Accounting for taste: preferences mediate the relationship between documentation time and ambulatory physician burnout.

OBJECTIVES: Physician burnout in the US has reached crisis levels, with one source identified as extensive after-hours documentation work in the electronic health record (EHR). Evidence has illustrated that physician preferences for after-hours work vary, such that after-hours work may not be universally burdensome. Our objectives were to analyze variation in preferences for after-hours documentation and assess if preferences mediate the relationship between after-hours documentation time and burnout. MATERIALS AND METHODS: We combined EHR active use data capturing physicians' hourly documentation work with survey data capturing documentation preferences and burnout. Our sample included 318 ambulatory physicians at MedStar Health. We conducted a mediation analysis to estimate if and how preferences mediated the relationship between after-hours documentation time and burnout. Our primary outcome was physician-reported burnout. We measured preferences for after-hours documentation work via a novel survey instrument (Burden Scenarios Assessment). We measured after-hours documentation time in the EHR as the total active time respondents spent documenting between 7 pm and 3 am. RESULTS: Physician preferences varied, with completing clinical documentation after clinic hours while at home the scenario rated most burdensome (52.8% of physicians), followed by dealing with prior authorization (49.5% of physicians). In mediation analyses, preferences partially mediated the relationship between after-hours documentation time and burnout. DISCUSSION: Physician preferences regarding EHR-based work play an important role in the relationship between after-hours documentation time and burnout. CONCLUSION: Studies of EHR work and burnout should incorporate preferences, and operational leaders should assess preferences to better target interventions aimed at EHR-based contributors to burnout.

Consistency is key: documentation distribution and efficiency in primary care.

OBJECTIVES: We analyzed the degree to which daily documentation patterns in primary care varied and whether specific patterns, consistency over time, and deviations from clinicians' usual patterns were associated with note-writing efficiency. MATERIALS AND METHODS: We used electronic health record (EHR) active use data from the Oracle Cerner Advance platform capturing hourly active documentation time for 498 physicians and advance practice clinicians (eg, nurse practitioners) for 65 152 clinic days. We used k-means clustering to identify distinct daily patterns of active documentation time and analyzed the relationship between these patterns and active documentation time per note. We determined each primary care clinician's (PCC) modal documentation pattern and analyzed how consistency and deviations were related to documentation efficiency. RESULTS: We identified 8 distinct daily documentation patterns; the 3 most common patterns accounted for 80.6% of PCC-days and differed primarily in average volume of documentation time (78.1 minutes per day; 35.4 minutes per day; 144.6 minutes per day); associations with note efficiency were mixed. PCCs with >80% of days attributable to a single pattern demonstrated significantly more efficient documentation than PCCs with lower consistency; for high-consistency PCCs, days that deviated from their usual patterns were associated with less efficient documentation. DISCUSSION: We found substantial variation in efficiency across daily documentation patterns, suggesting that PCC-level factors like EHR facility and consistency may be more important than when documentation occurs. There were substantial efficiency returns to consistency, and deviations from consistent patterns were costly. CONCLUSION: Organizational leaders aiming to reduce documentation burden should pay specific attention to the ability for PCCs to execute consistent documentation patterns day-to-day.

Physicians in ACOs report greater documentation burden.

OBJECTIVES: First, to analyze the relationship between value-based payment (VBP) program participation and documentation burden among office-based physicians. Second, to analyze the relationship between specific VBP programs (eg, accountable care organizations [ACOs]) and documentation burden. STUDY DESIGN: Retrospective analyses of US office-based physicians in 2019 and 2021. METHODS: We used cross-sectional data from the National Electronic Health Records Survey to measure VBP program participation and our outcomes of reported electronic health record (EHR) documentation burden. We used ordinary least squares regression models adjusting for physician and practice characteristics to estimate the relationship between participation in any VBP program and EHR burden outcomes. We also estimated the relationship between participation in 6 distinct VBP programs and our outcomes to decompose the aggregate relationship into program-specific estimates. RESULTS: In adjusted analyses, participation in any VBP program was associated with 10.5% greater probability of reporting more than 1 hour per day of after-hours documentation time (P = .01), which corresponded to an estimated additional 11 minutes per day (P = .03). Program-specific estimates illustrated that ACO participation drove the aggregate relationship, with ACO participants reporting greater after-hours documentation time (18 additional minutes per day; P < .001), more difficulty documenting (30.6% more likely; P < .001), and more inappropriateness of time spent documenting (21.7% more likely; P < .001). CONCLUSIONS: Office-based physicians participating in ACOs report greater documentation burden across several measures; the same is not true for other VBP programs. Although many ACOs relax documentation requirements for reimbursement, documentation for quality reporting and risk adjustment may lead to a net increase in burden, especially for physicians exposed to numerous programs and payers.

Telemedicine and In-Person Visit Modality Mix and Electronic Health Record Use in Primary Care.

This cross-sectional study investigates the association between day-to-day changes in telemedicine share and clinician time spent on electronic health record (EHR) use.

Interoperability in the Wild: Comparison of Real-World Electronic C-CDA Documents from Two Sources.

Although health information exchange (HIE) networks exist in multiple nations, providers still require access multiple sources to obtain medical records. We sought to measure and compare differences in data presence and concordance across regional HIE and EHR vendor-based networks. Using 1,054 randomly selected patients from a large health system in the US, we generated consolidated clinical document architecture (C-CDA) documents from each network. 778 (74%) patients had at least one C-CDA document present from either source. Among these patients, two-thirds had information in only one source. All documents contained demographics, but less than half of patients had data in clinical data domains. Moreover, data across HIE networks were not concordant. Results suggest that HIE networks have different, likely complementary, data available for the same patient, suggesting the need for better integration and deduplication for national HIE efforts.

The role of organizations in shaping physician use of electronic health records.

OBJECTIVE: The aim of the study was to (1) characterize organizational differences in primary care physicians' electronic health record (EHR) behavior; (2) assess within-organization consistency in EHR behaviors; and (3) identify whether organizational consistency is associated with physician-level efficiency. DATA SOURCES: EHR metadata capturing averaged weekly measures of EHR time and documentation composition from 75,124 US primary care physicians across 299 organizations between September 2020 and May 2021 were taken. EHR time measures include active time in orders, chart review, notes, messaging, time spent outside of scheduled hours, and total EHR time. Documentation composition measures include note length and percentage use of templated text or copy/paste. Efficiency is measured as the percent of visits with same-day note completion. STUDY DESIGN: All analyses are cross-sectional. Across-organization differences in EHR use and documentation composition are presented via 90th-to-10th percentile ratios of means and SDs. Multilevel modeling with post-estimation variance partitioning assesses the extent of an organizational signature-the proportion of variation in our measures attributable to organizations (versus specialty and individual behaviors). We measured organizational internal consistency for each measure via organization-level SD, which we grouped into quartiles for regression. Association between internally consistent (i.e., low SD) organizational EHR use and physician-level efficiency was assessed with multi-variable OLS models. DATA COLLECTION: Extraction from Epic's Signal platform used for measuring provider EHR efficiency. PRINCIPAL FINDINGS: EHR time per visit for physicians at a 90th percentile organization is 1.94 times the average EHR time at a 10th percentile organization. There is little evidence, on average, of an organizational signature. However, physicians in organizations with high internal consistency in EHR use demonstrate increased efficiency. Physicians in organizations with the highest internal consistency (top quartile) have a 3.77 percentage point higher same-day visit closure rates compared with peers in bottom quartile organizations (95% confidence interval: 0.0142-0.0612). CONCLUSIONS: Results suggest unrealized opportunities for organizations and policymakers to support consistency in how physicians engage in EHR-supported work.

Guidance for reporting analyses of metadata on electronic health record use.

INTRODUCTION: Research on how people interact with electronic health records (EHRs) increasingly involves the analysis of metadata on EHR use. These metadata can be recorded unobtrusively and capture EHR use at a scale unattainable through direct observation or self-reports. However, there is substantial variation in how metadata on EHR use are recorded, analyzed and described, limiting understanding, replication, and synthesis across studies. RECOMMENDATIONS: In this perspective, we provide guidance to those working with EHR use metadata by describing 4 common types, how they are recorded, and how they can be aggregated into higher-level measures of EHR use. We also describe guidelines for reporting analyses of EHR use metadata-or measures of EHR use derived from them-to foster clarity, standardization, and reproducibility in this emerging and critical area of research.

The health effects of nursing home specialization in post-acute care.

Nursing homes serve both long-term care and post-acute care (PAC) patients, two groups with distinct financing mechanisms and requirements for care. We examine empirically the effect of nursing home specialization in PAC using 2011-2018 data for Medicare patients admitted to nursing homes following a hospital stay. To address patient selection into specialized nursing homes, we use an instrumental variables approach that exploits variation over time in the distance from the patient's residential ZIP code to the closest nursing home with different levels of PAC specialization. We find that patients admitted to nursing homes more specialized in PAC have lower hospital readmissions and mortality, longer nursing home stays, and higher Medicare spending for the episode of care, suggesting that specialization improves patient outcomes but at higher costs.

Examining primary care provider experiences with using a clinical decision support tool for pain management.

Objective: To evaluate primary care provider (PCP) experiences using a clinical decision support (CDS) tool over 16 months following a user-centered design process and implementation. Materials and Methods: We conducted a qualitative evaluation of the Chronic Pain OneSheet (OneSheet), a chronic pain CDS tool. OneSheet provides pain- and opioid-related risks, benefits, and treatment information for patients with chronic pain to PCPs. Using the 5 Rights of CDS framework, we conducted and analyzed semi-structured interviews with 19 PCPs across 2 academic health systems. Results: PCPs stated that OneSheet mostly contained the right information required to treat patients with chronic pain and was correctly located in the electronic health record. PCPs used OneSheet for distinct subgroups of patients with chronic pain, including patients prescribed opioids, with poorly controlled pain, or new to a provider or clinic. PCPs reported variable workflow integration and selective use of certain OneSheet features driven by their preferences and patient population. PCPs recommended broadening OneSheet access to clinical staff and patients for data entry to address clinician time constraints. Discussion: Differences in patient subpopulations and workflow preferences had an outsized effect on CDS tool use even when the CDS contained the right information identified in a user-centered design process. Conclusions: To increase adoption and use, CDS design and implementation processes may benefit from increased tailoring that accommodates variation and dynamics among patients, visits, and providers.

Variations in Physician Telemedicine Provision.

This cross-sectional study assesses variation in the provision of telemedicine services among primary care physicians and quantifies the extent to which this variation may be explained by the individual physician vs temporal, patient, or visit factors.

I had not time to make it shorter: an exploratory analysis of how physicians reduce note length and time in notes.

OBJECTIVE: We analyze observed reductions in physician note length and documentation time, 2 contributors to electronic health record (EHR) burden and burnout. MATERIALS AND METHODS: We used EHR metadata from January to May, 2021 for 130 079 ambulatory physician Epic users. We identified cohorts of physicians who decreased note length and/or documentation time and analyzed changes in their note composition. RESULTS: 37 857 physicians decreased either note length (n = 15 647), time in notes (n = 15 417), or both (n = 6793). Note length decreases were primarily attributable to reductions in copy/paste text (average relative change of -18.9%) and templated text (-17.2%). Note time decreases were primarily attributable to reductions in manual text (-27.3%) and increases in note content from other care team members (+21.1%). DISCUSSION: Organizations must consider priorities and tradeoffs in the distinct approaches needed to address different contributors to EHR burden. CONCLUSION: Future research should explore scalable burden-reduction initiatives responsive to both note bloat and documentation time.

Documentation dynamics: Note composition, burden, and physician efficiency.

OBJECTIVE: To analyze how physician clinical note length and composition relate to electronic health record (EHR)-based measures of burden and efficiency that have been tied to burnout. DATA SOURCES AND STUDY SETTING: Secondary EHR use metadata capturing physician-level measures from 203,728 US-based ambulatory physicians using the Epic Systems EHR between September 2020 and May 2021. STUDY DESIGN: In this cross-sectional study, we analyzed physician clinical note length and note composition (e.g., content from manual or templated text). Our primary outcomes were three time-based measures of EHR burden (time writing EHR notes, time in the EHR after-hours, and EHR time on unscheduled days), and one measure of efficiency (percent of visits closed in the same day). We used multivariate regression to estimate the relationship between our outcomes and note length and composition. DATA EXTRACTION: Physician-week measures of EHR usage were extracted from Epic's Signal platform used for measuring provider EHR efficiency. We calculated physician-level averages for our measures of interest and assigned physicians to overall note length deciles and note composition deciles from six sources, including templated text, manual text, and copy/paste text. PRINCIPAL FINDINGS: Physicians in the top decile of note length demonstrated greater burden and lower efficiency than the median physician, spending 39% more time in the EHR after hours (p < 0.001) and closing 5.6 percentage points fewer visits on the same day (p < 0.001). Copy/paste demonstrated a similar dose/response relationship, with top-decile copy/paste users closing 6.8 percentage points fewer visits on the same day (p < 0.001) and spending more time in the EHR after hours and on days off (both p < 0.001). Templated text (e.g., Epic's SmartTools) demonstrated a non-linear relationship with burden and efficiency, with very low and very high levels of use associated with increased EHR burden and decreased efficiency. CONCLUSIONS: "Efficiency tools" like copy/paste and templated text meant to reduce documentation burden and increase provider efficiency may have limited efficacy.

Electronic Health Record Legal Settlements in the US Since the 2009 Health Information Technology for Economic and Clinical Health Act.

This cross-sectional study describes allegations of misconduct by electronic health record vendors.

Using event logs to observe interactions with electronic health records: an updated scoping review shows increasing use of vendor-derived measures.

OBJECTIVE: The aim of this article is to compare the aims, measures, methods, limitations, and scope of studies that employ vendor-derived and investigator-derived measures of electronic health record (EHR) use, and to assess measure consistency across studies. MATERIALS AND METHODS: We searched PubMed for articles published between July 2019 and December 2021 that employed measures of EHR use derived from EHR event logs. We coded the aims, measures, methods, limitations, and scope of each article and compared articles employing vendor-derived and investigator-derived measures. RESULTS: One hundred and two articles met inclusion criteria; 40 employed vendor-derived measures, 61 employed investigator-derived measures, and 1 employed both. Studies employing vendor-derived measures were more likely than those employing investigator-derived measures to observe EHR use only in ambulatory settings (83% vs 48%, P = .002) and only by physicians or advanced practice providers (100% vs 54% of studies, P < .001). Studies employing vendor-derived measures were also more likely to measure durations of EHR use (P < .001 for 6 different activities), but definitions of measures such as time outside scheduled hours varied widely. Eight articles reported measure validation. The reported limitations of vendor-derived measures included measure transparency and availability for certain clinical settings and roles. DISCUSSION: Vendor-derived measures are increasingly used to study EHR use, but only by certain clinical roles. Although poorly validated and variously defined, both vendor- and investigator-derived measures of EHR time are widely reported. CONCLUSION: The number of studies using event logs to observe EHR use continues to grow, but with inconsistent measure definitions and significant differences between studies that employ vendor-derived and investigator-derived measures.

Assessing the use of a clinical decision support tool for pain management in primary care.

Objective: Given time constraints, poorly organized information, and complex patients, primary care providers (PCPs) can benefit from clinical decision support (CDS) tools that aggregate and synthesize problem-specific patient information. First, this article describes the design and functionality of a CDS tool for chronic noncancer pain in primary care. Second, we report on the retrospective analysis of real-world usage of the tool in the context of a pragmatic trial. Materials and methods: The tool known as OneSheet was developed using user-centered principles and built in the Epic electronic health record (EHR) of 2 health systems. For each relevant patient, OneSheet presents pertinent information in a single EHR view to assist PCPs in completing guideline-recommended opioid risk mitigation tasks, review previous and current patient treatments, view patient-reported pain, physical function, and pain-related goals. Results: Overall, 69 PCPs accessed OneSheet 2411 times (since November 2020). PCP use of OneSheet varied significantly by provider and was highly skewed (site 1: median accesses per provider: 17 [interquartile range (IQR) 9-32]; site 2: median: 8 [IQR 5-16]). Seven "power users" accounted for 70% of the overall access instances across both sites. OneSheet has been accessed an average of 20 times weekly between the 2 sites. Discussion: Modest OneSheet use was observed relative to the number of eligible patients seen with chronic pain. Conclusions: Organizations implementing CDS tools are likely to see considerable provider-level variation in usage, suggesting that CDS tools may vary in their utility across PCPs, even for the same condition, because of differences in provider and care team workflows.

Variation in Support for Documentation Among Primary Care Physicians by Gender.

BACKGROUND: There are known gender differences in both time spent on the electronic health record (EHR) and burnout. Previous studies have described potential benefits of staff support for documentation for physician experience and EHR time. It is not known, however, to what extent availability of staff support for documentation differs by gender in the context of primary care. METHODS: This was a cross-sectional study of primary care physicians (PCPs) using data from the 2018 and 2019 National Electronic Health Records Survey administrations. After descriptively analyzing the prevalence of staff support for documentation, we used multivariable logistic regression to identify the adjusted relationship of staff support for documentation with gender. RESULTS: Among the 813 physicians who endorsed having an EHR (92.5% of sample, representing 296,854 physicians), female PCPs were significantly less likely than male PCPs (25.1% vs 37.3%; P = .04) to report having staff support for documentation. This difference was most pronounced in practices with a single physician and practices with more than 50% of patients insured by Medicaid. Gender differences persisted in analyses adjusted for practice ownership and percent of patients insured by Medicaid. CONCLUSIONS: Given positive effects of documentation support and known gender differences in burnout and EHR use times, the differences identified have important implications for the physician workforce. Future research should focus on identifying underlying reasons and potential solutions for the gender differences described.

Assessing the impact of patient access to clinical notes on clinician EHR documentation.

Recent policy changes have required health care delivery organizations provide patients electronic access to their clinical notes free of charge. There is concern that this could have an unintended consequence of increased electronic health record (EHR) work as clinicians may feel the need to adapt their documentation practices in light of their notes being accessible to patients, potentially exacerbating EHR-induced clinician burnout. Using a national, longitudinal data set consisting of all ambulatory care physicians and advance practice providers using an Epic Systems EHR, we used an interrupted time-series analysis to evaluate the immediate impact of the policy change on clinician note length and time spent documenting in the EHR. We found no evidence of a change in note length or time spent writing notes following the implementation of the policy, suggesting patient access to clinical notes did not increase documentation workload for clinicians.