Appl Clin Inform 2021; 12(03): 637-646
DOI: 10.1055/s-0041-1731678
Research Article

Novel Nonproprietary Measures of Ambulatory Electronic Health Record Use Associated with Physician Work Exhaustion

Amrita Sinha
1   Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
Tait D. Shanafelt
2   Division of Hematology and General Internal Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, United States
3   WellMD Center, Stanford University School of Medicine, Stanford, California, United States
Mickey Trockel
4   Division of Psychology and Behavioral Sciences, Department of General Psychiatry and Psychology, Stanford University School of Medicine, Stanford, California, United States
Hanhan Wang
5   WellMD & WellPhD Center, Stanford University School of Medicine, Stanford, California, United States
Christopher Sharp
6   Division of General Internal Medicine, Department of Medicine, Stanford University, Stanford, California, United States
› Author Affiliations
Funding None.


Background Accumulating evidence indicates an association between physician electronic health record (EHR) use after work hours and occupational distress including burnout. These studies are based on either physician perception of time spent in EHR through surveys which may be prone to bias or by utilizing vendor-defined EHR use measures which often rely on proprietary algorithms that may not take into account variation in physician's schedules which may underestimate time spent on the EHR outside of scheduled clinic time. The Stanford team developed and refined a nonproprietary EHR use algorithm to track the number of hours a physician spends logged into the EHR and calculates the Clinician Logged-in Outside Clinic (CLOC) time, the number of hours spent by a physician on the EHR outside of allocated time for patient care.

Objective The objective of our study was to measure the association between CLOC metrics and validated measures of physician burnout and professional fulfillment.

Methods Physicians from adult outpatient Internal Medicine, Neurology, Dermatology, Hematology, Oncology, Rheumatology, and Endocrinology departments who logged more than 8 hours of scheduled clinic time per week and answered the annual wellness survey administered in Spring 2019 were included in the analysis.

Results We observed a statistically significant positive correlation between CLOC ratio (defined as the ratio of CLOC time to allocated time for patient care) and work exhaustion (Pearson's r = 0.14; p = 0.04), but not interpersonal disengagement, burnout, or professional fulfillment.

Conclusion The CLOC metrics are potential objective EHR activity-based markers associated with physician work exhaustion. Our results suggest that the impact of time spent on EHR, while associated with exhaustion, does not appear to be a dominant factor driving the high rates of occupational burnout in physicians.

Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, and was reviewed by Stanford University Institutional Review Board.

Publication History

Received: 01 February 2021

Accepted: 25 May 2021

Article published online:
14 July 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

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