Practice Environments and Electronic Health Records Use in Primary Care: Reducing Nurse Practitioner Burnout

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Primary care provider burnout is a public health crisis with nearly 48% of providers reporting burnout. Provider burnout is also a threat to the United States (U.S.) primary care system because it is associated with poor patient, provider, and organizational outcomes. Currently, researchers have identified organizational (i.e., practice environment) and structural predictors (i.e., electronic health record [EHR] use) in primary care practices contributing to physician burnout. Yet, there is a dearth of scientific evidence on the association between primary care practice environment and EHR use with nurse practitioner (NP) burnout (i.e., an internalized feeling of emotional exhaustion, depersonalization, and low personal accomplishment). This is a problem because NPs are the largest growing primary care provider workforce in the U.S., and they increase access to care for Agency for Healthcare Research and Quality (AHRQ) priority populations such as low income and minorities including women, children, the elderly, and individuals with disabilities and living in rural and urban communities. Furthermore, primary care NPs are using complex EHRs and work in challenging environments with inefficient organizational policies and limited support and resources to deliver high quality patient care. Since use of complex EHRs and a poor primary care practice environment are predictors of physician burnout, the proposed secondary data analysis seeks to determine if this is also the case for primary care NPs. This dissertation will use cross-sectional survey data from 1014 NPs across two states in the 2018- 2019 Primary Care NP Study, which is the only existing dataset containing valid and reliable measures of primary care NP practice environment, EHR use, and burnout. The following specific aims are proposed. Aim 1 is to describe the NP practice environment, EHR use (i.e., computerized capabilities for patient care and electronic reminders for decision support), and burnout among NPs in primary care practices. Aim 2 is to investigate whether primary care NP practice environments (i.e., NP-physician relations, NP-administration relations, independent practice and support, and professional visibility) affect burnout. Aim 3 is to examine if use of complex EHRs contributes to NP burnout in primary care practices. We hypothesize that NPs in poor practice environments and use of complex EHRs will be associated with NP burnout. The Principal Investigator will build multi-level logistic regression models and cluster NPs within their practices to examine if EHR use and practice environments are associated with burnout. Findings will generate knowledge on primary care practice environment, EHR use, and burnout in NPs which can inform future interventions to improve NP, patient, and organizational outcomes. This R36 dissertation award will provide a valuable opportunity for a pre- doctoral student, who aspires to become an independent health services researcher, to generate evidence needed to reduce burnout and improve primary care delivery. Lastly, this study is aligned with the mission of the AHRQ to generate evidence that promotes higher quality, accessible, equitable, and affordable healthcare.