As of 8/20/2019, a total 6,421 records where obtained by searching PubMed and the Web of Science, and adding relevant references from the database articles. 6,031 titles were discarded due to irrelevant topics or duplication. 390 abstracts were reviewed, and 346 were discarded due to lack of original research or not physician-focused. This left 44 full-text articles that were assessed for eligibility, leaving 31 studies that fulfilled the inclusion criteria and used for the study [Figure 2][Table 1]. All of the studies obtained correlated information overload with some level of negative effects on physicians. Based upon the results of these 31 studies, two main topics were consistently raised relating to information overload and patient safety – the resultant cognitive burden and physician burnout.
The cognitive burden of information overload
Beasley et al.13 stated that “information overload occurs when there are too many data, e.g. written, verbal and non-verbal, and physician’s memory, for the clinician to organize, synthesize, draw conclusions from, or act on.” The overload of information can occur from copying & pasting into charts, use of templates, excessive alerts, and adding data that is necessary for billing but effectively useless for clinical care.13,14
Ahmed et al.15 illustrated the effect of cognitive load differences on error rates when using an EHR for clinical decision making. A group of 20 intensive care unit physicians were asked to review patient data in the form of a conventional versus novel streamlined EHR. The novel EHR was specifically designed to only display information that was deemed most salient to these physicians. The National Aeronautics and Space Administration (NASA) task load index (an objective measure of task load from 0-100; higher indicates more work load) was a median of 58 for the conventional EHR versus 38.8 for the novel version. Completion of the task using the conventional EHR took approximately twice as long and was associated with a median four times as many errors per subject as the novel user interface. This was consistent with the hypothesis that increased task load has significant detrimental effects on physicians’ ability to analyze data.
Eye tracker technology in the intensive care unit was studied by Wright et al. to pinpoint what aspects of a chart physicians actually utilize 16. They found that dynamic data such as vitals and lab values were reviewed most consistently, and that other routine information is unnecessary and hinders usability.
Koopman et al.9 performed a cognitive task analysis with 16 primary care physicians using simulated patient cases to better understand what information they considered most important for medical decision making. A consistent finding among these physicians was that the assessment and plan was reviewed first because it provided the majority of the necessary information in a concise manner. The physicians were frustrated by the review of systems section as it mostly provided redundant information and was another source of clutter. Physicians in the study also identified drivers of note overload: Billing (checklists for each section, especially review of systems), quality improvement measures (e.g., diabetic foot examination), avoiding malpractice, compliance (e.g., documenting informed consent, patient education), and the visit history and physical exam. An earlier study by Clarke et al. found similar results when they interviewed 15 primary care physicians about their information needs, finding the review of systems “superfluous,” and contributing to information overload.17
Belden et al.18 expanded on the idea of restructuring the fundamental structure of notes in the EHR to decrease cognitive overload. The traditional “SOAP” (Subjective, Objective, Assessment, Plan) note was compared to a newly proposed “APSO” (Assessment, Plan, Subjective, Objective) format with an option to hide other extraneous information. A simulated case with 16 physicians demonstrated that simply changing the format of the note without changing any of the actual data had a positive effect. The APSO note performed better in regard to usability, and the physicians strongly endorsed this style as more practical.
Information overload can also be mitigated through educating physicians to write more efficient notes. Kahn et al.19 demonstrated that physicians who undergo a training session and use a template write notes that are 25% shorter and take 1.3 hours less time.
A study done by Senathirajah et al. with 11 physicians reviewing the same patient data showed a significant increase in reading efficiency with a user composable interface versus a traditional EHR. 72% of patient data was reviewed more than once in conventional EHR’s compared to 17% in the user composable version. A conclusion offered by these authors was that the poor usability of conventional EHR’s decreases physician comprehension, requiring data to be revisited multiple times until it is fully understood.20
However, simply allowing for user composability does not guarantee increased efficiency as illustrated by Ratwani et al.21 The usability and safety of Cerner and Epic were assessed by having 4 different groups of 12-15 physicians at different institutions (two groups using Epic, two groups using Cerner) complete basic tasks such as ordering imaging, labs, and medication for fictitious patients. Performance was assessed by tracking error rates, clicks, and task completion time between the four groups. Results showed up to an 8-fold difference in task completion time and clicks between the groups at different sites using the same EHR. Both EHR’s are user composable, but factors such as implementation protocols and physician training varied between the two sites and were hypothesized as reasons for the vast difference in proficiency.
Alert fatigue is another potential source of information overload. In a survey of 2,590 primary care physicians, 69.6% reported receiving more information than they could effectively manage. 29.8% reported incidents where they personally missed test results that delayed patient care.14 Another study demonstrated that a clinician’s likelihood of accepting best practice reminders dropped markedly with increases in the number of reminders, number of repeated reminders for the same patient, and overall patient complexity.22 A program to decrease alerts of lower importance in the Department of Veteran’s Affairs was developed by Shah et al. in 2018, resulting in a reduction of mean daily notifications per physician from 128 to 116, and a concomitant savings of 1.5 hours of work per week per physician.23
Khairat et al.24 demonstrated how the burdens of EHR’s affected physicians differently depending on the stage of their careers. Six clinical case simulations were performed by ER residents and attendings, followed by a survey to assess perceived workload and satisfaction for EHR’s. Attending physicians showed significantly higher levels of frustration with the EHR in general compared to residents. Information overload was rated more significant for residents, while attendings found excessive alerting to be a more negative factor.
Physician frustration can be a result of information overload, with up to half of a work day spent working on an EHR and an additional 1-2 hours at home, according a study by Sinsky et al.5 Marked decreases in time spent with patients is reported by physicians to be a large source of dissatisfaction and burnout.24 A 2017 survey of primary care physicians showed that 75% of doctors reporting burnout attributed it to the burden of the EHR as the primary cause.25 A 2019 survey of 282 clinicians from 3 different institutions gave more insight on the specific factors that lead to EHR burnout. The most significant problems associated with EHR‘s included information overload, excessive data entry, and notes geared toward billing rather than patient care.26 Another survey of 1,792 physicians in 2019 revealed that physicians had a 2.8 times the odds of being burned out when they felt there was not enough time in the day for documentation.27 Burnout increases the risk of depression, substance abuse, strained relationships, and suicide among physicians, in addition to a significantly higher incidence of medical errors.28,29 Tawfik et al.29 reported that physicians with burnout had more than twice the odds of self-reported medical errors, after adjusting for specialty, work hours, fatigue, and work unit safety rating.