Physician wellness is vital to the delivery of high-quality health care and greatly affects the performance of health care systems [1]. Organizations have started including wellness programs among their top priorities in an attempt to reduce physician burnout [2]—a work-related syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment [3]. Physician burnout has been associated with career dissatisfaction [4], absenteeism and job turnover [5], reduced quality of care [6], and medical errors [7]. It is increasingly being measured, with high prevalence rates (78%) among American physicians [8], and almost 30% of Canadian physicians [9] have reported symptoms of burnout. The major contributors to physician burnout include individual factors (eg, age and education debt) [10] and work factors (eg, inefficient work processes, negative leadership, and limited interprofessional collaboration or advancement) [11]. Within psychiatry, workplace variables have been found to be a major stressor and may be more likely to perpetuate burnout [12]. Demands including navigating the working relationship with clients experiencing trauma—while often becoming the target of anger, hatred, and even violence—can be emotionally draining [13]. Moreover, burnout has also been known to span all phases of a physician’s career, including during medical school and residency, and a recent systematic review calculated a 33.7% burnout rate for psychiatry residents [14].

Among workplace inefficiencies, the use of health information technology such as electronic health records (EHRs) has been suggested to contribute to physician burnout in psychiatry [15,16]. With proper implementation, EHRs can improve the quality of health care by increasing time efficiency and guideline adherence and reducing medication errors [17]. However, the promise of improved quality of patient care through fast access to patient information and improved clinical decision-making support has not been attained in many health care organizations as the unintended consequences of EHRs proliferate [18].

These unintended consequences can be technical factors, such as poor software design, or sociotechnical factors, such as poor usability or workflow integration [19-22]. EHRs have often added to physicians’ cognitive load through excessive data entry requirements [23,24] and reduction of time spent with patients [25,26]. The provision of mental health care, in particular, poses an added level of complexity, including navigating multidisciplinary treatment plans, varying levels of care (ie, residential and partial hospitals) that do not fit neatly into the clinical or scheduling workflows [27], and the inability to capture and find important documentation [28,29]. Despite the challenges, the adoption of EHRs remains an important policy priority in most countries, showing a steady increase over the past 10 years and reaching an adoption rate of 75% in American [30] hospitals and 81% in Canadian [31] hospitals. Moving forward, the National Academy of Medicine calls for a human-centered approach to combat physician burnout by reducing unnecessary administrative burdens through improved design and implementation of technology and supportive regulatory policies [32].

Although there are numerous editorial and opinion pieces identifying EHRs as possible contributors to physician burnout [33,34], research in determining physicians’ perceptions of the impact of EHRs on burnout is scant [35]. In addition, there is a need to apply a variety of research methods to fully understand the complexity of the phenomenon to optimize technology and clinical workflows [35], given that previous studies used subjective, perception-based data for measuring both EHR-related stressors and burnout variables.

This study aimed to (1) identify the extent of burnout and the perceived contribution of the EHR toward burnout among our population of physicians and learners (residents and fellows); (2) identify significant contributors of burnout and EHR-related burnout; (3) explore differences between physicians and learners among factors previously identified as contributing to EHR-related burnout (time spent, use, and documentation styles within the EHR; EHR proficiency and training; and perceived usefulness of EHR); and (4) compare self-reported perceptions on EHR usage metrics using log data.

This study used a cross-sectional survey design to gather the perceptions of physicians and learners and back-end EHR usage logs to gather use patterns. It was conducted at Canada’s largest academic mental health hospital located in Toronto, Ontario. At the time of the survey distribution, the Centre for Addiction and Mental Health had 407 physicians, 208 of which were considered full-time (ie, ones who had a primary appointment with the hospital). Among these physicians were hospitalists and psychiatrists spread across 7 different clinical divisions. In addition, the study included 53 residents and 14 clinical fellows. Of the 37,065 unique patients admitted in the hospital, 63.10% (23,388/37,065) were treated for an admission diagnosis falling within two groups: schizophrenia or/psychotic disorders and substance use disorders [36]. Physicians used a comprehensive EHR, which was implemented 5 years before this study.

Depending on the email address used for the electronic survey links, usage log data for 201 participants in May and 198 participants in June were identified, which were then used to compare metrics that were also asked within the survey.

Ethical approval was obtained from the organization’s quality improvement projects ethics review board.

Demographic and practice characteristics of the study population are shown in Table 2. The survey was answered by 176 physicians and 32 learners. Response rates were 43.2% for physicians (full-time: 75% and part-time: 10%) and 47.7% for learners (fellows: 86% and residents: 40%). A total of 44.3% (78/176) of physicians and 50% (16/32) of learners were female; 46.0% (81/176) of physicians were in the 0 to 10 years practice timeframe and 26.1% (46/176) practiced for 21 years or more. Physicians saw a mean of 27 patients (median 25) per week and learners saw a mean of 14 patients (median 15).

A total of 25.6% (45/176) of all physicians and 19% (6/32) of learners identified as having one or more symptoms of burnout, as measured using the single-item measure from the Mini-Z. When asked about EHR contributing to burnout, 69.3% (122/176) of physicians and 67% (22/32) of learners reported feeling that the EHR always or almost always contributes to their symptoms of burnout. Within the subset of those individuals who experienced one or more symptoms of burnout (n=51), this perception of the EHR contributing to burnout was slightly more prevalent (155/208, 74.5%; Table 3).

Physicians and learners with higher levels of frustration and lower satisfaction with the EHR were significantly more burned out (Figure 1). Other variables that were significantly associated with burnout included participants’ perceptions of the EHR on keeping their patients safe (P=.002) and whether physicians perceived communication regarding EHR upgrades as efficient (P=.047).

Variables that had a significant association with perceptions of EHR contributing to burnout were low satisfaction with the EHR (P<.001) and frustration with the EHR (P<.001; Figure 1). Similarly, as with burnout, those who were content with communication surrounding EHR updates were also significantly less likely to perceive the EHR as a contributory factor to burnout (P=.003). Finally, those who were more proficient with the EHR were also significantly less likely to perceive it as contributing to their burnout (P=.01).

The experiences of physicians and learners who had low satisfaction with the EHR focused on usability issues and unintended consequences of the EHR on patient care. A total of 39 individuals reported usability issues such as it being nonintuitive, having too many clicks, or not being user-friendly, with one participant referring to it as “death by a thousand clicks” (Participant #94). Moreover, 48 respondents discussed difficulties with finding or retrieving information, including inaccessible documentation. Respondents also discussed time sinks because of the system being “slow” and “clunky” and noted the impact that technology has on direct patient care, such as “...has a negative impact on...the amount of quality face-to-face time I can spend with patients” (Participant #118).

Respondents with high EHR satisfaction used workarounds to complete tasks in the EHR, such as “type long consult notes in [Microsoft] word then copy” (Participant #33) or “enter my appointments in my Outlook calendar...” (Participant #66). Others discussed their knowledge of customization, such as “know how to insert personal short cuts” (Participant #103), or the use of back-end dictation or “use [voice recognition software] exclusively instead of typing progress notes” (Participant #125). Satisfied participants thought that the EHR allows for “communication with other care providers” and has “the ability to forward things easily to care providers in the circle of care” (Participant #168).

As gathered from usage logs, the median number of patients seen per month for all the survey respondents over the months of May and June 2019 was 60 patients (May, N=201, June, N=198), compared with the self-reported median of 80 patients (N=207). The median time spent on EHRs per patient for all survey respondents for the months of May and June 2019 was 16.4 min (May, N=201, June, N=198), compared with the self-reported median of 30 min (N=206). The median time spent on the EHR after hours (defined as 6 PM to 6 AM and weekends) for all survey respondents for the months of May and June 2019 was 2.37 hours (May, N=201, June, N=198), compared with the self-reported median of 8 hours (N=201).

Although overall satisfaction with EHRs remains low, reverting to paper documentation is not a viable alternative. This study adds to a growing body of evidence calling for a focus on EHR improvement [46]. The study data demonstrate that 67% of learners and 43% of physicians were satisfied with the system, which is comparable with other studies [47]. Among those who perceived the EHR in a negative light, a majority (>65%) of the respondents expressed dissatisfaction with the EHR (n=97).

This study helps in understanding physician burnout attributed to technology within the Canadian mental health context. Although the general burnout rate of physicians and learners (24.6%) was comparable with the Canadian national average (30%) [9], our survey found that the majority (69.6%) of physicians and learners attributed EHR to their symptoms of burnout, even when they did not identify as being burned out. Although other institutions have completed surveys to examine the role of technology in physician burnout [15,16,48], this study adds to the existing literature, providing data from a different geography and a robust baseline at our facility. Measuring burnout rates, as well as the significant EHR-related contributors to burnout within the hospital, have direct implications on practice. Our organization has created a multipronged approach toward improving physicians’ experience with the EHR, which includes direct feedback channels, improved education and communication around EHR updates, implementing speech recognition technology, and developing physician efficiency dashboards. Having a strong baseline measure of burnout allows us to measure the short- and long-term impact of initiatives at our hospital which aim to reduce physician burnout.

Due to the nature of this study, we were only able to report on associations between variables rather than causal relationships.

To improve the understanding of the complexity of EHR use, we used back-end EHR usage logs. However, because of the anonymity of the survey, we were unable to compare self-reported data with usage logs on an individual basis, and we could only provide an aggregate comparison of 3 measures. Furthermore, usage logs can lack the vital context around clinical workflows, and there has been varied validity and sensitivity of using such logs for mapping out clinical activity [54]. Validation of back-end EHR usage logs through direct observation was not carried out within this study environment; however, this analytics system has been used in previously published literature describing physicians’ EHR usage [42].

Despite numerous discussions and publications, there are striking differences in the understanding of what constitutes burnout and substantial variability in prevalence estimates of burnout among physicians [55]. This study used a single question from the Mini-Z, which was previously validated by physicians, and yielded results similar to those of the more commonly used Maslach Burnout Inventory [3].

Finally, because of the heterogeneity of EHRs, implementation practices, training, and organizational contexts, there exists a potential limitation in generalizing such results to other contexts.

This work is the first step in better understanding EHR-related physician burnout in a Canadian academic mental health environment, where we measured general burnout rates and its perceived link to EHR use through a survey that gathered self-perceptions. In addition, we compared self-perceptions with a back-end usage log for 3 important metrics and found that participants tended to overestimate their time spent on the EHR. This finding provides a valuable contribution toward the methodology for studying physician burnout and demonstrates the need to combine self-reported perceptions with objective data sources.

The contribution of this study to the literature on physician burnout demonstrates the importance of increasing end-user satisfaction and minimizing end-user frustration with the EHR, both significant factors that were associated with burnout within the study population. The results of this study emphasize the value of developing human-centered effective strategies to improve physicians’ experiences with EHRs, including efficient communication about EHR upgrades. Measuring burnout and understanding the impact of EHR-related stressors within the study population serves as a strong baseline, allowing us to measure the short- and long-term impact of multiple initiatives underway at our hospital aimed at reducing physician burnout.