour of protected time. The COMPASSS trial COMPASS (Colleagues Meeting to Promote and Sustain Satisfaction)

found that these meetings with colleagues led to an improvement in both meaning in work and burnout for participants.

This, and other programs like it, help improve professional satisfaction.

Other ways to address well-being is to encourage and collaborate on strategies regarding work-life balance, peer

support and the technologies that were instituted to support the clinical practice. Figure 2 depicts the express need for

balance in those dimensions that effect individuals’ perceptions of the world around them. Figure 3 dives deeper to

represent the multi-factorial topics that potentially feed into each driver.

Figure 2: Key drivers of burnout and engagement in physicians. Adapted from Mayo Clin Proc. 2017;92(1):129-146

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Figure 3: Drivers of burnout and engagement with examples of individual, work unit, organization and national factors

that influence each driver. EHR ¼ electronic health record; JCAHO ¼ Joint Commission on the Accreditation of

Healthcare Organizations. Adapted from Mayo Clin Proc. April 2016;91(4):422- 431

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Strategies to reduce burnout related to technology

1. Culture – Unfavorable organizational culture is an important predictor of clinician burnout. Clinician engagement is

related to the practice of participative management, social support and team interaction. Engaged staff members

exhibit more organizational citizenship behavior which benefits the organization. A culture of engagement is also

associated with overall superior performance. Physicians experience highest levels of engagement when they have

an acceptable degree of control over their work environment. Engaged physicians tend to receive higher patient

satisfaction ratings on patient surveys. Evidence also suggests that organizations with high staff morale outperform

those with low morale [46].

2. Training and education strategies – Provide consistent and efficient training sessions and targeted ongoing

education when needed. The KLAS Arch Collaborative demonstrates that an increase in training hours is highly

correlated with improved physician satisfaction [58]. Furthermore, continuous training programs have demonstrated

higher degrees of clinician satisfaction with the EHR. These programs are useful when new functionality is added to

the EHR, when code upgrades are implemented and when new regulatory rules are issued.

Cerner works to provide optimal educational and training products and services. Implementing a winning strategy

with adoption coaches at the elbow support, experienced clinical professionals and online training are just a few

ways we strive to help care organizations realize optimal training with the EHR.

3. EHR personalization – A qualitative assessment found that physicians value personalization of their individual

experiences with EHR systems [58].

The Millennium® EHR platform is designed to meet the specific capabilities of individual health care systems, clinical

and medical specialties and individual preferences. Following our Model Experience, a standard for adoption, we

deliver a user experience that grows with the evolving needs of care organizations. The Model Experience includes

workflow views that are personalized to specialties and venues of care. It is built for the needs of individual roles and

supports a streamlined chart review process that allows users to review data, document and make clinical decisions

without chart hopping, which may improve efficiency.

4. Clinician participation in innovation – The American Medical Association, the American Medical Informatics

Association and the American Nurses Association all encourage clinicians to participate in EHR design, system

workflow correlation to clinical practice and testing, giving them a seat at the table. Best practice is to support

standardization of technology and care process workflows which allows for the best possible adoption outcomes, as

well as a more seamless transition when taking new updates to EMR software.

Cerner recommends clinicians, particularly nurses, physicians and pharmacists, to be active participants in their

organization’s health care IT (HIT) governance process. When clinicians are fully engaged in a structured manner,

implementations tend to be more successful by every measure. As a participating member of the HIT governance

process, physicians and nurses secure their place in making decisions about the technology that supports and

impacts their practice and patient outcomes. Effective governance is challenging for most organizations regardless

of size or complexity and crucial to assuring technology supports business and clinical needs – aligning with the

strategic plan. [55,56]

13

.

5. Understand and reform practice inefficiencies – User data and time motion studies

performed by informatics teams provide information to assess specific support

needs and can highlight where efficiencies in care processes can be gained.

Cerner Lights On Network® and Cerner Advance, the Cerner user analytics

platform, provides helpful user data at the facility, unit and individual levels.

Rounding informatics teams trained to observe care process workflows and assess

for standardization and workarounds add weight to the Advance data that coincides

to provide guidance toward standardization and effective EHR use [57].

6. Streamlining physician documentation - Four major factors influencing satisfaction

with electronic documentation tools are time efficiency, availability/accessibility,

expressivity and quality [59]. Embedded voice recognition software, the use of

scribes, macros like dot phrases and typing are the most widely used methods to

document. A combination of these is a common approach. Evidence is unclear on

exactly which type of documentation strategy is optimal, suggesting that

documentation strategies are largely dependent on end-user preferences.

Cerner is leading the charge in documentation improvement with Virtual Scribe,

powered by AWS (Amazon Web Services) engine. It is an intelligent system that

captures voice and transcribes the patient visit in real time.

7. Standardized nursing documentation – The ANA advocates for the standardization of nursing documentation as it helps

to reduce cognitive burden, increase efficiency and allow for more direct patient care time, ultimately supporting better

patient outcomes [60].

The Essential Clinical Dataset (ECD) is the Cerner answer to address the need to standardize nursing documentation

globally, regardless of vendor [61]. The ECD provides the means to assure the necessary elements are presented for

documentation as determined by evidence based practice, regulatory requirements and practice based evidence.

8. Standardized ordersets – Reduction in serious medication errors have clearly been shown by using standardized

ordersets (Bates, et al., JAMA, 1998). The rationale for ordersets are to reduce the time required to enter orders, to

reduce errors and to increase accuracy during order entry. Furthermore, they should increase the completeness of

orders, have “built-in” decision support and evidence-driven care and reduce the variability in the care process enhancing

compliance with best practices.

9. Normalize alerts – Reduce alert fatigue. The design of mindful, helpful and appropriate alerts will help reduce alert

fatigue. For example, one study noted the creation of a list of 33 class-based, low-priority drug-drug interactions (DDI) do

not warrant being interruptive alerts in the EHR. In one institution, these accounted for 36% of the interactions displayed

[62].

Cerner has developed analytics dashboards to measure the effectiveness and types of alerts (interruptive vs passive

alerts) so to move the unnecessary, disruptive alerts within clinical workflow to a less conspicuous space.

10. Ensure clinical decision support (CDS) is effective – Following the five rights of clinical decision support: right

information, right person, right format, right channel and right time are useful in designing appropriate and well- regarded

systems. Recognizing that CDS is not a means to replace decision making by clinicians, it can certainly reduce cognitive

burden and call out subtle clinical findings for clinicians to consider.

11. Enabling team-based care – distributing the burden or work of providing care among multiple team members can be part

of the solution to alleviate clinician burnout. Concepts include multi-contributor patient care and documentation, message

pools, integrated care planning and discharge process, which highly emphasize social support structures within the

workplace [9].

The ANA advocates for

the standardization of

nursing documentation

as it helps to reduce

cognitive burden,

increase efficiency and

allow for more direct

patient care time,

ultimately supporting

better patient outcomes

[60].

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How is Cerner helping?

All of health care is moving at a rapid pace from digitized health care (a substitution for paper) to data-enabled

transformational changes in the industry. As we enter a new age promised by artificial intelligence (AI), machine learning,

blockchain and other advancements, Cerner will continue to lead the industry in reducing clinician burnout. We have

pivoted from simplified documentation and order entry to truly intelligent systems that leverage patient data to recognize

sepsis, SIRS, obstetric emergencies and many others. It is for this reason we have developed the Cerner Now/Next

concept. Among many initiatives, Now/Next keeps care organizations current on innovations with targeted software

updates. This can help a hospital system stay current with regulation, maintain healthy populations and satisfy payor

requirements.

It is doubtful that AI and machine learning would ever fully replace physician decision making. It will, rather, augment

decision making for clinicians. For example, within 30 seconds or so of a face-to-face conversation with a patient, the

average clinician can determine patient anxiety levels and emotions, educational level, general income bracket, ability to

leverage resources, medication compliance likelihood and other factors. Clinicians then rapidly adapt to interact with a

patient based on these observations.

What if a truly intelligent system objectively captured data points that aid the clinician in providing appropriate resources

to uplift and prevent patients from slipping through the cracks? It takes a clinician time and effort to search for

appropriate resources that match patients’ needs. We are leveraging artificial intelligence engines that help clinicians do

their job better.

Cerner is a participant in the ENABLE Study (Evaluation of Novel electronic health record use metrics and their

Association with Burnout and plans to Leave practice), funded by the American Medical Association, in collaboration with

Yale University and MedStar Health. Coauthoring the study is Dr. Anup Salgia. This paper will investigate the cause and

effects of physician burnout as it relates to the EHR. The findings from studies like this and others are already making a

positive impact in designing an optimal physician experience with Cerner solutions.

Improving the clinician workflow

To address these issues, Cerner is working to create a unified, efficient and standard experience for all clients through

several initiatives. These initiatives and suggestions are designed to help make the physician’s day easier

Adoption coaching

We understand that the more support and ongoing education we provide to our physician end users beyond go-live, the

greater satisfaction we see. Cerner adoption coaching services offer a full-scale model designed to help ensure

successful end-user adoption. We provide the support and guidance to help implement and optimize Cerner solutions to

increase user adoption, improve efficiency and improve user satisfaction. Coaching also allows for knowledge sharing

between peers and uses data analytics to benchmark local specialties against national user data.

Advanced interoperability

Interoperability allows clinicians to exchange and use patient information in near real time to make clinical decisions for

their patients. Cerner is a founding member of the CommonWell Health Alliance, a not-for-profit trade association

devoted to the simple vision that health data should be available to individuals and caregivers regardless of where care

occurs. To date, Cerner has connected the health care data of millions of patients securely with clinicians worldwide. Our

efforts in this realm are unparalleled in the industry.

15

Cerner.NEXT

The expanded Cerner-AWS (Amazon Web Services) collaboration is enabling physicians to make intelligent data-driven

decisions. This is being built on a massive foundation of data that is being scaled up to build a clinical decision support

infrastructure that improves patient care and patient outcomes.

Evolving the EHR

Work to advance care process workflows by enhancing the user experience and focusing on intuitive application design. Cerner invests in contemporary technologies such as natural language processing and an array of artificial intelligence solutions.

Human factors engineering team

Comprised of interaction and visual designers, human factors researchers and design strategists, this team is committed

to designing solutions around the end-user, creating consistent experiences for our clients. We do this by enhancing

workflows through advanced design practices, end-user feedback and current usability research, ensuring that the

perspective we gain during our research is from individuals who actively use the solutions being tested.

Product design workgroups

Cerner is committed to improving the EHR in partnership with clients, including the ENABLE study mentioned above, as

well as our focused clinician groups, such as the nursing client council and physician workgroups and affinity

groups/councils.

Learning framework

Our new approach to contemporary learning combines self-paced education in a variety of methods. This new blended

learning approach is prescriptive, engaging and role-based. It provides a well-rounded, multi-phased learning process to

help the learner stay on track in their learning journey.

Model system

The Cerner collection of strategic recommendations for leveraging best practices in outcomes excellence, for process

alignment and for health system experiences contribute to the optimal setup and use of the EHR. Adopting these sets of

recommendations allow clinicians and staff to perform at the top of their licensure.

Open standards

Cerner has delivered on its pledge to allow developers to advance physician usability using API/FHIR integration. There

are several apps in our app store that address specific clinical workflows such as anesthesiology, dermatology and

others. For more information, visit code.cerner.com (Cerner Open).

Regulatory

Cerner will remain an advocate at the national and state levels to lend a voice in the industry that benefits both patients

and clinicians alike.

16

Leadership education tools

In addition to the strategies mentioned, Cerner hosts workshops and programs to educate hospital, nursing and physician leadership on the skills necessary to address clinician burnout.

Cerner Advance

Delivering the best EHR experience to your clinicians is critical to their productivity, satisfaction and ability to deliver high-

quality outcomes. Cerner Advance is a tool to provide visibility to the clinician experience by bringing together end-user

data and expert analysis on a single platform.

Cerner Health Conference

Cerner hosts a weeklong annual conference that is attended by 10,000+ attendees who represent hundreds of clients

from across the globe. The conference fosters collaboration and networking in addition to providing updates to clients on

future developments at Cerner.

Clinical Community Forum

Meetings and activities specifically for clinicians who use Cerner solutions in practice.

CNO/CNIO Summit

The three-day annual meeting hosted by Cerner is specifically designed for CNOs/CNIOs to network with fellow CNOs,

CNIOs and Cerner associates. The summit is an excellent opportunity to discuss and learn about nursing-related

industry topics.

Physician, Nursing & Informatics Leadership Workshops

Increasing clinician leadership skills will assist with decreasing the rate of burnout. Cerner provides a workshop to

address core knowledge and skills nursing and physician leaders need in the dynamic health care environment with a

major focus on change management, leadership and governance.

Physician Architect Program

Cerner offers a program developed by physicians for physicians to help bridge the gap between the clinical and technical

aspects of Cerner solutions. This interactive course gives physicians an in-depth understanding of software

configurations, privileges, preferences and architecture. With this knowledge, physicians can have better conversations

with their IT colleagues in designing a system that works optimally for their particular institution.

Professional fulfillment and improved wellness

Below are other areas of focus above and beyond the EHR to help increase professional fulfillment and improve

clinician wellness.

Health care IT operations governance

Effective governance is critical and challenging for most organizations regardless of size or complexity. Clinical

representation and inclusion within the process is key to ensure the necessary input and successful adoption of the

invested technology selected to support clinical practice and business operations.

Change management (C.L.E.A.R.)

It has been said that change is the only constant in life. In 2019, Cerner made a commitment to helping clients manage

change by creating a consulting group that specifically addresses change management. Using the most tested

techniques, this offering can help manage culture in an ever-changing technology world. Whether a health care

organization is taking a software upgrade or a full EHR implementation, our change management group can provide the

tools and resources to simplify the most complex of software implementations.

EHR optimization

Invest in optimizing the EHR. Streamline workflows, reduce required activities and data entry, and ensure clinicians are

practicing at the top of their license. Provide the necessary staff to help with data entry and chart prep, ultimately

generating better reimbursement.

Workforce management

Cerner Clairvia℠ to ensure that care organizations balance the ideal utilization of nursing resources, especially as

technology becomes a key lever for success.

Cerner views clinician burnout as a serious threat to the entire health care industry. We are optimistic that technology will

continue to lead the way to improved clinician experiences. The first step in reducing clinician burnout is to acknowledge it

exists, then discover the cause and effect, and finally put actions in place to lower stress and create work-life balance.

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About Cerner

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we believe that what we do doesn’t just impact health

care – it impacts the world. It’s why, more than ever,

health care is too important to stay the same.™

Contact us for more information • anup.salgia@cerner.com

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