Defining Documentation Burden (DocBurden) and Excessive DocBurden for All Health Professionals: A Scoping Review

Keywords

electronic health records and systems - documentation burden - excessive documentation burden - clinician documentation - burden - usability - informatics - health informatics - health care

Background and Significance

Good clinical practice requires that health professionals (HPs) record their observations, interpretations, actions, and decisions—tasks commonly referred to as documentation—in their patients' health records. However, depending on whether the effort is seen by the HP as directly related to, adding value to, or outside of patient care, the effort expended can have significant impacts on their professional experience. Electronic health record (EHR) documentation burden (DocBurden) is a key contributor to HP burnout and is associated with decreased satisfaction in clinical practice,[1] [2] [3] loss of and negative impacts on HP time,[4] [5] [6] information overload with risk of increased medical errors,[7] [8] and negative patient safety outcomes.[9] [10] [11] [12] Burnout costs are estimated at $4.6 billion for U.S. physicians annually[13] and $1,600 per nurse annually.[14] The existing scope and definitions available of DocBurden lack consistency and standardization. The development of a standardized definition will allow for consensus building and alignment among research, policy, and operational groups focused on this issue and in turn enable the development of rigorous, reproducible, and meaningful measures to understand, trend, and evaluate the impact of interventions on DocBurden. In this paper, we are deliberate in defining HPs broadly as including but not limited to physicians, registered nurses, advanced practice providers, therapists, medical assistants, and any other interdisciplinary members of the clinical team that contribute to the delivery of patient care.

DocBurden and burnout have been associated together,[15] [16] [17] but impact and linkage between the two is not well quantified or measured.[18] [19] [20] [21] [22] Estimated rates and associated costs of DocBurden are also unknown, in part, due to a lack of explicit agreement within the scientific and health care communities on the definition of DocBurden and what would be considered unnecessarily heavy. DocBurden has been described and cited as having six contributory domains: reimbursement, regulatory, quality, usability, interoperability/standards, and self-imposed.[23] Through the work of the NLM-funded 25 × 5 Symposium and now with the American Medical Informatics Association (AMIA) 25 × 5 Task Force, we confirmed the American Nursing Informatics Association (ANIA)'s Six Domains of Burden Framework[23] (henceforth referred to as the ANIA Framework) framework applies to all health professions.[22] [24] [25] [26] [27] The ANIA Framework highlighted areas in need of further research, evaluation, and solutions to address that domain's contribution to DocBurden, each established as a domain in the framework.[23]

The breadth of clinical care settings and variety of individual HP experiences have impacted how DocBurden has been defined to date. Several national efforts are addressing the problem of DocBurden, including priorities to improve health worker well-being.[17] [28] [29] [30] AMIA 25 × 5 Task Force to Reduce Documentation Burden to 25% of current state,[22] [26] [27] [31] and the National Burden Reduction Collaborative,[32] note a common emergent theme across these efforts is a call for a definition of DocBurden that supports unified future policy, research, and regulatory efforts to support cross-organizational sharing and comparison of efforts.

Objective

In this study we aimed to: (1) conduct a scoping review[33] [34] to identify existing varying definitions and descriptions of DocBurden in the existing scholarly and gray literature, (2) perform a concept clarification[35] of DocBurden based on the scoping review results and in the context of the ANIA Six Domains of Burden Framework, and (3) develop and propose a standardized definition of DocBurden, and emergent-related terms, for HPs across all care settings to guide and align policy, research, and operational efforts to reduce excessive DocBurden.

Materials and Methods

A scoping review and concept clarification were the two primary methods used to systematically conduct this work. We followed three major steps: (1) conduct a scoping literature review to identify sources that use and/or define the concept of DocBurden and the related terms of “documentation,” “burden,” and “excessive burden,” “documentation burden,” and “excessive documentation burden”; then, extract key study characteristics, and definitions and descriptions of DocBurden from included sources in scoping corpus. (2) Identify an organizing framework and apply the concept clarification methodology in contextualizing the ANIA Framework within the literature and mapping the included sources to the six domains of burden. (3) Synthesize the corpus definitions into standardized definitions of documentation, burden, DocBurden, and excessive DocBurden. The approach created two opportunities in the analyses where novel concepts could be identified with reference to the ANIA Framework (i.e., through the analysis and synthesis of the definitions and descriptions of DocBurden; during the concept clarification while reviewing the analysis with the subject matter expert coauthors).

Scoping Review: Design and Search Strategy

We applied approaches from the Johanna Briggs Institute Manual for Evidence Synthesis of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extensions for Scoping Review (PRISMA-ScR) ([Supplementary Appendix A1], available in online version only).[33] [34] [36] Six databases, including PubMed, CINAHL, Scopus, Web of Science, Cochrane Database, and Google Scholar[37] were searched for scholarly, peer-reviewed journal articles and gray literature[37] (i.e., editorials, conference proceedings, power point slides, dissertations; [Table 1]). Dates did not delimit the search (resultant dates ranged from 1977 to 2023). The authors (J.B.W., D.R.L.) designed the search and consulted with a health sciences librarian to review objectives and the corresponding search strategy. The search included a mix of key terms related to documentation, types of clinicians, and burden or alternative terms that might be applied. The two searches (narrow and broad strategies) were conducted in July 2023 and yielded a combined 940 citation results ([Table 1]).

Table 1 Search strategies for scoping review

PubMed
Narrow	documentation burden AND “electronic health records” Filters: Meta- Analysis, Review, Systematic Review
Broad	“documentation burden” OR “burden of documentation,” no filters
Cochrane Database of Systematic Reviews
Narrow	documentation AND burden AND “electronic health record” in Title Abstract Keyword - (Word variations have been searched)
Broad	“documentation burden” OR “burden of documentation,” no filters
Web of Science
Narrow	documentation AND burden AND “electronic health record” (Topic) and Review Article or Meta Analysis or Systematic Review (Publication Type)
Broad	“documentation burden” (All Fields) OR “burden of documentation” (All Fields)
CINAHL Complete
Narrow	documentation AND burden AND “electronic health records”
Broad	“documentation burden” OR “burden of documentation,” no filters
Google Scholar
Narrow	“documentation burden” AND definition AND “electronic health records,” excludes citations and patents, sorted by relevance, sorted by Review Articles only
Broad	“documentation burden” OR “burden of documentation,” dates: 2013–2023
Scopus
Narrow	TITLE-ABS-KEY (documentation AND burden AND electronic AND health AND records) AND (LIMIT-TO (DOCTYPE, “re”) OR LIMIT-TO (DOCTYPE , “cp”) OR LIMIT-TO (DOCTYPE, “le”) OR LIMIT-TO (DOCTYPE, “no”) OR LIMIT-TO (DOCTYPE, “ch”) OR LIMIT-TO (DOCTYPE, “ed”) OR LIMIT-TO (DOCTYPE, “sh”))
Broad	TITLE-ABS-KEY (“documentation burden” OR “burden of documentation”)

Source: The authors developed and conducted this search and screening strategy by examining the literature to identify sources that either define or describe DocBurden.

Notes: Search conducted July 2023. These narrow and broad searches were combined, and duplicates were removed, prior to title and abstract screening. The rationale for the dual narrow and broad search approach was intended to be more comprehensive and inclusive.

Scoping Review: Study Selection, Eligibility Criteria, and Data Extraction

We used the Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia), to store, screen, and manage the review and results abstraction processes for articles retrieved from the six database searches ([Fig. 1]). A priori inclusion and exclusion criteria were established ([Table 2]).

Fig. 1 PRISMA diagram. Source: The authors analysis of the literature extracted during the Scoping Review sequential identification, screening, and inclusion of Database search results. Alt text: A flow diagram showing the numbers of sources from each database identified by the initial search, and then the steps taken shown in separate boxes at each stage of exclusion during the Scoping Review process, to reach the final 153 studies included in the extraction corpus.

Table 2 Title and abstract review criteria, screening inclusion and exclusion criteria

Title and abstract review criteria
Inclusion	Exclusion
• Articles impacting documentation for the clinician  • Medical literature or articles related to health care  • Articles that examine methods or interventions that impact documentation length or burden (e.g., scribes, speech recognition, AI)  • Documentation burden includes consumption and generation (e.g., synthesis, authoring, review, analysis of clinical data)  • Articles that discuss usability and its factors  • Articles specific to COVID-19 and documentation practices at that time (policy and standards changed to streamline documentation at that time)	• Articles that are focused exclusively on clinical outcomes (e.g., smoking cessation)  • Training articles about the task/workflow of documenting (e.g., student nurses, med students on completion metrics, adhering to regulatory guidelines)  • Articles on patient safety outcomes that do not connect through documentation burden role or mechanism  • Articles not available in English
Full-text review criteria
Inclusion	Exclusion
• Context is related to health care AND one of the below:  • There is an actual definition of documentation burden  • There is a description of documentation burden  • Reference to seminal documentation burden citation	• Documentation burden is not related to health care  • No description and/or definition of DocBurden  • Single mention in abstract only to DocBurden  • There is no reference or citation to other work about DocBurden  • Describing or defining an adjacent concept such as burnout, compassion fatigue, etc.  • Full text is unavailable or not available in English

Source: The authors developed and conducted this screening strategy by examining the literature identified in the 6-database search, to identify sources that either define or describe DocBurden.

We identified definitions as sources that stated how they defined DocBurden, where description citations provided uses of or some characteristics of the term without offering a definition. All reviewers met as a team to do an initial walk through of the screening process, review of the inclusion and exclusion criteria, and the method to approach using Covidence software. Any discrepancies during that process were iteratively discussed, and then individual screening commenced. At least two reviewers (B.D., C.D., M.G., D.R.L., R.L., or J.B.W.) independently evaluated the titles and abstracts for inclusion and exclusion criteria. Discrepancies were resolved by consensus. At least two reviewers then independently screened each full-text article. A final corpus of 153 full-text articles were extracted for definitions, descriptions, and an a priori set of study characteristics ([Supplementary Appendices A2], [A3], available in online version only).[36] Data were extracted by one reviewer (C.D., M.G., R.L. or J.B.W.) and verified by another (D.R.L. or J.B.W.). Once the extractions were complete, results were exported from Covidence for analysis.

Identify Framework and Concept Clarification

A concept clarification involves choosing, examining, and integrating existing definitions and descriptions of a concept and synthesizes them into one comprehensive definition through critical thinking. This method is appropriate when a framework offers key insights, but further adaptation is needed.[35] Specifically, we examined how the DocBurden literature fits within the ANIA Framework, or the “Six Domains of Burden: A Conceptual Framework to Address the Burden of Documentation in the Electronic Health Record.”[23]

The same authors who performed the scoping review screening and extraction reconvened to examine each of the included sources and identify themes and domains of burden from within each source in the corpus as they applied to the ANIA Framework ([Supplementary Appendix A3], available in online version only).[36] We cross-walked each of the 153 included sources from our scoping review with the six domains of DocBurden ([Fig. 2]). Coauthors (P.S., K.C., K.J., J.A.M., D.E.D., J.J.C., S.C., A.J.M., J.M., R.G.M., S.C.R., S.T.R.) with expertise in research (8), policy (3), and operational (3) and clinical informatics (5) domains related to DocBurden, provided expert review of the definitions (burden, excessive burden, documentation, DocBurden, and excessive DocBurden) and concept clarification. The emergent specification of necessary DocBurden and excessive DocBurden was made during the concept clarification. The full team achieved consensus regarding the alignment of ANIA Framework domains to the literature citations.

Fig. 2 Cross-walking scoping review sources by ANIA Framework Six Domains of DocBurden and Evidence Type. Source: The authors analysis of the literature extracted as in the scoping review and concept clarification ([Supplementary Appendices A2] and [A3], available in online version only),[36] cross-walking the sources to the six domains of burden in the ANIA Framework. Notes: The six domains of burden categories are: Interoperability/standards, Quality, Regulatory, Reimbursement, Self-imposed, and Usability. The evidence (article) types are: peer-reviewed research (navy blue); peer-reviewed literature review (royal blue); peer-reviewed perspective sources (light blue); nonpeer-reviewed research perspective sources (dark maroon); abstract, conference proceedings (rust); other (peach).

Results

Our initial search of the 6 databases yielded 940 citations, which we iteratively reviewed and screened to a final corpus of 153 articles ([Fig. 1], [Supplementary Appendix A2], available in online version only)[36] eligible for inclusion. Review of those 153 articles focused on extracting definitions or descriptions of DocBurden, applicable domains of burden based on the ANIA Framework categories, and other characteristics to support the concept clarification ([Supplementary Appendix A3], available in online version only).[36]

Few (n = 28) studies had an actual definition of DocBurden ([Table 3]). Of the 28 sources with distinct definitions, 11 of the sources offered an original definition of DocBurden, whereas the remaining 17 provided a reference in support of their definition. We identified 28 distinct definitions and 125 distinct descriptions of DocBurden from the 153 articles reviewed with varying amounts of conceptual and scope overlap ([Supplementary Appendix A3], available in online version only).[36]

Table 3 Definitions of documentation burden from scoping review sources

Author (y)	Original reference (vs. cited)	Definition (page number), [ANIA Framework Domain(s)]
AHRQA1 (2022)	Yes	“Documentation burden (both documenting and reviewing documents) contributes to clinician workloads, increased cognitive load, and has been found to negatively impact the quality of patient care delivered.” [Q, U]
BaschB1 (2018)	Yes	“Two new areas of burden further exacerbate health care inefficiency, including regulatory burden associated with specific documentation for incentive and/or quality programs, and what can be called “EHR burden”—burden resulting from poor design and usability, suboptimal implementation, and inadequate training.” (p. 914), [REG, REIM]
BosekB2 (2022)	Yes	“Documentation burden occurs when organizations use the EHR for more than documentation of care, such as billing and fulfilment of regulatory oversight.” (p. 6), [Q, REG, U]
CamilleriC1 (2022)	No	“The nurse documentation burden is nurse discontentment with documentation methods in the EMR system due to long work hours, time constraints, and patient workload linked increased possible human errors, decreased patient safety, poor documentation quality, and ultimately, nurse burnout.” (p. 172), [REIM, Q]
CohenC2 (2019)	Yes	“We defined burden for respondents as “work that does not add value.” (p. 15), [Q, REG, U]
CollinsC3 (2018)	Yes	“…our team sought to utilize log-file analyses to understand, quantify, and visualize the problem of documentation burden for a specific use case: nurses' flowsheet data entries in acute and critical care units.” (p. 349), [IS, Q, U]
EbbersE1 (2022)	No	“The findings of these studies suggest that not only the amount of time spent on the EHR is relevant for the experienced documentation burden, but also the actual effort put in by the healthcare professional is an important factor, which is also stated in a recent scoping review by Moy et al…” (p. 858), [Q, REG, REIM, U]
ElkindE2 (2022)	No	“Frontline nurses describe documentation burden as barriers to the patient and family experience, efficacy, and nurse well-being.” (p. 5), [IS, Q]
GesnerG1 (2021)	No	“Documentation burden is defined as the demand to document specific aspects of patient care as stipulated by policies implemented at the local, federal and state levels.” (p. 2), Q, REG, SI]
GesnerG2 (2022)	No	“Documentation burden is defined as the increased effort and time demand to document patient care in the EHR. For the purpose of this paper, the constructs for effort include EHR workload and usage, clinical documentation/review, and cognitively cumbersome work.” (p. 984), [REG, SI, U]
GonzalezG3 (2021)	Yes	“Documentation burden for the purpose of this project is defined as the documentation complexity leading to increased time spent on charting.” (p. 2), [U]
HarmonH1 (2020)	No	“An ever-increasing documentation requirement is known as documentation burden.” (p. 16), [IS, Q, REG, U]
HesselinkH2 (2023)	No	“The survey included reported time spent on documenting quality indicator data and validated measures for documentation burden (i.e., such documentation being unreasonable and unnecessary, [and time]) and elements of joy in work (i.e., intrinsic and extrinsic motivation, autonomy, relatedness and competence).” (p. 1), [Q]
HobensackH3 (2022)	No	“Documentation burden is the stress imposed by the excessive work required to generate clinical records of healthcare-related interactions and results from an imbalance between the usability and satisfaction of documentation systems alongside the clinical and regulatory demands of entering and consuming health record data.” (p. 440), [IS, Q, REG, REIM, SI, U]
KangK1 (2021)[62]	No	“[However], low fitness and poor alignment with user workflow are continued sources of documentation burden. In addition, increased mandatory documentation related to quality and reporting requirements by hospitals, which can cause data redundancy and documentation of content unrelated to patient care or outcomes, were additional sources of burden.” (p. 845), [Q, REG, U]
LevyL1 (2023)	Yes	“Documentation burden, defined as the excessive effort expended on healthcare documentation, is associated with a number of adverse outcomes, including clinician burnout, reduced quality of medical care, and disruption of clinical data contained in the electronic health record.” (p. 11), [IS, Q, REG, REIM, U]
MoyM1 (2021)	Yes	“…[one] type of documentation burden—workflow fragmentation…” (p. 894), [U]
MoyM2 (2021)	No	“…[they] have also contributed to EHR documentation burden among physicians—defined as added work (e.g., documentation) or actions (e.g., clicks) performed in the EHR beyond that which is required for good clinical care.” (p. 1003), [U]
MoyM3 (2023)	No	“Documentation burden is defined as “work that does not add value” (i.e., work beyond that which is required for good clinical care).” (p. 2), [IS, Q, REG, REIM, SI, U]
MoyM4 (2023)	No	Consistent with Cohen et al, we define EHR documentation burden as additional work (i.e., documentation or actions) performed in the EHR beyond that which is essential for “good” clinical care.” (p. 2), [Q, REG, REIM, U]
NguyenN1 (2023)	No	“Researchers have reported on the documentation burden (i.e., time and effort clinicians spend on documentation)…” (p. 255), [REG]
ONCO1 (2020)	Yes	“This report outlines three primary goals informed by extensive stakeholder outreach and engagement for reducing health care provider burden: (1) reduce the effort and time required to record information in EHRs for health care providers during care delivery. (2) Reduce the effort and time required to meet regulatory reporting requirements for clinicians, hospitals, and health care organizations. 3) Improve the functionality and intuitiveness (ease of use) of EHRs.” (p. 9), [IS, Q, REG, REIM, U]
PaddenP1 (2019)	No	“The increasing requests and requirements of nursing documentation have been branded burdensome, which can be thought of as a load heavier than average.” (p. 60), [IS, Q, U]
PeddieP2 (2017)	No	“We view documentation burden as the consequence of a configuration or arrangement of actors, resources, knowledge, and place.” (p. 264), [U]
RossettiR1 (2021)	Yes	“We define documentation burden as the stress imposed by the excessive work required to generate clinical records of healthcare-related interactions, occurring as a result of the imbalance between the usability and satisfaction of electronic health record (EHR) systems and clinical and regulatory demands of entering and consuming EHR data.” (p. 3), [IS, Q, REG, REIM, SI, U]
SchwartzS1 (2019)	No	“Documentation burden can be understood as a combination of many factors, including time, low usability, low satisfaction, and high cognitive spending.” (p. 1187), [U]
SuttonS2 (2020)	No	“Redundant documentation and regulatory requirements contribute to documentation burden, defined as the completion of unnecessary documentation elements in the electronic health record (EHR).” (p. 465), [Q, SI]
VoytovichV1 (2022)	Yes	“Clinicians spend a significant amount of their time charting information in electronic health records, leading to a notable documentation burden.” (p. 208), [U]

Source: The authors analysis of the sources from the scoping review that contained definitions of DocBurden and their characteristics are presented in this table.

Notes: The citation superscription (letter + number) refers to [Supplementary Appendix A2] (available in online version only) with a full list of all 153 extracted sources.[36] “Yes” = original definition offered in the source; “No” = definition referenced prior work in the source. ANIA Documentation Burden Key: (IS) interoperability and standards;(Q) quality; (REG) regulatory; (REIM) reimbursement; (SI) self-imposed; (U) usability.

Sixty-two percent of the 153 articles were peer-reviewed original research or literature reviews (n = 95), whereas 24% (n = 37) were peer-reviewed or nonpeer-reviewed perspective or editorial pieces. The remaining 14% of the sources were conference abstracts, power points slide decks, dissertations, or academic projects. [Fig. 3] shows the temporal trends in articles, with an inflection point around 2013.

Fig. 3 References by year (n = 153). Source: The authors present the number of included sources in the Scoping Review by year of publication.

Development of Standardized Definitions from Source Definitions

Using an iterative approach, we developed standard definitions based on the extracted definitions from the included scoping review sources ([Table 4]). By summarizing the conceptual similarities and differences of DocBurden definitions and descriptions, we achieved a standardized definition of DocBurden. We found commonalities between the definitions and also categorized the types of tasks that were mentioned in the included studies. We considered dictionary definitions of document,[38] documentation,[39] and burden.[40] As part of the concept clarification, we elicited feedback and refined the standardized definitions through three rounds of consensus discussion with expert coauthors ([Table 5]). One notable finding was that all descriptions of DocBurden had a negative connotation of burden, without separating or differentiating what tasks were necessary or required to carry out patient care. Terms referenced in the definitions that required additional context are defined in [Supplementary Appendix A4] (available in online version only).[41]

Table 4 Process steps of developing standardized definitions from scoping review corpus

Methods	Actions	Results/findings
Scoping review	• Develop search strategies  • Conduct search  • Extract doc burden definitions and descriptions	Scoping review synthesis yields a collection of descriptions and definitions of DocBurden
Concept clarification	• Cross-walk scoping review corpus with ANIA Six Domains of Burden Framework  • Core writing group drafts definitions distilling corpus definitions and descriptions  • Conduct three rounds of asynchronous review to refine standard definitions and scoping review findings	Draft standard definitions, including definitions for supporting relevant terms such as documentation Define emergent terms (i.e., burden, excessive DocBurden)
Present a standardized definition	• Conduct final expert coauthor round  • Develop exemplar figure of DocBurden vs. excessive DocBurden	Finalize DocBurden and excessive DocBurden definitions

Source: The steps presented align with the three objectives to use the scoping review corpus (1) of included studies' definitions and descriptions as the basis for the concept clarification (2) and cross-walking to the 6 ANIA Domains of Burden, and then to develop the standardized definitions (3). The steps during which emergent definitions arise for burden and excessive burden are also noted.

Table 5 Standardized definitions developed from source definitions[41]

Burden

Burden is defined as the load[41] (e.g., cognitive load,[41] workload,[41] or task load) experienced by an HP or health care team that is a necessary part of carrying out an activity or task[41] required for care delivery (i.e., medication administration, documenting a visit plan, writing a procedure, or operative note)

Excess burden

Excess Burden is defined as the excess or heavy load[41] (i.e., excess cognitive load, excess or stressful workload, or excess task load) experienced by an HP or health care team including, but not limited to, tasks that are not aligned in support of care delivery

Documentation

Documentation is the patient-centered collection or generation of clinical data, review of clinical data, analysis of clinical data, and synthesis of clinical data, all in support of direct patient care needs  These documentation tasks include but are not limited to the inputs and outputs necessary to support all aspects of the care and communication with the patient (e.g., the authoring of notes or flowsheets, synthesizing clinical data into diagnoses or clinical impressions, creation of care or treatment plans, and communication through the EHR[41] with patients and other HPs)

Documentation burden (DocBurden)

Expected load (see Documentation above) on HP of completing necessary tasks included in the documentation and EHR interaction

Excessive DocBurden

Excessive DocBurden is defined as the stress and unnecessarily heavy load or work (i.e., excessive burden) an HP or health care team experiences when the usability[41] of documentation systems and documentation activities (i.e., generation, review, analysis and synthesis of patient data[41]) are not aligned in support of patient care delivery

[41]Refers to terms defined in glossary file ([Supplementary Appendix A4], available in online version only)

Abbreviations: EHR, electronic health record; HP, health professional.

Source: The authors developed these standardized definitions of burden, excessive burden, documentation, documentation burden (or DocBurden), and excessive DocBurden through analysis of the scoping review corpus.

Presentation of Definitions

(Burden, Excess Burden, Documentation, DocBurden, Excess DocBurden)

Burden

We determined the following standard definition from our synthesis of the literature: Burden is defined as the load[40] [41] (e.g., cognitive load,[41] [42] workload,[41] or task load[41]) experienced by an HP or health care team that is a necessary part of carrying out an activity or task required for care delivery (i.e., medication administration, documenting a visit plan, writing a procedure or operative note). Contributors to burden may include the clinical environment, team makeup and dynamics, and individual factors (e.g., clinical expertise, training).

Excess Burden

We determined the following emergent standard definition from our synthesis of the literature: Excess Burden is defined as the excess or unnecessarily heavy load[40] [41] (i.e., excess cognitive load, excess or stressful workload, or excess task load) experienced by an HP or health care team including, but not limited to, tasks that are not aligned in support of care delivery.

Documentation

Documentation is an expected and required activity and product of patient care delivery. We observed that defining tasks included in documentation first is critical, and many sources did not offer a definition of documentation. Documentation included a range of activities from gathering information needed to care for the patient, gathering patient data itself (such as vital signs, point-of-care testing) and tasks of synthesizing,[41] and entering information into the EHR. We found that the term documentation was used as both a noun (e.g., an EHR note created for a visit as a document) and a verb (e.g., documented, documenting, and documents) in the sources reviewed.[38] [39] [41]

We determined the following standard definition from our synthesis of the literature: Documentation is the patient-centered collection or generation of clinical data, review of clinical data, analysis of clinical data, and synthesis of clinical data,[41] all in support of direct patient care needs. These documentation tasks include but are not limited to the inputs and outputs necessary to support all aspects of the care and communication with the patient (e.g., the authoring of notes or flowsheets, synthesizing clinical data into diagnoses or clinical impressions, creation of care or treatment plans, and communication through the EHR with patients and other HPs).

Documentation Burden

DocBurden is defined as the expected load (see Documentation above) on HP of completing necessary tasks included in documentation and EHR interaction. The included sources did not often differentiate between DocBurden and excessive DocBurden (defined below).

Excessive DocBurden

Based on multiple iterations with the coauthors immersed in the reviewed literature and measurement goals ([Table 4]), we arrived at the definition of excessive DocBurden that conveys the central roles of usability, a domain from the ANIA Framework, and the documentation activities themselves, in relation to the HP experience of burden when providing patient care. We determined the following emergent standard definition from our synthesis of the literature: Excessive DocBurden is defined as the stress and unnecessarily heavy load or work (i.e., excessive burden) an HP or health care team experiences when the usability[41] of documentation systems and documentation activities (i.e., generation, review, analysis, and synthesis of patient data) are not aligned in support of patient care delivery.

The majority of articles were focused on physicians only (n = 56, 37%) or nurses only (n = 44, 29%), whereas fewer articles considered all types of HPs (n = 43, 28%). We found variability related to the stakeholder perspective and HP population. Three sources from the corpus mapped solely to the ANIA reimbursement domain, whereas 45 of the 153 sources were categorized to reimbursement in combination with other domains of burden. Few studies examined interventions to mitigate burden. Some focused on the use of scribes for HP transcription (n = 18, 12%) as a potential solution. However, several research citations that focused on scribes had study outcomes such as the amount of time HPs were able to spend engaging with patients rather than the EHR, without explicit linkage to DocBurden.[43] [44] Additionally, patients were the focus of two included sources (1%).[45] [46]

The concept clarification we performed confirmed the usefulness and relevance of the taxonomy of the ANIA Framework and their suggestion that usability is at the core of all six domains of DocBurden, not just the domain specifically labeled usability.[23] We found evidence of all domains in the 153 articles; however, usability, quality, and self-imposed had the greatest number of representations. In nine sources, all six domains were discussed in the same reference. Further, we observed that many citations had more than one domain covered, and the three domains that were also most common (usability, quality, and self-imposed), often co-occurred ([Fig. 2]).

Discussion

The rapid evolution and increasing attention that DocBurden has recently received motivated this work to establish a standard definition of DocBurden.[24] Based on our initial search and review, we expanded our search and screening criteria to include articles that described or attempted to describe DocBurden and excessive DocBurden, in addition to those that provided an explicit definition.

“Burden” Connotation: Negative versus Neutral

A definition of burden was not established in the majority of sources. There was a negative connotation attached to burden and there was no neutral state identified in these sources. We reflect that this representation does not align with the dictionary definition of burden[40] and further the sources do not distinguish between the baseline or required task load that is integral to patient care and what is excessive.[47] We therefore highlight the need in future work to differentiate between the usual tasks (or burden) including documentation required for patient care delivery (i.e., medication administration,[41] procedure notes, and clinical impression[41] documentation), rounding, and transitions of care between members of the clinical team, and the excessive tasks that contribute to excessive DocBurden.[48] However, if we are imposing solutions that have poor usability[49] and excessive requirements for this necessary documentation,[50] then that can create a different situation (i.e., too many clicks to complete an order or decision support process),[51] [52] where the process of necessary documentation leads to excessive DocBurden ([Fig. 4]). We consider the need to mitigate both DocBurden and excessive DocBurden, with further work needed to understand which tasks fall into which category.[53] [54]

Fig. 4 Medication ordering and administration exemplar: burden and excessive burden. Source: The authors designed this graphic to illustrate the iterative nature of medication administration, including burden (i.e., dark blue gear) and instances of excessive burden (i.e., light blue gears). Notes: The health care professional roles noted in the dark blue gear are: PP = health professional—prescribing provider (MD, NP, PA); RN = health professional—registered nurse. The excess burden domain examples in light blue are the six domains of burden categories: IS = interoperability/standards, Q = quality, RG = regulatory, RI = reimbursement, SI = self-imposed, U = usability.

Emergent Terminology of Excessive DocBurden

We acknowledge that recognition of DocBurden is not new[55] [56] and relies on HP perceived experiences.[57] [58] However, the term excessive DocBurden is an emergent term from this work. We found that sources in the corpus often did not distinguish between the base challenge of usability in documentation that is integral to patient care (DocBurden) from unnecessary EHR tasks EHR tasks (excessive DocBurden). For example, the capture and planning of patient care and treatment activities within a patient's record are a necessary part of patient care delivery and longitudinal understanding of patient conditions.[59] By distinguishing between DocBurden and excessive DocBurden, this terminology allows for a more nuanced understanding of DocBurden, intended to describe and support the measurement of the HP experience.

There should be robust governance around which EHR documentation requirements are added to HPs' workloads. Too often, additional data collection effort is shifted to the HP, who is expected to capture the data needed for use outside of what is required for documentation of patient care delivery.[60] Our definition is inclusive of the concepts of: (1) systems that may lack appropriate usability design principles, (2) the need to define necessity in measuring documentation and differentiating between DocBurden and excessive DocBurden, and (3) activities that may inherently not be appropriate for HPs to complete.

Cross-walking to American Nursing Informatics Association Framework Domains of Burden

Usability, quality, and self-imposed domains were the top three domain topics found in the studies we analyzed. With our focus on sources exploring the HP experience of excessive DocBurden, it follows that sources in these domains presented work linked to end-users. Our finding demonstrating a focus on usability in the literature, which aligns with the ANIA Framework in suggesting that usability underlies all six domains.[23] Few sources focused solely on reimbursement, although health care is driven by financial considerations.[55] [59] [61] Future research is needed to understand the financial impacts of excessive EHR burden on quality of care, patient safety, and the HP workforce.

Role and Impact of a Standard Excessive DocBurden Definition

Creating a standard definition of excessive DocBurden also requires clarifying assumptions, language, and scope. For example, the assumed definition and scope of the term “documentation” varied across different types of HPs, care settings,[62] and investigators. We observed that in some settings, particularly those focused on physicians, documentation referred only to clinical notes, while in other settings, particularly those focused on registered nurses, documentation referred to all forms of structured and unstructured data entry and review. In the corpus, there was also a lack of consensus on whether data retrieval/review was included or excluded as part of documentation. Likewise, when considering the primary and secondary purposes of documentation, it is useful to clarify that our definition of burden explicitly addresses HP's experience in the delivery of high-value patient care. At its worst, excessive DocBurden can be a barrier to efficient HP work and teamwork, and communication between HPs and patients, which can impede providing the best care.

DocBurden has been noted to be a contributor to clinician burnout,[63] [64] and there can be a presumption of a shared understanding, or instances of conflation or interchangeable usage with research focused on burnout, wellness, and resilience.[16] [28] [65] [66] One of the barriers to the adoption of a standardized definition for excessive DocBurden has been the co-occurrence of terms and phrases used interchangeably when a different but adjacent concept is being considered,[67] such as the concepts of HP burnout,[68] or clerical or purely administrative burden.[69] We observed an anticipated inflection point in included sources around 2013, aligned with expansion of EHR implementation after the HITECH Act.[70]

The work of Johnson et al[56] offers a foundational perspective to understand the historic influences of our current state of burden and conveys the importance of a clear definition as we consider the unintended consequences of developing the EHR (e.g., adding to documentation process instead of streamlining it, resulting in excess burden).[29] [71] Returning the focus to the patient and their well-being, through the use of tools, such as clinical decision support, and those that support interoperability and usability, will inherently involve turning away from what the authors present as a focus on the “finances.”[56] Our definition of DocBurden could enable moving from what they call the “Era of Entanglement” to an active phase of mitigation but will require a rethinking of the HP experience and role in clinical care.[56]

Consideration of the Patient (and Caregiver)

We found two studies[45] [46] that considered the patient as a member of the clinical team who might be experiencing DocBurden. As impacts of information blocking legislation take effect,[31] it will be important to consider whether the patient will need to receive greater consideration when measuring and mitigating DocBurden and attend to the potential risk of shifting burden to the patient or their caregiver. Consistent with a clinical informatics vision for the EHR,[60] the primary purpose of documentation is to support the clinical care provided to patients, improve clinical decision making, and enable smooth transitions between levels of care by ensuring continuity through clear and concise communication to facilitate a shared situational awareness of the patient and conditions impacting the patient.

Limitations

Our robust and inclusive search of six available search databases occurred in July 2023; discourse regarding DocBurden is rapidly gaining attention, particularly in the gray literature. Due to our focus on identifying definitions and descriptions of DocBurden, we examined sources selected for that characteristic; sources were not examined for the rigor of the primary work other than by categorization of the type of publication. Factors that may have impacted our search include the lack of existing Medical Subject Headings terms for DocBurden, a significant amount of gray literature on this topic, and limited indexing of key words. Therefore, we conducted both a broad and narrow search ([Table 1]). Several definitions identified ([Table 3]) were linked to work produced from the clinical informatics community, including the 25 × 5 initiative,[25] [26] [27] [31] [59] [63] [72] [73] [74] and from the human–computer interaction community.[75] Further, several publications on the list had the same first author ([Table 3]), so the number of unique researchers or research teams examining DocBurden is lower than the 28 studies would suggest. Lastly, while a description was provided on how the authors approached interrater reliability for evidence screening and selection in the methods, Cohen's kappa was not calculated, which may be considered a limitation of this scoping review method and approach.[34]

Policy Implications

Agencies such as the Center for Medicare and Medicaid Services' Office of Burden Reduction and Health Informatics,[30] and the Office of the Surgeon General of the United States have both announced initiatives in support of reducing DocBurden.[28] This definition of HP excessive DocBurden is in response to a call for action from policy stakeholders, including the AMIA 25 × 5 Task Force, which is leading efforts to mitigate excessive DocBurden.[27] [31] [32] [76] Additionally, while many agencies and HP societies report concern with the impact of HP excessive DocBurden on the health care workforce,[60] few generalizable measurement options or implementable solutions are offered. To address this, the AMIA 25 × 5 Task Force submitted a topic nomination to the Agency for Healthcare Research and Quality Evidence-Based Practice Centers program in June 2022.[77] The funded Technical Brief[76] is now available, which found that few generalizable measurement approaches capture the HP experience of DocBurden.[78]

Moving Forward

This scoping review confirmed that the state of the science is currently focused on describing and reporting the need for mitigating action.[56] Approximately 21% of the articles reviewed with DocBurden definitions or descriptions were editorials or white papers. It is telling that many research articles in the DocBurden domain did not offer a description or definition.

Further, research efforts may benefit from measuring the impact of interventions while considering those affected by the interventions, with particular attention to avoiding shifting excess DocBurden between care team members. In the case of scribes, for example, studies frequently implied that DocBurden would be reduced when using scribes.[79] [80] In considering the scribe as a member of the health care team, as we do, then adding a scribe is merely shifting the DocBurden and does not reduce the overall excessive DocBurden on the interprofessional team. This example of the inherent risk of making assumptions about what mitigates excessive DocBurden supports the assertion that a standardized definition will enable alignment and reproducibility of research to achieve measurable decrements in excessive DocBurden. Further, any standardized definition may need to be revisited over time to ensure that it remains aligned with DocBurden reduction practices and advances in the field.

Conclusion

The way in which excessive DocBurden is defined and described within the health care system and related literature has real-world impacts and clinical implications, including the framing of how to measure DocBurden. A clear, standardized definition is essential for effective alignment of efforts to reduce DocBurden and excessive DocBurden, and measure progress toward this goal. Our scoping review presents an inclusive and interprofessional standardized definition of DocBurden as a basis for future studies, work, and policies and serves to increase clarity on the concept, current discourse, and recent progression of excessive DocBurden within the U.S. health system.

Clinical Relevance Statement

What is a standardized definition of excessive DocBurden to guide and align efforts to reduce burden across a variety of domains, settings, and from various stakeholder perspectives for all HPs? After reading this work, readers will understand the concept of DocBurden and excessive DocBurden based on the results of a scoping review and concept clarification. We cross-walked the scoping review corpus to the ANIA Framework Six Domains of Burden. Readers will be able to articulate a singular standardized definition of excessive DocBurden, developed from the scoping review corpus, that can be applied to all HPs.

Multiple-Choice Questions

1. After which year there was an increase in citations in the literature on the topic of DocBurden?

   • 2009

   • 1998

   • 2013

   • 2023

   Correct Answer: The correct answer is option c. We found that citations in the DocBurden body of literature increased significantly in our analyses after 2013. We show in [Fig. 3] that citations increased gradually after 2013, and there a continued steady increase in the years since. Federal legislation leading to the widespread implementation of EHR in hospitals occurred starting in 2011.[69] Some have hypothesized that these events contributed to the growing attention to and discussions of DocBurden.[59]

2. Which of the following is a domain of DocBurden, where a domain references the aspect of work in the EHR affected by burden?

   • Information technology

   • Usability

   • Cognitive load

   • Public health

   Correct Answer: The correct answer is option b. Domains of burden have been explored in the ANIA Framework of Six Domains of Burden. Domains identified include usability, which is more commonly cited, regulatory, reimbursement, quality, self-imposed, and interoperability.[23] In the scoping review, we identified that 9 of the 153 sources cited all six domains of burden, and many sources explored more than one domain in their work ([Supplementary Appendix A3], available in online version only).[36]

3. Which members of the health care team are affected by excessive DocBurden?

   • Nurses and nurse practitioners only

   • Patients and physicians only

   • Physicians, nurses, and patients only

   • All members of the health care team

   Correct Answer: The correct answer is option d. While 56% of scoping review sources focus on physicians, and 29% of sources focused on nurses, all members of the health care interdisciplinary team can be affected by excessive DocBurden. [Fig. 4] gives an example of how excessive DocBurden can affect medication administration.

4. DocBurden is the ________ load on the HP of completing necessary tasks included in documentation and EHR interaction.

   • Excessive

   • Expected

   • Unanticipated

   • Fluid

   Correct Answer: The correct answer is option b. The analyses of our scoping review resulted in a standardized definition of DocBurden, as “[the] expected load on HPs of completing necessary tasks included in documentation and EHR interaction.” We identified that while burden carries a negative connotation in most sources, this differs from the dictionary definition of burden which is a neutral state. We therefore define excessive DocBurden as “[the] stress and unnecessarily heavy load or work (i.e., excessive DocBurden) an HP or health care team experiences when the usability[41] of documentation systems and documentation activities are not aligned in support of patient care delivery ([Table 5]).

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