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Video and other technologies are reshaping the delivery of health care, yet barriers related to workflow and possible provider fatigue suggest that a thorough evaluation is needed for quality and process improvement.
This scoping review explored the relationship among technology, fatigue, and health care to improve the conditions for providers.
A 6-stage scoping review of literature (from 10 databases) published from 2000 to 2020 that focused on technology, health care, and fatigue was conducted. Technologies included synchronous video, telephone, informatics systems, asynchronous wearable sensors, and mobile health devices for health care in 4 concept areas related to provider experience: behavioral, cognitive, emotional, and physical impact; workplace at the individual, clinic, hospital, and system or organizational levels; well-being, burnout, and stress; and perceptions regarding technology. Qualitative content, discourse, and framework analyses were used to thematically analyze data for developing a spectrum of health to risk of fatigue to manifestations of burnout.
Of the 4221 potential literature references, 202 (4.79%) were duplicates, and our review of the titles and abstracts of 4019 (95.21%) found that 3837 (90.9%) were irrelevant. A full-text review of 182 studies revealed that 12 (6.6%) studies met all the criteria related to technology, health care, and fatigue, and these studied the behavioral, emotional, cognitive, and physical impact of workflow at the individual, hospital, and system or organizational levels. Video and electronic health record use has been associated with physical eye fatigue; neck pain; stress; tiredness; and behavioral impacts related to additional effort owing to barriers, trouble with engagement, emotional wear and tear and exhaustion, cognitive inattention, effort, expecting problems, multitasking and workload, and emotional experiences (eg, anger, irritability, stress, and concern about well-being). An additional 14 studies that evaluated behavioral, emotional, and cognitive impacts without focusing on fatigue found high user ratings on data quality, accuracy, and processing but low satisfaction with clerical tasks, the effort required in work, and interruptions costing time, resulting in more errors, stress, and frustration. Our qualitative analysis suggests a spectrum from health to risk and provides an outline of organizational approaches to human factors and technology in health care. Business, occupational health, human factors, and well-being literature have not studied technology fatigue and burnout; however, their findings help contextualize technology-based fatigue to suggest guidelines. Few studies were found to contextually evaluate differences according to health professions and practice contexts.
Health care systems need to evaluate the impact of technology in accordance with the Quadruple Aim to support providers’ well-being and prevent workload burden, fatigue, and burnout. Implementation and effectiveness approaches and a multilevel approach with objective measures for clinical, human factors, training, professional development, and administrative workflow are suggested. This requires institutional strategies and competencies to integrate health care quality, technology and well-being outcomes.
Technology is reshaping the delivery of health care worldwide as a facilitator, practice extender, and virtual team member for person- and patient-centered care [
Technology challenges include learning to use it personally and professionally and integrating it into workflow and screen time [
It appears that there is a gap in how health care providers typically use EHRs and other technologies, the amount of effort required for workflow, and how this leads to fatigue (or burnout). Health care is starting to evaluate the longitudinal continua of work engagement and burnout, the development of burnout in relation to job demands and resources, and the role of psychosocial working conditions [
The relationship among technology, fatigue, and health care can be better understood by reviewing the broad literature on health, business, occupational health, technology, and well-being. This will help with the following:
Find data on the intersection of technology, fatigue, and health care (eg, association, mediation, and cause).
Provide an overview of the business, occupational health, and well-being literature to contextualize technology-based fatigue, its components, and related processes.
Suggest guidelines for health care related to technology, well-being, and fatigue at provider, clinic, and system levels to advance self-assessment, quality improvement, and necessary organizational and social improvements to promote a culture of well-being.
A literature search via the Medical Subject Headings of the keywords spanned from January 2000 to December 2020, using the original 6-stage scoping review process [
This scoping review explores the relationship among technology, fatigue, and health care to improve the conditions for providers. It focuses on the overarching question: “What is technology-based fatigue and what are its consequences for providers and patients?” The subquestions are as follows:
What are the characteristics of technology-based fatigue and its associated factors, including technologies?
Does technology and associated fatigue impact provider health (burnout, compassion fatigue, and well-being)?
How does provider burnout or well-being associated with technology affect the delivery of care; therapeutic relationships; and quality of care offered in person, by video, and by other technologies?
What are strategies or interventions being used to prevent or ameliorate technology fatigue?
The goal was to synthesize clinical, provider, administrative, business, and other workplace data and consider the current and target states for using technologies in a healthy way to prevent or minimize problems and focus efforts on further assessment and intervention.
A total of 10 literature databases were queried by a librarian: PubMed, APA PsycNET, Embase, PsycINFO database via the Ebsco platform, Web of Science, Scopus, Social Sciences Citation Index, Telemedicine Information Exchange database, Centre for Reviews and Dissemination, and Cochrane Database of Systematic Reviews and Central Register of Controlled Trials. The search focused on technology, health care, and fatigue via synchronous telepsychiatry and tele-behavioral or tele-mental health, though telephone, asynchronous, mobile health, tablets, and text were also searched. It also included types of health providers (ie, clinician, provider, counselor, employee, medical nurse or physician, psychiatrist, psychologist, social worker, therapist, and worker), assessment, care, evaluation, screening, therapy, triage, and treatment. The initial search targeted 4 concept areas by using specific terms as shown in
Behavioral impact
Cognitive impact
Emotional impact
Physical impact
One author (DMH) screened titles and abstracts of 4221 potential references, excluding 202 (4.79%) based on duplication and 3837 (90.9%) that did not meet the search criteria. Notably, 2 of 3 authors (DMH, CMA, or SAS) reviewed the full text of 182 articles, but only 12 (6.6%) met the inclusion criteria related to health care, technology, and fatigue based on consensus (
Search flowchart: diagram of studies reviewed. eConsult: electronic consultation.
A data charting form was used to extract data, and notes were organized consistent with a descriptive analytical method by each reviewer. The reviewers compared and consolidated the information using a qualitative content analysis approach [
Results were organized based on the objectives into tables and figures, with key concepts and components of technology-based fatigue outlined and described, partially based on excerpts from published topics. As this research area, although critical, is nascent, findings were reported individually.
The technologies used have evolved considerably, making these articles a challenge to compare. Qualitative steps to analyze disparate populations, data and methods of studies were used [
A comparison of health and resilience, risk to well-being, and manifestations of technology-based fatigue and burnout. EHR: electronic health record.
Impact of the implementation of technology integration and utilization toward hybrid care on health and well-being over time.
Expert opinions were solicited to review preliminary findings and suggest additional steps for improvement. A list of relevant experts was compiled from (1) behavioral health organizations internationally (eg, Psychiatry, Psychology, Social work, and Addiction); (2) technology-related special interest groups of organizations (eg, the American Telemedicine Association American Medical or Nursing Informatics Associations and Coalition for Technology in Behavioral Sciences); (3) health organizations related to quality improvement, human resources, occupational health, and lean systems (eg, Agency for Healthcare Research and Quality, American National Standards Institute, Healthcare Information and Management Systems Society, Joint Commission, and World Health Organization); and (4) federal (ie, US National Academy of Sciences, US. National Institute of Health, US Department of Defense, and US Veterans Health Administration) and academic institutions (ie, Mayo Clinic and University of California); and (5) researchers, authors, editors, and editorial board members.
Experts were invited by email from 7 countries (Australia, Canada, Germany, India, Italy, the United Kingdom, and the United States) by several means, including attending a live videoconference expert feedback session and providing qualitative feedback. The lead author (DMH) facilitated the use of a scribe, and each of the 3 sessions lasted 50 minutes. The abstract, objectives, methods, tables, and figures were sent to experts a week in advance. The session started with a brief introduction based on the abstract, objectives, and overview of the table and figure content (10 minutes). This was followed by general questions, comments, and suggestions, including review of the data charting and search criteria (20 minutes). The input was summarized and themes were extracted to guide the organization (eg, headings in rows) and content (eg, in the columns) of tables and figures. The questions were asked to solicit additional feedback (10 minutes), and other suggestions were provided at the end of the session. Feedback was collated based on previous studies using consensus and modified Delphi processes [
The results are organized per objectives (intersection of technology, fatigue, and health care; business, occupational health, and well-being literature; and guidelines for health care), which align with the search of the 4 concept areas (behavioral, cognitive, emotional, and physical impact; workplace at the individual, clinic, hospital, and system or organizational levels; well-being, burnout, and stress; and provider perceptions regarding technology). Business, occupational health, and well-being literature did not study technology fatigue and burnout; however, findings help contextualize technology-based fatigue to suggest guidelines at provider, clinic, and system levels for health care. Few studies were found to contextually evaluate differences according to health professions and practice contexts.
Expert opinions and feedback (N=19) contributed by attending a live expert feedback session and providing qualitative feedback, completing a qualitative and quantitative 6-item Likert-scale survey (16/19, 84%), or providing qualitative feedback via email (2/19, 10%). Of the 19 attendees in expert feedback sessions, 8 (42%) were psychiatrists, 5 (26%) were psychologists, 2 (10%) were marriage and family therapists, 1 (5%) was a physician (not psychiatrist), 1 (5%) was a counselor, 1 (5%) was a social worker, and 1 (5%) was a systems engineer. Results showed that most attendees agreed or strongly agreed that (1) “The results provided in tables are organized in the ballpark and relatively complete” (18/19 93%), (2) “The tables are a practical way to identify, analyze, and begin to address technology problems for providers and systems” (13/19, 69%); and (3) “The figures substantially help to compare and contrast the continuum of health versus fatigue versus burnout” (13/19, 69%).
A total of 12 papers met the inclusion criteria based on the consensus of the authors [
These studies were conducted in the United States, although a study compared providers’ impact across countries. Only 17% (2/12) studies discussed the physical environment, occupational health approaches, mobile care, telework, or lean, human factors, and user design approaches to workflow. System onboarding and training enables users to get oriented and informally sets expectations, but often there are no processes for ongoing self-, peer-, and system-assessment of experience or skills. Workplace, workspace, ergonomic, and technology implementation are gaining more attention in health care [
Studies have focused on the use [
Approximately 45.8% (3338/7279) of the physicians worked for >60 hours per week compared with 10% (3442/34,420) of US workers in other fields [
Implementation studies of usability suggest that there are multiple opportunities to improve the use of EHRs across professions, particularly in relation to usability [
A total of 14 studies explored provider experiences or perceptions about technology that may apply to fatigue but did not directly investigate it. These studies focused on EHR and videos (6/14, 43%); combinations of video display terminals (VDTs), computers, and phones (6/14, 43%); smartphones or PDA (1/14, 7%), or EHR alone (1/14, 7%;
Studies that focused on EHR time log data for physicians [
Qualitative analysis of the literature suggests a continuum from health to risk of fatigue to manifestations of digital burnout (
A qualitative analysis suggested multiple opportunities for regulators, policy makers, EHR developers, payers, health system leadership, and users to collectively improve the use of EHRs and other technologies (
From the 1980s to 2021, there has been a shift in the perception of the origin of technology problems in business, occupational health, and other area [
Findings from VDT studies of occupational hygiene (eg, climate, lighting, and electrostatic conditions) and ophthalmologic dimensions appear to be quite pertinent to video, EHR, and psychosocial work commonly associated with
Displays and workflow interventions have been successful in many respects. A 15-minute work period with microbreaks [
There are overlaps and differences between burnout and prolonged fatigue [
Conceptualization of fatigue and burnout may also be organized according to engagement and job stress [
A shift to a culture of well-being with technology use requires the evaluation, implementation, and monitoring of individual, workplace, workflow, and institutional strategies (
A shift to a culture of well-being that incorporates technology will require adaptations and quality improvement in the areas of technology, physical environment, occupational health, and specific evaluations and interventions. Therefore, objective measures to evaluate, promote, and enhance well-being are required. At a minimum, consideration is needed for the cognitive, behavioral, emotional, and physical impact of workflows. Such consideration is needed at the individual, clinic, hospital, and system or organizational levels. This could include adjustments in information systems (IS) and IT, use of lean methods and emphasis on interprofessional education efforts with technology team-based care from the Institute of Healthcare Improvement and Agency for Healthcare Research and Quality [
Health care provider well-being and health appear to be related to the technological integration of video, EHR, and mobile health over time (
Studies related to the implementation and evaluation of technology are increasingly sophisticated and provide a starting place despite varying widely in duration, approaches, methods, and quality of measures. The 12 studies that met all the inclusion criteria for technology, health care, and fatigue studied the behavioral, emotional, cognitive, and physical impact of workflow at individual, hospital, and system or organizational levels (
Beneficial changes in workplace culture, focus on well-being, and prevention of burnout from other fields are beginning to be used in health care [
To begin to address challenges in health care related to fatigue and burnout, including those associated with technology, a substantial collaborative effort is needed from health system leadership, organizational researchers, IT and IS specialists, and potentially the government [
A structural and functional redesign of systems would emphasize evaluation, effectiveness, implementation, and application of process improvement [
This scoping review has some limitations. First, there were fewer findings than we expected using our inclusion and exclusion criteria, despite a broad scope, to find the relationships between health care, fatigue, and synchronous (video, telephone, and informatic systems) and asynchronous (wearable sensors and mobile health devices) technologies. Second, only 1 author reviewed the titles and abstracts. Third, the entire search was described but not saved and consolidated as an appendix for reviewers; reresearch findings of the 2 main databases were included as an appendix for reviewers. Although the terms, databases, and dates are a guide to other researchers, this omission does not enable others to simulate the approach. Fourth, given the small sample sizes, heterogeneous methods, and variable study duration, the team was unable to apply a systematic quality evaluation system or draw conclusions using a quantitative meta-analysis. Cross-sectional studies of associations with multiple factors in applied rather than controlled settings have limitations. Fifth, the stratification of behavioral, cognitive, emotional, and physical domains of impact, although heuristically helpful, could have been operationalized more rigorously. Similarly,
Health care delivery and systems are increasingly incorporating technology but need to evaluate its impact in accordance with the Quadruple Aim to support providers. Approaches with causal questions and longitudinal implementation research could benefit from a multilevel approach with objective measures for clinical and human factors, training, professional development, and administrative workflows. If done well, technology integration could further population-centered health and effectiveness of service delivery, although the redesign of financing, reimbursement, regulatory, and other changes may be necessary. Integration of health care quality outcomes with those for technology and well-being is suggested and requires institutional strategies and competencies. Otherwise, continued advances in the use of technology may inadvertently worsen provider workload burden, fatigue, and burnout.
Studies at the intersection of technology, health care, and fatigue.
Studies of the reviews focused on technology-related experiences in health care for clinicians aside from fatigue.
Human factors and technology in health care: organizational responses for prevention and adjustment of workflow.
Guidelines for clinicians, systems, and organizations in health care for technology use and well-being.
electronic health record
information systems
information technology
Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews
video display terminal
The authors would like to thank the American Telemedicine Association; Telemental Health Interest Group; Coalition for Technology in Behavioral Science; Department of Psychiatry and Behavioral Sciences, University of California; Davis School of Medicine; Veteran Affairs Northern California Health Care System; and Mental Health Service Office of Connected Care, Department of Veterans Affairs for their support.
None declared.