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  1. Background Increased work through electronic health record (EHR) messaging is frequently cited as a factor of physician burnout. However, studies to date have relied on anecdotal or self-reported measures, which limit the ability to match EHR use patterns with continuous stress patterns throughout the day. Objective The aim of this study is to collect EHR use and physiologic stress data through unobtrusive means that provide objective and continuous measures, cluster distinct patterns of EHR inbox work, identify physicians’ daily physiologic stress patterns, and evaluate the association between EHR inbox work patterns and physician physiologic stress. Methods Physicians were recruited frommore »5 medical centers. Participants (N=47) were given wrist-worn devices (Garmin Vivosmart 3) with heart rate sensors to wear for 7 days. The devices measured physiological stress throughout the day based on heart rate variability (HRV). Perceived stress was also measured with self-reports through experience sampling and a one-time survey. From the EHR system logs, the time attributed to different activities was quantified. By using a clustering algorithm, distinct inbox work patterns were identified and their associated stress measures were compared. The effects of EHR use on physician stress were examined using a generalized linear mixed effects model. Results Physicians spent an average of 1.08 hours doing EHR inbox work out of an average total EHR time of 3.5 hours. Patient messages accounted for most of the inbox work time (mean 37%, SD 11%). A total of 3 patterns of inbox work emerged: inbox work mostly outside work hours, inbox work mostly during work hours, and inbox work extending after hours that were mostly contiguous to work hours. Across these 3 groups, physiologic stress patterns showed 3 periods in which stress increased: in the first hour of work, early in the afternoon, and in the evening. Physicians in group 1 had the longest average stress duration during work hours (80 out of 243 min of valid HRV data; P=.02), as measured by physiological sensors. Inbox work duration, the rate of EHR window switching (moving from one screen to another), the proportion of inbox work done outside of work hours, inbox work batching, and the day of the week were each independently associated with daily stress duration (marginal R2=15%). Individual-level random effects were significant and explained most of the variation in stress (conditional R2=98%). Conclusions This study is among the first to demonstrate associations between electronic inbox work and physiological stress. We identified 3 potentially modifiable factors associated with stress: EHR window switching, inbox work duration, and inbox work outside work hours. Organizations seeking to reduce physician stress may consider system-based changes to reduce EHR window switching or inbox work duration or the incorporation of inbox management time into work hours.« less
  2. Abstract Objectives Electronic health record systems are increasingly used to send messages to physicians, but research on physicians’ inbox use patterns is limited. This study’s aims were to (1) quantify the time primary care physicians (PCPs) spend managing inboxes; (2) describe daily patterns of inbox use; (3) investigate which types of messages consume the most time; and (4) identify factors associated with inbox work duration. Materials and Methods We analyzed 1 month of electronic inbox data for 1275 PCPs in a large medical group and linked these data with physicians’ demographic data. Results PCPs spent an average of 52 minutesmore »on inbox management on workdays, including 19 minutes (37%) outside work hours. Temporal patterns of electronic inbox use differed from other EHR functions such as charting. Patient-initiated messages (28%) and results (29%) accounted for the most inbox work time. PCPs with higher inbox work duration were more likely to be female (P < .001), have more patient encounters (P < .001), have older patients (P < .001), spend proportionally more time on patient messages (P < .001), and spend more time per message (P < .001). Compared with PCPs with the lowest duration of time on inbox work, PCPs with the highest duration had more message views per workday (200 vs 109; P < .001) and spent more time on the inbox outside work hours (30 minutes vs 9.7 minutes; P < .001). Conclusions Electronic inbox work by PCPs requires roughly an hour per workday, much of which occurs outside scheduled work hours. Interventions to assist PCPs in handling patient-initiated messages and results may help alleviate inbox workload.« less
  3. Abstract

    We describe a controlled experiment, aiming to study productivity and stress effects of email interruptions and activity interactions in the modern office. The measurement set includes multimodal data forn = 63 knowledge workers who volunteered for this experiment and were randomly assigned into four groups: (G1/G2) Batch email interruptions with/without exogenous stress. (G3/G4) Continual email interruptions with/without exogenous stress. To provide context, the experiment’s email treatments were surrounded by typical office tasks. The captured variables include physiological indicators of stress, measures of report writing quality and keystroke dynamics, as well as psychometric scores and biographic information detailing participants’ profiles. Investigations poweredmore »by this dataset are expected to lead to personalized recommendations for handling email interruptions and a deeper understanding of synergistic and antagonistic office activities. Given the centrality of email in the modern office, and the importance of office work to people’s lives and the economy, the present data have a valuable role to play.

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  4. Workplace environments are characterized by frequent interruptions that can lead to stress. However, measures of stress due to interruptions are typically obtained through self-reports, which can be affected by memory and emotional biases. In this paper, we use a thermal imaging system to obtain objective measures of stress and investigate personality differences in contexts of high and low interruptions. Since a major source of workplace interruptions is email, we studied 63 participants while multitasking in a controlled office environment with two different email contexts: managing email in batch mode or with frequent interruptions. We discovered that people who score highmore »in Neuroticism are significantly more stressed in batching environments than those low in Neuroticism. People who are more stressed finish emails faster. Last, using Linguistic Inquiry Word Count on the email text, we find that higher stressed people in multitasking environments use more anger in their emails. These findings help to disambiguate prior conflicting results on email batching and stress.« less