With growing levels of clinician burnout both before and during the COVID-19 pandemic, the burden associated with the use of electronic health record (EHR) systems has emerged as a paramount challenge [1]. In particular, with an increase in reporting and clinical research needs required by consumers of health data (ie, administrators and researchers) during the spread of the pandemic, there have been additional burden for data generators (ie, providers who document care in the EHR) [2]. This has resulted in clinicians spending more time using the EHR system to complete documentation than actual patient care. The recent call to action by Shanafelt [3] highlighted the importance of thinking about how digital technologies are being introduced as another component into the clinical environment. In particular, there is a greater demand to think about better designed solutions that fit the needs of clinicians [3]. In addition to reports by physicians on the impact of EHR burden on burnout [4,5], this has resulted in numerous recommendations from organizations such as the Ontario Medical Association [6] on reconsidering the impact and use of technology in clinical practice. Therefore, it is likely that EHR-related burden, in addition to the efforts and challenges involved in managing the pandemic, have collectively led clinician burnout to an all-time high [7,8].

As EHR systems are increasingly enhanced with advanced features to improve patient care, such as clinical decision support and predictive analytics, the impact of these capabilities on clinicians’ ability to effectively and meaningfully deliver care must not be forgotten. As highlighted in many commentaries on this topic and most recently, in a chapter on EHR burden by the National Academies of Sciences, Engineering, and Medicine [9], the use of the EHR must not detract from the core aspects of medicine, such as the therapeutic relationship, nor cause unnecessary frustration, complexity, and burden on clinicians [10]. In this context, many initiatives in this field have recently emerged. For example, the Clickbusters initiative, developed by the Vanderbilt Clinical Informatics Centre [11], aims to reduce the number of unnecessary alerts delivered to end users, thereby reducing EHR burden and burnout.

Of note, most efforts to date that address EHR-related burden for clinicians have focused on the US context, with scant evidence emerging from other countries. Given that each country has varying practice and clinical requirements, the factors and bottlenecks that influence EHR burden in various settings are likely different. For example, in a recent survey on EHR burnout conducted as part of the 25×5 Symposium [12] in the United States, documentation requirements for reimbursement were cited as a main factor leading to EHR burden for physicians. These challenges are specific to the US context and do not apply to many other countries, including Canada, where health care is publicly funded. However, even without such reimbursement-driven documentation requirements in Canada, we face substantial EHR-related burnout rates [13] comparable with those in other countries. In addition, it is expected that the challenges associated with EHR burden differ across disciplines. For example, given that mental health relies heavily on narrative documentation, the pain points in using the EHR would likely differ from those experienced by specialties that rely on the use of forms or structured templates. Without sufficient discussion and evidence in the literature on how mental health care organizations in Canada are managing these challenges, there is a lack of guidance for these organizations to build relevant and effective initiatives in their own settings. Moreover, it is unclear how existing best practices for system development and implementation (eg, super users) should be best leveraged to address EHR burden. Given these evidence gaps, we seek to contribute to the emerging body of evidence and support the collective effort of reducing EHR burden for all disciplines across countries.

In this viewpoint paper, we describe our efforts to reduce EHR burden for physicians at a large academic mental health hospital in Canada. Building on our previously published studies focused on needs assessment, implementation, and evaluation of individual initiatives [4,14,15], this viewpoint shares the development and implementation of our overarching strategy. We discuss our Physician Engagement Strategy, which aims at identifying and addressing opportunities for EHR improvements at our site. On the basis of our experience to date, we conclude with key success factors and lessons learned in developing and implementing the initiatives included in this strategy.

The Physician Engagement Strategy was implemented in a large academic mental health hospital that provides care to >34,000 patients experiencing mental illness in Toronto, Ontario, Canada. In an effort to improve the quality and continuity of patient care, the organization implemented an integrated EHR system (Cerner Millennium) in 2014. Now, the organization offers a paperless care environment, where all processes, from orders to medication administration, are conducted through and with the EHR system. With a single source of truth, the organization has since been able to improve key quality of care outcomes by enhancing medication safety [16] and embedding psychiatric risk flags in the system [17]. This has resulted in obtaining the highest rating (stage 7) on the Electronic Medical Record Adoption Model [18] and level 6 on the Adoption Model for Analytics Maturity [19] from the Healthcare Information and Management Systems Society. Most notably, the organization was awarded the prestigious Davies Enterprise Award in 2018 [20]. On average, the EHR system is used by >400 physicians to deliver care at the organization.

Despite these achievements and the organization’s focus on improving the safety and quality of patient care, physicians have had mounting concerns regarding the usability of the EHR in their daily workflows, highlighting it as a major source of burnout in our 2017 physician wellness survey (conducted with all physicians across the hospital) [15]. Our organization’s wider Physician Engagement, Wellness, and Excellence Strategy included several interventions to improve physician support at the individual, team, and organizational levels. One of the six proposed initiatives under this strategy included efforts to optimize use of EHRs to enhance the efficiency of practice [15]. In alignment with departmental leadership (VS) needs to optimize the use of EHR and reduce the associated burden for clinicians, leadership (DJ) from information management prioritized clinician-driven innovation, including efforts to address EHR-related clinician burnout. Consequently, in 2018, the inaugural Chief Medical Information Officer (CMIO) was tasked with improving physicians’ experiences with the EHR to reduce EHR-related burden. Given the importance of leadership buy-in and prioritization of strategies, the CMIO developed and implemented a multipronged strategy to address the ongoing and emerging challenges for physicians related to the use of the EHR.

Consistent with academic practices, we sought to inform our Physician Engagement Strategy with the latest evidence. Given the number of interventions aimed at combating EHR-related burnout in the published literature, our team conducted a rapid literature review on this topic [25]. From a review of 50 related articles published between 2014 and 2019, we found that the measurement of EHR burden needs to be performed both subjectively (eg, via surveys) and objectively (eg, using use data) [26]. We also identified that interventions to reduce EHR burnout were focused on four main aspects: enhancing and redesigning the interface of EHR screens, delivering tailored education and training to end users, improving communication, and providing additional support for administrative tasks [25]. To implement many of these interventions, approaches similar to a Plan-Do-Study-Act cycle for quality improvement [27] were used, which was in alignment with our needs assessment process (ie, measuring pain points). Through our literature review, we also learned that following the implementation of interventions, it is essential to continue enhancing and optimizing these through further evaluation using analytics data, surveys, and other methods. Although findings from our literature review have laid the foundational building blocks of our strategy, it was important to adapt and align these strategies and interventions to the specific challenges present within our organization.

On the basis of our in-depth needs assessment and review of the literature, we developed our first iteration of the Physician Engagement Strategy in 2020. In the development of this physician-centric multipronged approach, we had in-depth discussions with our information technology (IT) and clinical leadership teams to ensure feasibility and availability of resources. An overview of the strategy is depicted in Figure 1. The strategy comprises four main goals: (1) improving the handling and resolution of EHR issues; (2) enhancing physician engagement and leadership opportunities on EHR-related decisions; (3) leveraging communication, education, and informatics strategies to increase efficient and meaningful use of the EHR; and (4) measuring the impact of these strategies to achieve data-driven insights.

Throughout the implementation of initiatives to support these goals, 3 main guiding principles (pillars) were considered essential for success. Foremost, it was critical to engage all relevant stakeholders and frontline physicians to ensure that their perspectives are heard and any challenges are brought up for examination. We also considered it important to provide physicians an opportunity to be inspired to participate in leadership roles and be involved in the decision-making process of EHR changes that impact patient care and physicians’ use of the EHR. Finally, we detailed a multitude of initiatives aimed at collectively supporting the ability to change the use of the EHR system such that it improves efficiency and end user experience. Throughout these pillars, we also ensured that there was a focus on measuring outcomes to evaluate whether the specific initiatives have worked as intended. The initiatives outlined in the strategy are described in detail below.

To engage physicians across our organization, we developed an EHR SWAT team initiative through adaptation of initiatives [28] identified from our literature review. Traditional governance models have focused on identifying and implementing requirements solely by the IT team [3]. However, from the IT perspective, there is often a lack of understanding of the actual requirements needed for the change to be impactful. Moreover, many of the changes often affect other clinical areas (eg, pharmacy and laboratory). Thus, implementing in isolation can lead to more downstream challenges. As such, the SWAT team model, which mirrors other initiatives at the University of Colorado School of Medicine [28,29], overcomes this challenge by bringing together a collaborative team to discuss and identify a commonly agreed set of requirements for each issue. Our team-based intervention (SWAT) included assembling an interdisciplinary team of specialists including our CMIO; clinical informatics nurses and educators; and representatives from pharmacy informatics, health information management, clinical applications, and project management [14]. Through this intervention, we met with physicians from each of the seven academic divisions across our organization, collected EHR change requests, and prioritized them into four categories: (1) additional education, (2) quick fixes (<6 weeks), (3) future fixes (≥1 year), and (4) unable to address owing to technical or regulatory restraints. In total, we gathered 118 requests (eg, including adding keyword search functionality, minimizing freezing, and auto-faxing) [14].

To our knowledge, the Physician Engagement Strategy is one-of-a-kind collaborative approach in a Canadian mental health setting that aims to engage both frontline physicians, physician leadership, and IT leaders in reducing EHR burden. Previous national strategies in the United States to reduce clinician burnout have included recommendations such as engaging clinicians in the design and deployment of health IT to ensure the effectiveness, efficiency, usability, and safety of the technology [9], which we have implemented thoroughly throughout our strategy, especially within the engage and inspire pillars. The Office of the National Coordinator for Health Information Technology in the United States has also released its Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs, which includes recommendations such as better alignment of the EHR system design with real-world clinical workflows, increase in end user training, and improvement of the clinical documentation functionality [40], which we implemented through our EHR SWAT teams, peer education, and speech recognition initiatives, respectively. Our development of a shared vision and approach enables a concerted strategy developed and implemented with feedback and alignment across all stakeholder groups. As the digital health ecosystem (eg, web-based care) continues to become integral to clinical care, the numerous venues for discussion across multiple departments allow for unbiased feedback and opportunities to align the road maps of the EHR and related technologies.

As we enter the third year of implementing the EHR Physician Engagement Strategy, a few lessons learned that will guide future approaches to optimize the reach and impact of our strategy were identified. Foremost, it is essential that frontline physicians are recognized as the main stakeholders and decision makers in our strategy. Across all our initiatives, careful deliberation and stepwise iterative approaches were used to embed physicians’ perspectives and feedback in the implementation and to roll out plans. These stepwise approaches ensured that any red flags can be considered and mitigated before the roll out of any initiatives. For example, for speech recognition technology, extensive consultation sessions were conducted before the development of the implementation plan. Understanding physicians’ desires and needs helped curate the main components to consider in such an implementation plan. In addition, these discussions should be considered in multidisciplinary forums. Given that the organization has >70 clinics, each specializing in different diagnoses, treatment, or patient populations, it is expected that significant heterogeneity exists in terms of workflows and EHR use patterns. Ensuring that IT and clinical stakeholders from these clinics are engaged in the decision-making process reduces the possibility of unexpected roadblocks or unintended consequences during implementation. In addition, we realized that periodic review of the initiatives can yield synergistic opportunities to better align and reinforce initiatives within the strategy. In particular, interconnected initiatives can inform each other and maximize their success. For example, during the implementation of speech recognition, the Physician Think Tank was used to identify physicians’ needs before the implementation. In addition, the CMIO newsletter was found to be a useful way to communicate updates and success outcomes to all physicians at the organization. Thus, the initiatives of this strategy enable a concerted effort to reduce EHR burden.

As we continue to implement and expand the Physician Engagement Strategy, it has become increasingly important to consider this work in the broader field of EHR burden and digital technologies. We expect that this road map will continue to expand as new features and technologies are becoming embedded within the organization. In this accord, we highlight a few important next steps that we hope to achieve in the coming years. First, many of the interventions available in the literature have not focused on evaluating their impact on EHR burden. With the advent of EHR back-end use data, there is a timely opportunity to evaluate the impact of these initiatives on efficiency and satisfaction with using the EHR. In the next year, we will focus on evaluating and determining the impact of these initiatives using our established evaluation methodologies. We will also explore the perceptions and experiences of clinicians in participating in these initiatives (eg, multidisciplinary groups and super users) to address EHR-related burden [37]. In addition, a number of emerging trends, such as measurement-based care [41,42] and web-based care [43], are becoming evident in our digital mental health infrastructure. As these models of care are streamlined, it would be useful to evaluate their impact on EHR burden. Future work should explore how these initiatives can be made useful prospectively in the planning and implementation of these digital models of care at the organizational level. Finally, we are currently exploring opportunities to embed these initiatives as part of creative professional activities for academic promotions. Doing so may help to support the development of hybrid physicians [44] who are equipped to enable the effective use of informatics by physicians to deliver better mental health care.

As EHR-related burden continues to be a critical challenge for many health care systems, we introduce our EHR Physician Engagement Strategy as an approach to reducing these unintended consequences. This strategy involves a multipronged approach that aims to engage clinicians in reimagining their future EHR experiences and empower them as central stakeholders and advocates for digital technologies to achieve the quadruple aim of health care. Future work should focus on evaluating the impact of these initiatives on EHR burden and expanding the impact of this work to other digital health tools at the organization.