Stress and Burnout Related to Electronic Health Record Use among Healthcare Providers during the COVID-19 Pandemic in Saudi Arabia: A Preliminary National Randomized Survey

Healthcare providers’ burnout may potentially have a negative impact on patient care. The use of the electronic health record (EHR) increases the burden for healthcare providers (HCPs), particularly during the coronavirus disease-2019 (COVID-19) pandemic. This study assessed the stress and burnout related to the use of EHRs and health information technology (HIT) tools among HCPs during COVID-19 in Saudi Arabia. We used a self-developed survey tool. It consisted of five sections; demographics and professional data, experience using EHR, effects of EHR use, use of EHR and technology tools during COVID-19, and health and wellbeing. The survey link was emailed to a random sample of HCPs registered with a national scientific regulatory body. Univariate, bivariate, and multivariate analyses were performed to measure the association between burnout and study variables. A total of 182 participants completed the survey. 50.5% of participants reported a presence of HIT-related stress, and 40.1% reported a presence of burnout. The variables independently associated with burnout were providing tertiary level of care, working with COVID-19 suspected cases, dissatisfaction with EHRs, and agreement with the statement that using EHRs added frustration to the workday. Further research that explores possible solutions is warranted to minimize burnout among HCPs, especially during infectious outbreaks.


Introduction
With the global spread of the novel coronavirus disease-2019 (COVID- 19), the use of technology to support patient care has seen a rapid rise. Technological tools were used to support patient care during the COVID-19 pandemic crisis through early detection of suspected individuals with the virus using artificial intelligence [1,2], generating big data analytics, reporting real-time data [3], and providing virtual care to patients [4]. The use of electronic health records (EHRs) to support patient care during COVID-19 has also been a focus of many healthcare organizations [5]. The EHR effectively handled COVID-19 by including standardized triage systems, enhancing ordering tools, securing communication tools, automating reporting and analysis, and providing telemedicine consultations, and patient portal services [5].
Despite the advantages of using EHRs in healthcare organizations as a tool to manage the COVID-19 outbreak [5], many healthcare providers (HCPs) reported an increased burden, burnout, and work dissatisfaction related to using EHR systems [6,7]. COVID-19 level of HCPs' burnout from using the EHRs, we are unable to understand the underlying reasons for HCPs' burnout, improve the system features, and enhance supporting policies. While some studies measured the effective use of other technology tools during COVID-19 [21,23,26], to our knowledge, no study has assessed the burden related to the use of EHRs and other HIT tools during the COVID-19 pandemic among HCPs in our region. Therefore, our aim was to assess stress and burnout related to the use of EHRs and other HIT tools among HCPs during COVID-19 in Saudi Arabia.

Survey Development
We used a self-developed survey instrument that was constructed based on reviewing several studies related to burnout, EHRs, and COVID-19 [9,18,20,[28][29][30]. Before distributing the survey, we conducted a pilot study [31] by asking 37 HCPs, representing different specialties, to review the instrument and test the feasibility of the study. Based on the feedback received, a few wording issues and answer options were modified. The final survey instrument consisted of five sections with a total of 35 questions: (1) demographics and professional data, (2) experience using EHR systems, (3) effects of EHR use, (4) use of EHRs features and technology tools during COVID-19, and (5) health and wellbeing (Appendix A). The questions were developed in several formats: closed-ended, 5-point Likert scale, and binary "yes" and "no" questions. Section five that measured HIT-related stress included three questions (sufficiency of time for documentation at work, the amount of time spent using the EHR remotely at home, and does the use of EHR add frustration) used by Haskell J, et al. [18] to measure HIT-related stress adapted from the Mini z Burnout Survey [28]. Section 5 also measured self-perception of burnout using a single reliable item developed by Schmoldt et al. [29] and validated among HCPs [30], which consisted of a 5-point Likert scale identifying symptoms of burnout among participants. To identify if the burnout resulting from EHR use has increased during the pandemic, we asked the participants about their perceptions of burnout (Appendix A).

Survey Distribution
We used the SCFHS email database to distribute the survey [16]. The survey invitation including the purpose of the study with a link to the web-based survey was emailed to a random sample of 10,000 HCPs registered at the SCFHS. Self-identifying practicing HCPs who use the EHR at their respective workplaces were eligible for the study. Our study excluded interns, medical students, and HCPs who do not use EHRs in their workplace.
The survey was open for nine months with reminder emails sent two weeks after the first invitation.
This study was approved by the Institutional Review Board at King Saud University, College of Medicine (IRB# E-3-20-4938).

Statistical Analysis
We used SPSS 19 software to produce descriptive statistics, covering demographic and professional characteristics, HIT characteristics, burnout, technology tools used during COVID-19, and participants' perception regarding burnout associated with EHR use during COVID-19. For analysis purposes and due to the close response percentages, we combined responses of 5-point Likert scales into three categories [18].
Our two main variables are burnout and HIT-related stress. We determined the presence of HIT-related stress if one or more of the following response categories were indicated: (1) agree/strongly agree that EHRs add to the frustration of the workday, (2) moderately high/excessive use of the EHR at home, and/or (3) poor/marginal time for documentation [18]. To determine burnout among our sample, participants who had <2 on the 5-point scale were defined as "do not have symptoms of burnout," while participants who had >3 on the 5-point scale were recognized as "having one or more symptoms of burnout" [18].
To measure the association between burnout and demographic, professional, and HIT characteristics among participants, we calculated odds ratio (OR) in unadjusted and adjusted logistic regression models [18,22,32]. Logistic regression is used to measure the association of one or more independent (predictor) variables with a binary dependent (outcome) variable. The strength of the association is measured by reporting OR [33]. The independent variables in our study were demographic, professional, and HIT characteristics, while the dependent variable was presence of burnout. The univariate logistic regression model includes only one predictor, which is reported by the unadjusted OR. The multivariate logistic regression includes more than one predictor variables, which are reported by the adjusted ORs. We only presented the significant variables found in the unadjusted simple logistic regression model for the multivariate regression model. The significance level was assessed at 0.05.

Results
A total of 182 participants completed the survey. We could not calculate the response rate due to our inability to determine which emails were up-to-date and delivered to the inboxes of HCPs. More than half of the participants were younger than 45 years, male, married, and non-Saudi (  4 2.34 (3.351) Years of using EHR 4 6.10 (4.422) When asked about the level of satisfaction with EHR, 107 (58.8%) participants were either satisfied or very satisfied. A total of 151 out of 182 (83%) participants indicated that in general they did not have access to the EHR from home prior to the COVID-19 pandemic. Among those with access to the EHR from home, 20 out of 31 (64.5%) participants indicated an opportunity to work from home. Regarding the impact of EHR on workflow, more than 60% of participants either agreed or strongly agreed that EHR systems improve communication, enhance patients care and improve patient safety. Furthermore, more than 50% of the participants felt that EHR systems improve their job satisfaction and clinical workflow ( Table 2). Regarding the use of technology during the COVID-19 pandemic, 130 (70%) of participants used e-prescription, followed by the use of messaging communication tools 112 (61.5%). The least electronic feature used by participants was the EHR remote access 59 (32.4%) ( Figure 1).
A total of 110 (60%) of participants agreed that using shared computer peripheral devices causes fear in becoming infected with the COVID-19, while 94 (51.6%) of participants slightly or moderately reported that the burnout they experience from the use of EHRs and its associated features has increased due to the COVID-19 pandemic ( Figure 2). more than 60% of participants either agreed or strongly agreed that EHR systems improve communication, enhance patients care and improve patient safety. Furthermore, more than 50% of the participants felt that EHR systems improve their job satisfaction and clinical workflow ( Table 2). Regarding the use of technology during the COVID-19 pandemic, 130 (70%) of participants used e-prescription, followed by the use of messaging communication tools 112 (61.5%). The least electronic feature used by participants was the EHR remote access 59 (32.4%) (Figure 1).  A total of 110 (60%) of participants agreed that using shared computer peripheral devices causes fear in becoming infected with the COVID-19, while 94 (51.6%) of participants slightly or moderately reported that the burnout they experience from the use of EHRs and its associated features has increased due to the COVID-19 pandemic (Figure 2). In regard to HIT-related stress, 92 (50.5%) of participants reported the presence of HIT-related stress. When participants were asked to determine which measures specifically contributed to HIT-related stress, 62 (34.1%) of participants either agreed or strongly agreed that using the EHR adds frustration to their day. A total of 136 (74.7%) participants reported their proficiency in EHR use as satisfactory or good ( Table 2). Due to the low number of physicians among each specialty, we did not report HIT-related stress measures based on physicians' specialty.
Regarding burnout, 73 (40.1%) of participants reported the presence of burnout, with 37 (50%) identifying as physicians. (Table 3). In the unadjusted model, the following seven variables were significantly associated with the presence of burnout: female gender, tertiary level of care, physician as a health care profession, working with both suspected and confirmed COVID-19 cases, neither In regard to HIT-related stress, 92 (50.5%) of participants reported the presence of HIT-related stress. When participants were asked to determine which measures specifically contributed to HIT-related stress, 62 (34.1%) of participants either agreed or strongly agreed that using the EHR adds frustration to their day. A total of 136 (74.7%) participants reported their proficiency in EHR use as satisfactory or good (Table 2). Due to the low number of physicians among each specialty, we did not report HIT-related stress measures based on physicians' specialty.
Regarding burnout, 73 (40.1%) of participants reported the presence of burnout, with 37 (50%) identifying as physicians. (Table 3). In the unadjusted model, the following seven variables were significantly associated with the presence of burnout: female gender, tertiary level of care, physician as a health care profession, working with both suspected and confirmed COVID-19 cases, neither satisfied nor dissatisfied and very dissatisfied or dissatisfied with EHR, participants who think or may think that sharing computer peripherals causes fear in becoming infected with the COVID-19, and agreement about using the EHR adds frustration to daily work (Table 4). In the adjusted model, which included only variables significantly associated with burnout in the unadjusted model, the variables that remained independently associated with burnout were four variables; tertiary level of care, working with COVID-19 suspected cases, very dissatisfied or dissatisfied with EHR, and agreement with the statement that using the EHR adds frustration to the workday. Working in tertiary healthcare organizations was associated with 5.077 times the odds of burnout compared to working in primary healthcare organizations (AOR 5.077, 95% CI 1.557 to 16.550). Providing care to suspected COVID-19 cases was associated with 4.059 times the odds of burnout compared to pro-Healthcare 2021, 9, 1367 9 of 18 viding care to non-COVID-19 cases (AOR 4.059, 95% CI 1.592 to 10.345). Dissatisfaction with EHR was associated with 3.245 times the odds of burnout (AOR 3.245, 95% CI 1.252 to 8.414). Lastly, agreeing that the EHR adds to daily frustration was associated with higher odds of burnout than neither agreement nor disagreement and disagreement with the statement (AOR 5.569, 95% CI 2.159 to 14.366) ( Table 4).

Discussion
Our objective was to measure the presence of stress and burnout among HCPs from using EHRs and HIT tools during the COVID-19 pandemic. It is critical to develop methods to measure and report levels of stress and burnout from using EHR systems on a national level, representing different healthcare sectors in the country. Our findings demonstrated variability in the demographics of our participants and their reported levels of stress and burnout. Our study is relevant to the current global effects of the pandemic on HCPs and their daily use of technology in providing patient care within the Saudi context. Results from our study add to a growing body of evidence calling for a focus on measuring the effects of technology used by HCPs and its impact on stress and burnout [18,22,34,35].
Although overall satisfaction with EHRs among our participants was relatively high, HIT-related stress and burnout reports were found. Half of our participants reported HITrelated stress, with slightly half reporting burnout. These results were consistent with what has been reported previously by other researchers [18,19,22,36]. In addition, more than half moderately reported that the burnout they experience from EHRs and their associated features has increased due to the COVID-19 pandemic. Several predictors were associated with HCPs' burnout. In particular, participants who provided care to suspected COVID-19 patients, and providing tertiary level of care. Furthermore, our study identified several predictors related to EHR, which contribute to increased odds of burnout; dissatisfaction with EHR, and feeling that EHRs add to daily frustration. Thus, HCPs who were not satisfied with EHRs were more likely to experience burnout compared to HCPs who were satisfied with EHRs. Similarly, HCPs who felt that EHRs add to daily frustration were more likely to experience burnout compared with HCPs who did not report frustration.
During the COVID-19 pandemic, many participants believed that the use of EHRs adds frustration to their daily tasks, which increases their burnout [37]. Most participants reported a higher tendency of using e-prescriptions followed by messaging communication tools such as SMS or WhatsApp. While working on e-prescriptions was found to be time-consuming [38], it is essential to develop EHR tasks, which support clinical processes and automation, such as the use of machine learning and artificial intelligence [38]. Providing EHR customization and one-to-one training sessions are examples of suggested strategies to improve reported burnout among HCPs using EHR tools [22,39,40]. While using the EHR remote access feature was not common among our participants before the pandemic, accessing EHRs remotely has been increased during the pandemic. Indeed, the number of HCPs working from home has increased with the pandemic. Their work from home involved several duties such as providing virtual consultations and clinical advice, conducting virtual triage, and providing virtual prescriptions [41].
Safety concerns about the fear of the spread of COVID-19 were linked to burnout among participants. More than half of the participants were concerned when dealing with shared devices, e.g., computers and tablets, within the hospital during COVID-19. In addition, caring for suspected COVID-19 cases was associated with higher burnout rates among participants than providing care to non-COVID-19 cases. This reflects that participants were concerned about themselves and their families' safety [36], which was in line with studies reporting fear of being infected was a leading risk factor of anxiety and depression in the workplace [42,43]. These safety concerns need to be addressed to decrease burnout experience among HCPs by providing a safe hospital environment, safety training, and developing up-to-date safety guidelines and protocols [36]. These solutions might help decrease the chances of burnout due to safety concerns but may not necessarily work for all HCPs [43]. As the pandemic evolved, healthcare institutions need to develop an integrated psychological response for HCPs with the occupational and psychological challenge of MERS-CoV outbreaks, especially that anxiety over COVID-19 may increase during the pandemic [44][45][46]. It is vital that healthcare facilities provide more monitoring for burnout and enhance emotional and psychological support for all HCPs [47].
Working in a tertiary healthcare organization was associated with more burnout as compared to working in a primary healthcare organization. This may be due to the type of patients seen at tertiary healthcare organizations, i.e., more specialized, and more complicated cases. Such factors should be considered by tertiary hospitals administration to improve HCPs' wellbeing. Several interventions to decrease burnout might be used during this pandemic, such as increasing medical resources, recruiting additional HCPs, benefiting from telemedicine, and reducing excessive working hours [48].
The stress and burnout were measurable and prevalent among our participants. Specifically, physicians working with EHRs in our sample reported levels of HIT-related stress, particularly those reporting frustration with the use of EHR. Despite that, previous studies showed variations across medical specialties regarding the presence of HIT-related stress. Our findings may not be able to reflect the actual differences in specialty due to the limited number of participants. It is worth exploring the relationship between specialty and burnout on a larger sample to compare the results with other reports, which measured the levels of stress and burnout among specialists during COVID-19, such as the Medscape National Physician Burnout & Suicide Report 2021 [49].
Future studies to explore the HCPs' burnout and HIT-related stress during the evolving COVID-19 pandemic are warranted. Other research should also examine strategically possible coping solutions that might reduce burnout and HIT-related stress by focusing on enhancing EHRs satisfaction.
Three issues may affect the generalizability of our study. First, we relied on only one distribution method, SCFHS's email database, to distribute the survey nationally. Although we used different approaches to increase responses, e.g., sending two reminders to HCPs and allowing responses to be anonymous, the responses to our survey were still low. Distributing the survey was at the peak of the pandemic in Saudi Arabia [13] with a long data collection period, which may also be related to inadequate responses among HCPs. Other methods such as social media announcements need to be employed to increase participation in future research. Second, we used one method to capture the perceived stress and burnout related to the use of EHRs during the COVID-19 pandemic as reported by our participants. Other additional methods for measuring stress and burnout related to the use of EHRs, e.g., conducting an observational study and analyzing actual EHR data, may support our study's findings. Lastly, most of our participants were physicians. Their experiences may not be generalizable to other HCPs. Focusing on other HCPs, e.g., nurses and pharmacists, would potentially explore other dimensions.

Conclusions
Although our survey response rate was low, our study demonstrated that HIT-related stress, especially the feeling that the use of EHRs adds frustration to the daily work, was a predictor for burnout among HCPs. Working in tertiary hospitals and working with COVID-19-suspected cases were also predictive factors of burnout. Further research that explores possible solutions is warranted to minimize stress and burnout among HCPs, especially during the infectious disease outbreak. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Not applicable.

Acknowledgments:
The authors would like to thank Saudi Commission for Health Specialties for facilitating the data collection process. The authors thank King Saud University for their technical and scientific support.

Conflicts of Interest:
The authors declare no conflict of interest.

Appendix A. The Distributed Survey
Dear Participant, The purpose of this online survey is to learn how healthcare practitioners perceive the use of electronic health records (EHRs) and other technological tools and their impact on stress during the COVID 19 pandemic. This study is approved by King Saud University College of Medicine IRB (Project No. E-3-20-4938). The targeted sample is healthcare practitioners who use EHR and provide direct patient care. It will take approximately 10-15 min to answer this survey.
Your answers are confidential, surveys will be de-identified, and results will only be reported as aggregate data. Please feel free to contact the principle investigator, email: jalmulhem@ksu.edu.sa to answer your questions. If you are willing to participate in this online survey, please click "Next" to begin.