Investigating the impact of electronic health records on the wellbeing of physicians: a qualitative study in Canada

Introduction

Background

Electronic health records (EHRs) are comprehensive systems that collect patient health information from various healthcare settings, including primary care, hospitals, and other public and private medical facilities that a patient has visited (1). Many healthcare organizations are concerned about the impact of EHRs on the wellbeing of physicians (2). On one hand, physicians who are content with EHR systems are more likely to feel fulfilled in their roles and report higher levels of job satisfaction (3). EHRs can also improve communication and coordination among healthcare providers by allowing real-time access to patient records, thereby lowering stress levels in the workplace (4). Furthermore, EHRs give physicians more flexibility in managing their schedules by providing remote access to patient records (5,6). On the other hand, EHRs have been linked to physician burnout (7-13), with multiple studies identifying them as a primary cause of increased stress and burnout (10).

In addition to the EHRs, other factors can affect the wellbeing of physicians. In an effort to better understand health workforce wellbeing, numerous wellbeing frameworks have been developed. The National Health Service (NHS) health and wellbeing framework offers a comprehensive structure for understanding factors that influence physician wellbeing. This model, created in 2021, introduces seven health and wellbeing domains and sixteen elements within these domains that are related to the wellbeing of the healthcare workforce (14). The United States (US) National Academy of Medicine framework identifies factors that overlap with the NHS framework, such as professional relationships, time pressure and encroachment on personal time and organizational culture. However, the US framework also highlights additional factors not explicitly emphasized in the NHS framework, such as time patient-related factors and administrative burden (15).

In this study, we selected the NHS framework because many of its dimensions are reflective of the Canadian context. Although healthcare systems in Canada and the United Kingdom (UK) might have some structural differences, both operate publicly funded healthcare systems and face similar challenges, including workforce shortages (16,17), heavy workloads (18,19), and EHR interoperability issues (20,21). These challenges affect physician wellbeing in comparable ways. Findings from the Canadian Medical Association’s (CMA) 2021 National Physician Health Survey (NPHS) support this alignment. The national survey identified important aspects of wellbeing including personal health, relationships, fulfilment at work, leadership, work environment, and access to professional support, that closely align with the NHS framework (22).

Rationale and knowledge gap

ConnectCare^®, an EHR system in Alberta, Canada, based on an EPIC Systems platform, integrates data from all healthcare facilities that are managed by a healthcare organization (23). The launch of ConnectCare in 2019 represented a substantial change in the workflow for physicians. To the best of our knowledge, no study has examined the impact of this roll-out on the wellbeing of physicians.

Objective

This research aims to fill this gap by utilizing the NHS framework to investigate how the introduction of ConnectCare has affected various domains of wellbeing. We present this article in accordance with the SRQR reporting checklist (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-58/rc) (24).

Methods

Design

In this study, a qualitative research approach was employed. Qualitative research involves the collection and analysis of participants’ experiences, perceptions, and behaviors, providing insights into real-world issues (25).

Study setting

The study setting was an academic quaternary teaching hospital that provided a wide range of diagnostic and treatment services to both inpatients and outpatients, treating over 700,000 patients annually, with 885 beds and 221 physicians (1,26,27). It was selected as the first site in Alberta for the launch of ConnectCare in 2019.

Sample and recruitment strategy

Using convenience sampling, one of the study team members (R.P.P.) sent an invitation email to potential participants explaining the study. Eleven physicians from various specialties, including hematology, neurology, nephrology, dermatology, gastroenterology, general internal medicine, and pulmonary medicine agreed to participate in this study. This sample was intended to reflect the general sentiments of specialists and not to explore in depth physicians’ experiences. Our participant selection focused on physicians who had agreed to participate in a previous study involving ConnectCare usage data (28). We specifically included physicians who follow up with patients over the long term and therefore use the EHR to monitor patients (chronic disease management). Emergency physicians and surgeons who typically do not engage in this type of interaction, were not included. Primary care physicians were also not included as they do not use ConnectCare in the jurisdiction where the study was conducted. Table 1 shows the demographic information of these physicians.

Data collection

A pre-focus group with five physicians was conducted on January 29^th, 2024, prior to the focus groups using the same set of questions to ensure clarity and appropriateness. This session was run in the same format as the focus groups. Two in-person focus group sessions were held on March 20^th and 21^st, 2024, with each session lasting 1 hour. A focus group guide, developed based on the NHS framework, was used to facilitate the sessions. Notes and reflections were documented immediately after each focus group. Both focus groups were recorded and transcribed verbatim. The transcripts were then reviewed for accuracy and uploaded into NVivo 14 for analysis. Participants were anonymized, and we used the code ‘FMD’, in which ‘F’ indicates the focus group and ‘MD’ indicates the participant. Across the two main focus groups, participants raised similar points to the pre-focus group, and no new themes emerged, suggesting that thematic saturation had been reached.

Data analysis

The focus group transcripts were analyzed using inductive thematic analysis, following the six-step approach of Braun and Clarke (29). Over several meetings with the research team, themes and sub-themes were reviewed, revised and finalized through an iterative process. Demographic data were analyzed descriptively to provide context for the thematic analysis.

Member checking

Study findings were sent to all participants via email, inviting them to review the results and provide feedback as a form of member checking.

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study received ethics approval from the University of Alberta’s Research Ethics Board (Study ID: Pro00136880) on December 22, 2023 and informed consent was taken from all the participants.

Results (see Table 2)

Several key themes and subthemes providing insights into EHR-related factors that affect the wellbeing of physicians were identified. For quotes supporting each theme and subtheme, see Table 3.

Theme: impact of EHRs on personal health and wellbeing

This theme is about how EHRs affect personal health and wellbeing of physicians, referring to various aspects of health such as mental and physical wellbeing.

I think ConnectCare has impacted like our overall wellbeing, and I don’t think it’s been very healthy for our wellbeing. (F1MD2).

This theme comprised four subthemes: tacit expectations of physicians, adapting to EHRs, work-life balance affected by EHRs, and workload affected by EHRs.

Subtheme: tacit expectations of physicians for constant availability

Tacit expectations refer to the implicit and unspoken demands placed on physicians, particularly regarding their availability and responsiveness. Participants expressed feeling a constant obligation to be available and respond quickly to patients or the healthcare team due to the nature of ConnectCare. Since they could connect to the system through their desktops or mobile devices, there was an implied expectation that they would always be accessible to address any queries in real time or with only minimal delay.

This constant availability extended beyond regular working hours, into after-hours or in the middle of the night, adding to the stress of not responding within minutes and making it harder for participants to unwind and rest. The secure chat feature, while useful, also contributed to the expectation of constant availability.

Subtheme: adapting to EHRs

Adapting to EHRs is about the process of learning and becoming comfortable with the new EHR, and then effectively incorporating it into daily clinical practice. The majority of participants found adapting to ConnectCare challenging, as it introduced a new layer of stress and required considerable effort to learn and integrate it into their well-established existing workflow. They shared a range of experiences and challenges during this transition, mentioning that the learning curve for even perceived simple tasks was steep and time-consuming. The initial phase of implementation was particularly stressful for users because they perceived to have had inadequate training. The continuous updates and changes in the user interface and functionality further complicated the adaptation process, requiring ongoing learning. Despite these challenges, some physicians managed to adapt over time and even appreciated the system. However, it was noted that older physicians might have a harder time adjusting to EHRs.

Subtheme: work-life balance affected by EHRs

This subtheme is about the impact of EHRs on the work-life balance of physicians and their ability to separate professional life from personal life. Physicians mentioned the need to complete extensive documentation and respond to numerous inbox messages in ConnectCare. Since they often did not have enough time in the hospital to complete tasks related to ConnectCare, some of them were using their personal time at home to compensate. However, younger physicians with school-aged children appreciated the ability to work from home, enabling them to complete their EHR tasks while also being able to spend time with their families, which was seen as helpful for their work-life balance. It was also noted that clinicians can receive disruptive messages from the system even on nights when they are not on call, affecting their sleep.

Subtheme: workload affected by EHRs

This subtheme is about the impact of EHRs on increasing the workload of physicians. The focus group participants noted various ways in which ConnectCare had increased their workload, from the large number of inbox messages and cumbersome documentation processes to the integration of administrative tasks that were previously managed by clerical staff. They mentioned that this process was more time-consuming than traditional paper-based methods because it now involves navigating complex software interfaces and ensuring that all required fields are accurately filled out. This increase in workload had reduced the time left for direct patient-facing care and performing clinical duties.

These changes appeared to reduce their efficiency and increase workload-related stress among healthcare providers.

Theme: impact of EHRs on professional relationships

This theme explores how the implementation and use of EHRs have influenced relationships among healthcare professionals, as well as between professionals and patients. EHRs can both enhance and strain these relationships.

Collaboration, I think teamwork in many ways has improved because of ConnectCare. (F1MD3).

This theme comprised three subthemes: relationship with nurses, relationship with patients, and relationship with physicians.

Subtheme: relationship with nurses

This subtheme explores how the implementation of ConnectCare has affected the relationship between physicians and nurses. One of the participants reported that having access to nurses’ documentation is helpful in care coordination and another mentioned that the asynchronous messaging system facilitates interactions with the nursing team and other multidisciplinary members. Participants also reported that while ConnectCare had the potential to streamline communication, it introduced challenges that they felt strained the relationship between physicians and nurses. A prominent issue highlighted frequently was the constant and often unnecessary messaging from nurses at all hours, which made physicians feel that their time and need to disconnect from work were not being respected by their nursing colleagues. Additionally, participants noted that nurses sometimes expect quick replies, leading to misunderstandings and frustration when physicians cannot meet these expectations. This misalignment sometimes created tension, as nurses might have perceived physicians as unresponsive or uncooperative.

Subtheme: relationship with patients

This subtheme delves into how the implementation of ConnectCare has influenced the interactions and connections of physicians with their patients. Physicians found the accessibility of patient information beneficial, as it provides them with comprehensive background information before engaging with patients. This preparation enabled them to be better informed and more engaged during patient interactions. Additionally, the secure chat feature allowed physicians to communicate directly with patients.

A common concern among physicians was the increased time spent on the computer, which seemed to detract from direct patient care. Physicians expressed frustration about having to concentrate on documentation instead of engaging with patients. They noted that this emphasis on the computer had reduced the interactions with patients. It also interfered with the natural flow of patient consultations and reduced the quality time they could spend with patients.

Subtheme: relationship with physicians

This subtheme explores how the implementation of ConnectCare has influenced interactions and collaborations among physicians. Participants mentioned that ConnectCare has facilitated instant communication, and this capability has improved teamwork and collaboration, particularly in managing patient care across different locations. According to users, the ability to update patient charts in real-time and share images and patient data instantly helped keep all team members informed about changes in patient management.

Participants believed that the asynchronous nature of communication via ConnectCare was advantageous, as it allowed them to send messages without disrupting their colleagues’ ongoing activities. They particularly appreciated the secure chat function for its perceived efficiency in facilitating rapid responses. They felt that it enabled them to quickly reach out to colleagues for advice or information.

Another advantage of ConnectCare reported by participants was having access to the documentation of their colleagues in patient records. They stated that with access to the notes or treatment plans of other physicians, they could make more informed decisions. On the other hand, physicians also noted that ConnectCare has limited some direct interaction with colleagues. They found that relying solely on brief notes in the system is insufficient and sometimes they prefer direct conversations for a clearer understanding of patient care transitions. It was mentioned that a lack of face-to-face interactions with colleagues due to communication through ConnectCare sometimes created barriers to effective communication and collaboration.

Theme: information and technology (IT) support

This theme explores the various ConnectCare support services available to physicians, which are essential for ensuring users can utilize the system efficiently. It also delves into their experiences with these support services, providing insights into how well these resources meet their needs and facilitate their use of ConnectCare.

The lack of ConnectCare support is problematic. (F1MD7).

Based on the responses of participants, there are two types of support services: informal and formal.

Subtheme: informal support

Informal support refers to the assistance provided by colleagues, residents, and other team members. This type of support is based on shared experiences and knowledge of the issue. When clinicians experience problems with ConnectCare, physicians mentioned that they often seek help from their colleagues. Some of the physicians reported creating WhatsApp groups to discuss and resolve issues. Residents were also reported as a source of support.

While the experience with informal support was generally positive, it also had drawbacks. It was noted that relying on colleagues for support took time away from their primary responsibilities and affected their sense of self-efficacy.

Subtheme: formal support

Formal support refers to the structured assistance provided by designated help desks and support services specifically established for ConnectCare. This service was designed to identify problems and offer the most efficient solutions. However, participants noted that this service was primarily beneficial for minor issues, such as password changes or resetting the system when it froze. When faced with clinical problems, such as placing orders or entering therapy plans, the help desk system was reported to not be helpful. Physicians mentioned the need for formal support services to help them handle more complex and technical issues that informal support might not address adequately. The formal support system for ConnectCare appeared to be ineffective for many users, especially when immediate assistance was needed. The reliance on a ticket system that did not provide real-time help often led to delays and frustration.

Theme: software and hardware factors

The theme “Software and hardware factors” emerged as one of the concerns among physicians using ConnectCare. This theme is about various aspects of the software and hardware related to the EHR system that impact the usability and overall satisfaction of physicians.

I would say overall the thing about ConnectCare is that it’s just made everything a bit slower. (F1MD6).

Subtheme: inefficiency of software

The subtheme of “inefficiency of software” highlights three specific software issues that hinder the efficient use of ConnectCare: login time, not being user-friendly and software updates.

Sub-subtheme: login time

Login time refers to the duration it takes for a user to access a system or application after entering their login information, typically including the time from when they start the login process until they gain full access to the features of the system. Physicians stated that the login process to ConnectCare takes an excessive amount of time away from their daily work, which not only affects their ability to access the system quickly but can also contribute to burnout and overall dissatisfaction with the system. They noted that the amount of valuable time wasted daily could otherwise be spent on patient care or critical tasks. Some participants expressed a preference for more advanced and quicker login methods such as biometric or touch-based login solutions.

Sub-subtheme: not being user-friendly

Not being user-friendly means that a system or software is difficult to use, often due to complex navigation and system design, or requiring significant effort to perform basic tasks. Physicians expressed dissatisfaction with the user-friendliness of ConnectCare, describing it as cumbersome and time-consuming, complicating rather than simplifying their workflow. Several participants summarized their experiences by explicitly stating that ConnectCare is not user-friendly. The process of referring patients, consulting with other specialists and entering routine orders was challenging for them. They also stated that the prescription process had become time-consuming, and the system had generated many inaccurate alerts.

Sub-subtheme: software updates

Software updates refer to the process of making changes to software to improve its performance, fix issues, enhance security, or add new features. One of the concerns raised by physicians was ConnectCare updates. While these updates were intended to improve the functionality and performance of ConnectCare, they often came with changes that led to disruptions in workflow.

Subtheme: insufficiency of hardware

Hardware insufficiency emerged as the next subtheme within this theme, highlighting hardware factors that affect physicians’ usability of ConnectCare and access to it. Two main factors mentioned are: inadequate number of terminals and equipment malfunction.

Sub-subtheme: inadequate number of terminals

Inadequate number of terminals means that there are not enough computer stations or devices available for users to access a system, leading to delays or inefficiencies in completing tasks. Physicians highlighted the insufficient number of terminals on inpatient units, referred to as workstations on wheels (WOWs), available for accessing ConnectCare. This shortage often led to delays and added stress as healthcare providers struggled to find available workstations.

This issue was exacerbated by the poor placement and design of available workstations which further diminished usability and privacy. One physician highlighted the issue of workstations being crammed into inappropriate spaces, making dictation and private communication difficult.

Sub-subtheme: equipment malfunction

Equipment malfunction refers to a failure or improper functioning of a computer or device, which disrupts performance and impacts the usability of the device. Physicians reported numerous instances of malfunctioning equipment, such as keyboards that had been broken for extended periods, printers that created confusion and interruptions, and computers that did not work.

Physicians needed this equipment to chart on their patients and had raised the issue before, but the response they received was that there were not enough resources to replace or repair the equipment.

Theme: utilization of data

One of the themes that emerged from the thematic analysis is “utilization of data”. This theme explores the role of data collection through ConnectCare and the feedback on wellbeing data in addressing physicians’ wellbeing. The underlying meaning of this theme is that healthcare organizations can use data to craft targeted strategies and interventions that enhance the wellbeing of physicians. By analyzing data, organizations can pinpoint where their efforts should be concentrated. Participants shared their opinions about the importance of data collection, stating that:

If we’re talking about our wellness, whether we feel the organization is ready to do something or not right now, they darn well should know about it. If they don’t know about it or are not taking it seriously, they never will, unless they’re not getting the data. (F1MD3).

Within this theme, three subthemes were identified: valuation of metrics, approach to assessing wellbeing and accountability for action on wellbeing feedback.

Subtheme: valuation of metrics

The subtheme “valuation of metrics” refers to the importance of analyzing data collected through EHRs, such as the frequency and duration of usage, specific features accessed, and patterns of documentation, to provide a view of how physicians interact with the system. This subtheme explores the perceptions of physicians of the metrics collected by ConnectCare, and their relevance in assessing wellbeing. Some physicians acknowledged the potential benefits of the automatically collected data that might not be voluntarily reported (such as logging in after hours) in providing insights into wellbeing. However, some cautioned that drawing conclusions from raw data without considering individual circumstances and choices could be problematic. Two participants expressed that they intentionally opt to complete their EHR tasks later at home in order to spend time with their families and noted this as a positive aspect.

Participants also pointed out the limitations of using EHR metrics to capture the complexities of physician wellbeing, emphasizing that it’s difficult to measure wellbeing with automatic monitoring because most aspects are emotional or psychological, which a computer is not able to measure.

Subtheme: approach to assessing wellbeing

This subtheme delves into the perspectives of physicians on the potential for ConnectCare to include prompts that periodically ask users to rate their wellbeing to understand whether ConnectCare is an appropriate vehicle to gather real-time data on wellbeing directly from the users.

All participants stated that they would ignore such prompts and expressed skepticism and concern about the validity, reliability, and anonymity of the data collected through this method.

Moreover, it was mentioned that external factors unrelated to ConnectCare and the context in which the prompts appear could influence the responses, leading to inconsistent and possibly misleading data.

Subtheme: accountability for action on wellbeing feedback

Accountability for action on wellbeing feedback explores the perceptions of participants of how well the feedback regarding their wellbeing is considered by the organization and other related organizations. Although participants acknowledged the importance of assessing and monitoring wellbeing, they were skeptical about the accountability and responsiveness to this feedback. Many felt that the organization was not genuinely interested or prepared to address their concerns.

There was a consensus among participants that effective feedback mechanisms should not only collect data but also lead to tangible actions. They were more likely to trust and engage with feedback mechanisms when they believed that their concerns would lead to real, actionable changes. Some physicians acknowledged the possible role of the other organizations as advocacy groups in better representing their interests.

Theme: overall value of EHRs

The theme is about the overall perspective of participants on EHRs. To explore this, users were asked to weigh the balance of positive and negative aspects and consider whether, given the opportunity, they would prefer to return to a pre-ConnectCare era of paper charting. Despite all challenges explained in previous themes, all participants said they would stay with the current system.

Yeah, I don’t think anybody wants to go back to non-ConnectCare days. (F1MD4).

The themes identified in this study were organized into three categories: system-related, technology-related, and individual-related (Table 4). This categorization suggests where major challenges to effective EHR implementation arise.

Discussion

Key findings

This study sheds light on how ConnectCare has affected the wellbeing of physicians. Participants described feeling more stressed as they feel constant pressure to be available and respond quickly. Another challenge for physicians was adapting to new technology and managing the increased administrative burden, which disrupted work-life balance and heightened their workload. However, some participants deliberately shifted EHR tasks to after-hours, or “pajama time”, to meet personal or family needs, using it as a way to maintain flexibility and work-life balance rather than as a sign of burnout. ConnectCare has had a dual impact on relationships within the healthcare setting. On the one hand, it has facilitated teamwork and collaboration among healthcare teams. However, it has also introduced stress in relationships with nurses due to unrealistic response time expectations and a lack of clarity around communication guidelines. While ConnectCare has enabled better communication with patients through secure chat features, it has also detracted from direct patient care during face-to-face interactions. This study also revealed significant gaps in both formal and informal support systems, as well as issues with the software and hardware that contributed to inefficiency and frustration among users. There is noticeable skepticism regarding the use of ConnectCare for real-time wellbeing assessments, highlighting the need for more thoughtful and transparent approaches to measuring and addressing physician wellbeing.

Comparison with similar research

The findings from this study are comparable with previously published work. In a study of primary care physicians at Kaiser Permanente Northern California, physicians mentioned patient expectations for quick responses and the urgency felt from a full inbox as huge stressors (9). EHRs can create the impression of a 24/7 work environment for physicians with increased pressure to be immediately available for patient care at all times (2).

Adapting to ConnectCare was another source of stress for physicians in this study. According to another study, 43% of physicians thought initial EHR training which can facilitate the adaptation process was “less than adequate”, with nearly 95% believing it could be improved (30).

ConnectCare has also disrupted the work life balance of physicians and increased their workload. This problem stems from the need for documentation and management of a large volume of messages in the system. Several previous studies found that the amount of time spent on EHRs at the workplace and home was one of the most frequently identified factors contributing to clinician stress and burnout (10,31). A survey by the CMA of 3,864 practicing physicians and medical residents, showed that 49% of Canadian physicians felt the time spent on EHRs at home is excessive or moderately high (22). These factors contribute to the high levels of stress and burnout that many physicians experience (7-9). However, physicians’ preferences for performing EHR tasks at home, such as documentation, influence the relationship between after-hours EHR work and burnout and should be considered (32).

ConnectCare had both positive and negative impacts on the relationship of physicians with patients, nurses, and other physicians.

Regarding the relationship between physicians and nurses, the findings align with research indicating that EHRs have negatively impacted communication and coordination among them (33). One reason for this is excessive nursing documentation, which makes it harder for physicians to access key information and causes dissatisfaction. However, EHRs have also improved collaboration and information exchange by allowing physicians access to nurses’ documentation (34).

With respect to the relationship between physicians and patients, the finding aligns with research indicating that EHRs have improved patient health monitoring (35) and communication with patients (5), but also negatively impacted the face-to-face interaction of physicians with patients by taking valuable time away from direct patient care (9,35-37).

Among physicians, ConnectCare has enhanced teamwork and collaboration by enabling instant communication and easy access to documentation. Previous studies have also shown that EHRs can facilitate communication among physicians through tools like in-basket messaging (38) and improve access to patient health information, leading to better continuity of care (5,39). However, ConnectCare was also seen as a barrier to face-to-face interactions among physicians. One study indicated that the reduction in personal interactions due to reliance on EHR communication had a negative impact on the wellbeing of physicians (2).

Regarding IT support, evidence suggests that inadequate IT support is a significant factor contributing to clinician stress and burnout related to EHR (10). Physicians who perceived their organization’s EHR implementation, training, and support as effective were more likely to report lower levels of burnout. Additionally, having on-site EHR support has been identified as a key factor that can improve physician wellbeing and EHR satisfaction (40).

This study revealed a critical need for improvements in both the software and hardware aspects of ConnectCare to enhance physician satisfaction and efficiency. This issue has been reported in other EHRs, where the login process was found to be similarly slow and takes a considerable amount of time (41). The current design of ConnectCare was also not noted to be user-friendly. Other studies have reported that these systems are often burdened by sophisticated navigation structures, such as complex webs of windows, icons, menus, and pointers (9,10). Another study found that EHR systems are often designed around billing and administrative requirements rather than clinical workflows, which contributes to clinician stress and burnout through issues such as billing-oriented notes, interference with patient care, and excessive data entry (12). ConnectCare updates were also identified as an issue. Previous studies have shown that constant change, may lead to higher levels of stress, burnout, and decreased productivity (10,42).

This study also highlighted the perceptions of participants about the idea of utilizing embedded ConnectCare metrics (e.g., pajama time) as indicators of user wellbeing. While participants acknowledged that these metrics could provide insights into aspects like work hours within the EHRs, they believed that such metrics may not be able to capture the personal choices made to balance professional and family responsibilities. By adjusting their schedules, physicians can achieve a better balance between professional and personal responsibilities. In this sense, while EHRs can sometimes be perceived as burdensome, they also can offer a degree of flexibility and present opportunities for individuals to make choices that enhance their work-life integration.

However, some studies have used EHR metrics such as time burden (12,40,43,44) and workload (45,46) to assess the impact of EHRs on the wellbeing of physicians without considering the fact that these metrics may not represent the context and personal choices of physicians. Our study suggests that such an approach may lead to biased conclusions by ignoring physicians’ contexts and intentional decisions.

Lastly, in their broader evaluation of the value of EHRs, participants recognized that the benefit of accessing patient information outweighed the drawbacks, as this capability leads to better-informed decisions and enhances patient care. Additionally, while participants recognized the difficulties associated with the EHR, they preferred to remain with the current system instead of reverting to paper records.

Limitations

In this study, several limitations should be noted. The sample size was limited to a specific group and may not fully represent the diversity of experiences across different physician specialties and different healthcare settings. Potential for selection bias also exists, as participants in the previous study volunteered to allow their ConnectCare data to be collected and analyzed (28). The third limitation of this study was the limited number of focus groups conducted. Due to constraints in the availability of participants, only two focus groups were held, each lasting 1 hour. Although many of the themes were consistently identified across both groups, there were a few points mentioned only in the second focus group. These points could have been further validated or expanded upon if a third focus group had been conducted.

Reflexivity statement

V.S.: I have a master’s degree in health policy research, and my academic interest lies in health technologies. To mitigate personal biases, the focus group questions were developed using the NHS framework and reviewed with study committee members to ensure balanced coverage. After each session, I documented my reflections to remain aware of potential bias. During data analysis, transcripts, codes, and emerging themes were reviewed and discussed with committee members, whose feedback helped ensure that the findings were not overrepresented or influenced by my personal views.

D.M.: I am a professor of health policy and have been for 25 years. My research interests include health technology assessment and comprehensive health evidence reviews. This study was an extension of my interest in these areas and followed an earlier study funded by the Canadian Institutes of Health Research on the utilization of Alberta’s clinical information system for which I was co-PI. I had no relationship with any of the individual physicians participating in the study.

T.S.: I am a health services researcher with 20 years of experience conducting health technology assessments and health evidence reviews to inform policy decisions. My interest is in methods for assessing the value of new technologies using health quality improvement frameworks based on systems-thinking principles, such as the Institute of Medicine’s Quintuple Aim Framework. I do not have a clinical background and depend on collaborative working relationships with clinicians to ensure the work reflects some understanding of the clinical perspective. We do this through regular and frequent check-ins throughout a project.

R.P.P.: I am a professor of medicine and previous assistant dean for faculty affairs in the Office of Faculty Wellbeing. This study meshes important professional interests in clinician wellbeing and its determinants, including the implementation and utilization of electronic health records. I am also a part-time practicing clinician, so my profession and academic interests are also personal as I, and my clinical colleagues, actively engage with clinical information systems as lived experiences.

Conclusions

In conclusion, the impact of EHRs on physician wellbeing is both positive and negative and ultimately involves trade-offs. The extent to which the positive aspects outweigh the negative ones depends largely on individual experiences, the level of support, and the healthcare settings, and while the detracting features of the EHR were considerable, it is noteworthy that reverting to paper charting was not favored.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SRQR reporting checklist. Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-58/rc

Data Sharing Statement: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-58/dss

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-58/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-58/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study received ethics approval from the University of Alberta’s Research Ethics Board (Study ID: Pro00136880) on December 22, 2023 and informed consent was taken from all the participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Avdagovska M, Kuziemsky C, Koosha H, et al. Exploring the Impact of In Basket Metrics on the Adoption of a New Electronic Health Record System Among Specialists in a Tertiary Hospital in Alberta: Descriptive Study. J Med Internet Res 2024;26:e53122. [Crossref] [PubMed]
2. Tai-Seale M, Dillon EC, Yang Y, et al. Physicians' Well-Being Linked To In-Basket Messages Generated By Algorithms In Electronic Health Records. Health Aff (Millwood) 2019;38:1073-8. [Crossref] [PubMed]
3. McBride S, Alexander GL, Baernholdt M, et al. Scoping review: Positive and negative impact of technology on clinicians. Nurs Outlook 2023;71:101918. [Crossref] [PubMed]
4. Quinn M, Forman J, Harrod M, et al. Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process. Diagnosis (Berl) 2019;6:241-8. [Crossref] [PubMed]
5. King J, Patel V, Jamoom EW, et al. Clinical benefits of electronic health record use: national findings. Health Serv Res 2014;49:392-404. [Crossref] [PubMed]
6. Bouvé Communications. 7 Key Benefits of EHR Systems. 2023. Available online: https://bouve.northeastern.edu/news/7-key-benefits-of-ehr-systems/
7. Muhiyaddin R, Elfadl A, Mohamed E, et al. Electronic Health Records and Physician Burnout: A Scoping Review. Stud Health Technol Inform 2022;289:481-4. [Crossref] [PubMed]
8. Koon S. Physician Well-being and the Future of Health Information Technology. Mayo Clin Proc Innov Qual Outcomes 2021;5:753-61. [Crossref] [PubMed]
9. Budd J. Burnout Related to Electronic Health Record Use in Primary Care. J Prim Care Community Health 2023;14:21501319231166921. [Crossref] [PubMed]
10. Alobayli F, O'Connor S, Holloway A, et al. Electronic Health Record Stress and Burnout Among Clinicians in Hospital Settings: A Systematic Review. Digit Health 2023;9:20552076231220241. [Crossref] [PubMed]
11. Khairat S, Coleman C, Ottmar P, et al. Association of Electronic Health Record Use With Physician Fatigue and Efficiency. JAMA Netw Open 2020;3:e207385. [Crossref] [PubMed]
12. Kroth PJ, Morioka-Douglas N, Veres S, et al. Association of Electronic Health Record Design and Use Factors With Clinician Stress and Burnout. JAMA Netw Open 2019;2:e199609. [Crossref] [PubMed]
13. Mosquera MJ, Ward HB, Holland C, et al. Using objective clinical metrics to understand the relationship between the electronic health record and physician well-being: observational pilot study. BJPsych Open 2021;7:e174. [Crossref] [PubMed]
14. NHS. NHS health and wellbeing framework. 2021. Available online: https://www.england.nhs.uk/publication/nhs-health-and-wellbeing-framework/
15. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington (DC): National Academies Press (US); 2019.
16. Malko AV, Huckfeldt V. Physician shortage in Canada: a review of contributing factors. Glob J Health Sci 2017;9:68.
17. Buchan J, Charlesworth A, Gershlick B, et al. Rising pressure: the NHS workforce challenge. Health Foundation 2017;17.
18. information Cifh. Balancing the needs of Canadians and our health workforce. 2024. Available online: https://www.cihi.ca/en/taking-the-pulse-measuring-shared-priorities-for-canadian-health-care-2024/health-workforce-and-surgeries/balancing-the-needs-of-canadians-and-our-health
19. Hobbs FDR, Bankhead C, Mukhtar T, et al. Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007-14. Lancet 2016;387:2323-30. [Crossref] [PubMed]
20. Li E, Lounsbury O, Hasnain M, et al. Physician experiences of electronic health record interoperability and its practical impact on care delivery in the English NHS: a cross-sectional survey study. BMJ Open 2025;15:e096669. [Crossref] [PubMed]
21. Khatami A, Marcus J, Arslan F, et al. Towards a Regulatory Framework for Electronic Medical Record Interoperability in Canada. Stud Health Technol Inform 2024;312:59-63. [Crossref] [PubMed]
22. Canadian Medical Association. National Physician Health Survey reports. 2021. Available online: https://www.cma.ca/physician-wellness-hub/resources/national-physician-health-survey-reports
23. LLP EY. Review of Connect Care, Alberta Netcare and MyHealth Records. 2020. Available onlne: https://open.alberta.ca/dataset/1394ebca-9869-40d6-b5af-3c6870557f21/resource/d9558cbb-220e-4b28-a05e-3d9773d4d9ac/download/health-review-of-connect-care-alberta-netcare-myhealth-records-2020-03.pdf
24. O'Brien BC, Harris IB, Beckman TJ, et al. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med 2014;89:1245-51. [Crossref] [PubMed]
25. Tenny S, Brannan JM, Brannan GD. Qualitative Study. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.
26. Hospital UoA. 2024. Available online: https://givetouhf.ca/university-of-alberta-hospital/
27. Wikipedia. University of Alberta Hospital. 2025. Available onlne: https://en.wikipedia.org/wiki/University_of_Alberta_Hospital
28. Avdagovska M, Kuziemsky C, Koosha H, et al. Exploring the Impact of In Basket Metrics on the Adoption of a New Electronic Health Record System Among Specialists in a Tertiary Hospital in Alberta: Descriptive Study. J Med Internet Res 2024;26:e53122. [Crossref] [PubMed]
29. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology 2006;3:77-101. [Crossref] [PubMed]
30. Mohan V, Garrison C, Gold JA. Using a New Model of Electronic Health Record Training to Reduce Physician Burnout: A Plan for Action. JMIR Med Inform 2021;9:e29374. [Crossref] [PubMed]
31. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. Mayo Clin Proc 2016;91:836-48. [Crossref] [PubMed]
32. Apathy NC, Hartman-Hall H, Tran A, et al. Accounting for taste: preferences mediate the relationship between documentation time and ambulatory physician burnout. J Am Med Inform Assoc 2024;31:2246-54. [Crossref] [PubMed]
33. Munoz D, Bastian N, Ventura M. A Workflow Assessment for a Pediatric Intensive Care Unit: A Mixed-Methods Approach. IIE Annual Conference Proceedings. 2014. Available online: https://www.researchgate.net/publication/274371754_A_Workflow_Assessment_for_a_Pediatric_Intensive_Care_Unit_A_Mixed-Methods_Approach#3
34. Lloyd S, Long K, Oshni Alvandi A, et al. A National Survey of EMR Usability: Comparisons between medical and nursing professions in the hospital and primary care sectors in Australia and Finland. Int J Med Inform 2021;154:104535. [Crossref] [PubMed]
35. Tabche C, Raheem M, Alolaqi A, et al. Effect of electronic health records on doctor-patient relationship in Arabian gulf countries: a systematic review. Front Digit Health 2023;5:1252227. [Crossref] [PubMed]
36. Eberts M, Capurro D. Patient and Physician Perceptions of the Impact of Electronic Health Records on the Patient-Physician Relationship. Appl Clin Inform 2019;10:729-34. [Crossref] [PubMed]
37. Córdova González GA. Electronic health records: its effects on the doctor-patient relationship and the role of the computer in the clinical setting. Health Technol 2022;12:305-11.
38. Amano A, Brown-Johnson CG, Winget M, et al. Perspectives on the Intersection of Electronic Health Records and Health Care Team Communication, Function, and Well-being. JAMA Netw Open 2023;6:e2313178. [Crossref] [PubMed]
39. Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy 2011;4:47-55. [Crossref] [PubMed]
40. Nguyen OT, Jenkins NJ, Khanna N, et al. A systematic review of contributing factors of and solutions to electronic health record-related impacts on physician well-being. J Am Med Inform Assoc 2021;28:974-84. [Crossref] [PubMed]
41. Jeppson J. EHR Response Time & Reliability. 2022. Available online: https://klasresearch.com/archcollaborative/report/ehr-response-time-and-reliability/423
42. Sieck CJ, Pearl N, Bright TJ, et al. A qualitative study of physician perspectives on adaptation to electronic health records. BMC Med Inform Decis Mak 2020;20:25. [Crossref] [PubMed]
43. Gardner R, Cooper E, Harris D, et al. A statewide assessment of physician burnout and health information technology-related stress. J Gen Intern Med 2018;33:S102.
44. Mehta LS, Lewis SJ, Duvernoy CS, et al. Abstract 16198: Burnout and career satisfaction among cardiologists. Circulation 2017;136:A16198.
45. McPeek-Hinz E, Boazak M, Sexton JB, et al. Clinician Burnout Associated With Sex, Clinician Type, Work Culture, and Use of Electronic Health Records. JAMA Netw Open 2021;4:e215686. [Crossref] [PubMed]
46. DiAngi YT, Stevens LA, Halpern-Felsher B, et al. Electronic health record (EHR) training program identifies a new tool to quantify the EHR time burden and improves providers' perceived control over their workload in the EHR. JAMIA Open 2019;2:222-30. [Crossref] [PubMed]