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

Abstract

Objectives: Efforts to reduce documentation burden (DocBurden) for all health professionals (HP) are aligned with national initiatives to improve clinician wellness and patient safety. Yet DocBurden has not been precisely defined, limiting national conversations and rigorous, reproducible, and meaningful measures. Increasing attention to DocBurden motivated this work to establish a standard definition of DocBurden, with the emergence of excessive DocBurden as a term.

Methods: We conducted a scoping review of DocBurden definitions and descriptions, searching six databases for scholarly, peer-reviewed, and gray literature sources, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extensions for Scoping Review guidance. For the concept clarification phase of work, we used the American Nursing Informatics Association's Six Domains of Burden Framework.

Results: A total of 153 articles were included based on a priori criteria. Most articles described a focus on DocBurden, but only 18% (n = 28) provided a definition. We define excessive DocBurden as the stress and unnecessarily heavy work an HP or health care team experiences when usability of documentation systems and documentation activities (i.e., generation, review, analysis, and synthesis of patient data) are not aligned in support of care delivery. A negative connotation was attached to burden without a neutral state in included sources, which does not align with dictionary definitions of burden.

Conclusion: Existing literature does not distinguish between a baseline or required task load to conduct patient care resulting from usability issues (DocBurden), and the unnecessarily heavy tasks and requirements that contribute to excessive DocBurden. Our definition of excessive DocBurden explicitly acknowledges this distinction, to support development of meaningful measures for understanding and intervening on excessive DocBurden locally, nationally, and internationally.

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.

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), 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).

Fig. 3

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

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.