Impact of response bias in three surveys on primary care providers' experiences with electronic health records.

OBJECTIVE: To identify impacts of different survey methodologies assessing primary care physicians' (PCPs') experiences with electronic health records (EHRs), we compared three surveys: the 2022 Continuous Certification Questionnaire (CCQ) from the American Board of Family Medicine, the 2022 University of California San Francisco (UCSF) Physician Health IT Survey, and the 2021 National Electronic Health Records Survey (NEHRS). MATERIALS AND METHODS: We evaluated differences between survey pairs using Rao-Scott corrected chi-square tests, which account for weighting. RESULTS: CCQ received 3991 responses from PCPs (100% response rate), UCSF received 1375 (3.6% response rate), and NEHRS received 858 (18.2% response rate). Substantial, statistically significant differences in demographics were detected across the surveys. CCQ respondents were younger and more likely to work in a health system; NEHRS respondents were more likely to work in private practice; and UCSF respondents disproportionately practiced in larger academic settings. Many EHR experience indicators were similar between CCQ and NEHRS, but CCQ respondents reported higher documentation burden. DISCUSSION: The UCSF approach is unlikely to supply reliable data. Significant demographic differences between CCQ and NEHRS raise response bias concerns, and while there were similarities in some reported EHR experiences, there were important, significant differences. CONCLUSION: Federal EHR policy monitoring and maintenance require reliable data. This test of existing and alternative sources suggest that diversified data sources are necessary to understand physicians' experiences with EHRs and interoperability. Comprehensive surveys administered by specialty boards have the potential to contribute to these efforts, since they are likely to be free of response bias.

Comparison of Hospital Mortality and Readmission Rates by Physician and Patient Sex.

BACKGROUND: Little is known as to whether the effects of physician sex on patients' clinical outcomes vary by patient sex. OBJECTIVE: To examine whether the association between physician sex and hospital outcomes varied between female and male patients hospitalized with medical conditions. DESIGN: Retrospective observational study. SETTING: Medicare claims data. PATIENTS: 20% random sample of Medicare fee-for-service beneficiaries hospitalized with medical conditions during 2016 to 2019 and treated by hospitalists. MEASUREMENTS: The primary outcomes were patients' 30-day mortality and readmission rates, adjusted for patient and physician characteristics and hospital-level averages of exposures (effectively comparing physicians within the same hospital). RESULTS: Of 458 108 female and 318 819 male patients, 142 465 (31.1%) and 97 500 (30.6%) were treated by female physicians, respectively. Both female and male patients had a lower patient mortality when treated by female physicians; however, the benefit of receiving care from female physicians was larger for female patients than for male patients (difference-in-differences, -0.16 percentage points [pp] [95% CI, -0.42 to 0.10 pp]). For female patients, the difference between female and male physicians was large and clinically meaningful (adjusted mortality rates, 8.15% vs. 8.38%; average marginal effect [AME], -0.24 pp [CI, -0.41 to -0.07 pp]). For male patients, an important difference between female and male physicians could be ruled out (10.15% vs. 10.23%; AME, -0.08 pp [CI, -0.29 to 0.14 pp]). The pattern was similar for patients' readmission rates. LIMITATION: The findings may not be generalizable to younger populations. CONCLUSION: The findings indicate that patients have lower mortality and readmission rates when treated by female physicians, and the benefit of receiving treatments from female physicians is larger for female patients than for male patients. PRIMARY FUNDING SOURCE: Gregory Annenberg Weingarten, GRoW @ Annenberg.

Trends in Scientific Collaboration Between Men and Women Following the #MeToo Movement.

BACKGROUND: The #MeToo movement raised global awareness about harassment in the workplace. Concerns were raised, however, that the movement may have unintendedly harmed women in academia by decreasing collaboration invitations from men in senior positions, who might be more reluctant to collaborate. OBJECTIVE: To analyze whether collaborations between first author women and last author men decreased after the #MeToo movement. DESIGN: Retrospective observational study. PARTICIPANTS: Names of first and last authors of 122,450 US review articles from the PubMed database published between 2014 and 2020. MAIN MEASURES: Change in the proportion of review articles with a first author woman and a last author man following the peak of the #MeToo movement in October 2017. Additionally, among review articles with a last author man, trends of women first authorship in the USA and Europe (control group) were compared. KEY RESULTS: We analyzed 122,450 review articles with first and last authors from US institutions. Of 85,015 articles by a man last author, 37.5% (31,902) had a woman first author. In contrast, when the last author was a woman, the first author was also a woman in 53.6% of articles (20,078) (p<0.001 for difference). Among review articles with a last author man, there was no change in the proportion of articles with a woman first author before versus after the peak of the #MeToo movement (e.g., p=0.13 for difference between the 12 months following October 2017 compared to the pre-#Me-too period). Among European institutions, of 72,036 articles by a man last author, 43.4% (31,294) had a woman first author, higher than the proportion observed in the USA. Trends in collaboration between first author women and last author men were similar in the USA and Europe after the peak of the #MeToo movement (p=0.65). CONCLUSIONS: The #MeToo movement was not associated with a reduction in the rate of scientific review article authorship collaborations between first author women and last author men in the life sciences. These findings, if generalizable, suggest it is possible to promote accountability for harassment in the workplace without limiting decreases in collaboration.

Proportion Of Preventive Primary Care Visits Nearly Doubled, Especially Among Medicare Beneficiaries, 2001-19.

There is debate about the value of preventive visits in primary care, and multiple policy trends during the past fifteen years may have influenced the likelihood of US adults undergoing preventive primary care visits. Using nationally representative, serial cross-sectional data on adult visits to primary care physicians from the 2001-19 National Ambulatory Medical Care Survey, we characterized temporal trends in the proportion of primary care visits with a preventive focus and the differential characteristics of these visits. Based on a sample of 139,783 unweighted (5,902,144,258 weighted) US primary care visits, we found that the proportion of primary care visits with a preventive focus increased between 2001 and 2019 (12.8 percent of visits in 2001-02 versus 24.6 percent in 2018-19; [Formula: see text]), with the greatest rate of increase seen for people with Medicare. Primary care visits with a preventive focus involved more time spent with the physician and addressed fewer reasons for the visit compared with problem-based visits. At least one of the following was significantly more likely to occur during a preventive visit than a problem-based visit: counseling provision, ordering of preventive labs, or ordering of a preventive image or procedure. Our findings demonstrate a relative increase in preventive versus problem-based visits in primary care and suggest the importance of enhanced insurance coverage in influencing preventive care delivery trends.

System-Level Factors and Time Spent on Electronic Health Records by Primary Care Physicians.

Importance: Primary care physicians (PCPs) spend the most time on the electronic health record (EHR) of any specialty. Thus, it is critical to understand what factors contribute to varying levels of PCP time spent on EHRs. Objective: To characterize variation in EHR time across PCPs and primary care clinics, and to describe how specific PCP, patient panel, clinic, and team collaboration factors are associated with PCPs' time spent on EHRs. Design, Setting, and Participants: This cross-sectional study included 307 PCPs practicing across 31 primary care clinics at Massachusetts General Hospital and Brigham and Women's Hospital during 2021. Data were analyzed from October 2022 to October 2023. Main Outcomes and Measures: Total per-visit EHR time, total per-visit pajama time (ie, time spent on the EHR between 5:30 pm to 7:00 am and on weekends), and total per-visit time on the electronic inbox as measured by activity log data derived from an EHR database. Results: The sample included 307 PCPs (183 [59.6%] female). On a per-visit basis, PCPs spent a median (IQR) of 36.2 (28.9-45.7) total minutes on the EHR, 6.2 (3.1-11.5) minutes of pajama time, and 7.8 (5.5-10.7) minutes on the electronic inbox. When comparing PCP time expenditure by clinic, median (IQR) total EHR time, median (IQR) pajama time, and median (IQR) electronic inbox time ranged from 23.5 (20.7-53.1) to 47.9 (30.6-70.7) minutes per visit, 1.7 (0.7-10.5) to 13.1 (7.7-28.2) minutes per visit, and 4.7 (4.1-5.2) to 10.8 (8.9-15.2) minutes per visit, respectively. In a multivariable model with an outcome of total per-visit EHR time per visit, an above median percentage of teamwork on orders was associated with 3.81 (95% CI, 0.49-7.13) minutes per visit fewer and having a clinic pharmacy technician was associated with 7.87 (95% CI, 2.03-13.72) minutes per visit fewer. Practicing in a community health center was associated with fewer minutes of total EHR time per visit (5.40 [95% CI, 0.06-10.74] minutes). Conclusions and Relevance: There is substantial variation in EHR time among individual PCPs and PCPs within clinics. Organization-level factors, such as team collaboration on orders, support for medication refill functions, and practicing in a community health center, are associated with lower EHR time for PCPs. These findings highlight the importance of addressing EHR burden at a systems level.

The Electronic Inbox-Benefits, Questions, and Solutions for the Road Ahead.

This Viewpoint looks at digital communication between patients and physicians, including approaches to provide adequate support for these efforts that balance patient needs with appropriate time investments from clinicians.

Ctrl-C: a cross-sectional study of the electronic health record usage patterns of US oncology clinicians.

Despite some positive impact, the use of electronic health records (EHRs) has been associated with negative effects, such as emotional exhaustion. We sought to compare EHR use patterns for oncology vs nononcology medical specialists. In this cross-sectional study, we employed EHR usage data for 349 ambulatory health-care systems nationwide collected from the vendor Epic from January to August 2019. We compared note composition, message volume, and time in the EHR system for oncology vs nononcology clinicians. Compared with nononcology medical specialists, oncologists had a statistically significantly greater percentage of notes derived from Copy and Paste functions but less SmartPhrase use. They received more total EHR messages per day than other medical specialists, with a higher proportion of results and system-generated messages. Our results point to priorities for enhancing EHR systems to meet the needs of oncology clinicians, particularly as related to facilitating the complex documentation, results, and therapy involved in oncology care.

Comparison of Work Patterns Between Physicians and Advanced Practice Practitioners in Primary Care and Specialty Practice Settings.

Importance: Despite the increasing involvement of advanced practice practitioners (APPs; ie, nurse practitioners and physician assistants) in care delivery across specialties, the work patterns of APPs compared with physicians and how they are integrated into care teams have not been well characterized. Objective: To characterize differences between physicians and APPs across specialty types related to days with appointments, visit types seen, and time spent using the electronic health record (EHR). Design, Setting, and Participants: This nationwide, cross-sectional study used EHR data from physicians and APPs (ie, nurse practitioners and physician assistants) at all US institutions that used Epic Systems' EHR between January and May 2021. Data analysis was performed from March 2022 to April 2023. Main Outcomes and Measures: Appointment scheduling patterns, percentage of new and established and level of evaluation and management (E/M) visits, and EHR use metrics per day and week. Results: The sample consisted of 217 924 clinicians across 389 organizations, including 174 939 physicians and 42 985 APPs. Although primary care physicians were more likely than APPs to have more than 3 days per week with appointments (50 921 physicians [79.5%] vs 17 095 APPs [77.9%]), this trend was reversed for medical (38 645 physicians [64.8%] vs 8124 APPs [74.0%]) and surgical (24 155 physicians [47.1%] vs 5198 APPs [51.7%]) specialties. Medical and surgical specialty physicians saw 6.7 and 7.4 percentage points, respectively, more new patient visits than did their APP counterparts, whereas primary care physicians saw 2.8 percentage points fewer new patient visits than did APPs. Physicians saw a greater percentage of level 4 or 5 visits across all specialties. Medical and surgical physicians spent 34.3 and 45.8 fewer minutes per day, respectively, using the EHR than did APPs in their specialties, whereas primary care physicians spent 17.7 minutes per day more. These differences translated to primary care physicians spending 96.3 minutes more per week using the EHR than APPs, whereas medical and surgical physicians spent 149.9 and 140.7 fewer minutes, respectively, than did their APP counterparts. Conclusions and Relevance: This cross-sectional, national study of clinicians found significant differences in visit and EHR patterns for physicians compared with APPs across specialty types. By underscoring the different current usage of physicians vs APPs across specialty types, this study helps place into context the work and visit patterns of physicians compared with APPs and serves as a foundation for evaluations of clinical outcomes and quality.

The Association of Work Overload with Burnout and Intent to Leave the Job Across the Healthcare Workforce During COVID-19.

BACKGROUND: Burnout has risen across healthcare workers during the pandemic, contributing to workforce turnover. While prior literature has largely focused on physicians and nurses, there is a need to better characterize and identify actionable predictors of burnout and work intentions across healthcare role types. OBJECTIVE: To characterize the association of work overload with rates of burnout and intent to leave (ITL) the job in a large national sample of healthcare workers. DESIGN: Cross-sectional survey study conducted between April and December 2020. SETTING: A total of 206 large healthcare organizations. PARTICIPANTS: Physicians, nurses, other clinical staff, and non-clinical staff. MEASURES: Work overload, burnout, and ITL. RESULTS: The sample of 43,026 respondents (mean response rate 44%) was comprised of 35.2% physicians, 25.7% nurses, 13.3% other clinical staff, and 25.8% non-clinical staff. The overall burnout rate was 49.9% (56.0% in nursing, 54.1% in other clinical staff, 47.3% in physicians, and 45.6% in non-clinical staff; p < 0.001 for difference). ITL was reported by 28.7% of healthcare workers, with nurses most likely to report ITL (41.0%), followed by non-clinical staff (32.6%), other clinical staff (32.1%), and physicians (24.3%) (p < 0.001 for difference). The prevalence of perceived work overload ranged from 37.1% among physicians to 47.4% in other clinical staff. In propensity-weighted models, work overload was significantly associated with burnout (adjusted risk ratio (ARR) 2.21 to 2.90) and intent to leave (ARR 1.73 to 2.10) across role types. LIMITATIONS: Organizations' participation in the survey was voluntary. CONCLUSIONS: There are high rates of burnout and intent to leave the job across healthcare roles. Proactively addressing work overload across multiple role types may help with concerning trends across the healthcare workforce. This will require a more granular understanding of sources of work overload across different role types, and a commitment to matching work demands to capacity for all healthcare workers.

Variation in Family Physicians' Experiences Across Different Electronic Health Record Platforms: a Descriptive Study.

BACKGROUND: Electronic health records (EHRs) have been connected to excessive workload and physician burnout. Little is known about variation in physician experience with different EHRs, however. OBJECTIVE: To analyze variation in reported usability and satisfaction across EHRs. DESIGN: Internet-based survey available between December 2021 and October 2022 integrated into American Board of Family Medicine (ABFM) certification process. PARTICIPANTS: ABFM-certified family physicians who use an EHR with at least 50 total responding physicians. MEASUREMENTS: Self-reported experience of EHR usability and satisfaction. KEY RESULTS: We analyzed the responses of 3358 physicians who used one of nine EHRs. Epic, athenahealth, and Practice Fusion were rated significantly higher across six measures of usability. Overall, between 10 and 30% reported being very satisfied with their EHR, and another 32 to 40% report being somewhat satisfied. Physicians who use athenahealth or Epic were most likely to be very satisfied, while physicians using Allscripts, Cerner, or Greenway were the least likely to be very satisfied. EHR-specific factors were the greatest overall influence on variation in satisfaction: they explained 48% of variation in the probability of being very satisfied with Epic, 46% with eClinical Works, 14% with athenahealth, and 49% with Cerner. CONCLUSIONS: Meaningful differences exist in physician-reported usability and overall satisfaction with EHRs, largely explained by EHR-specific factors. User-centric design and implementation, and robust ongoing evaluation are needed to reduce physician burden and ensure excellent experience with EHRs.

Association of Clinician Practice Ownership With Ability of Primary Care Practices to Improve Quality Without Increasing Burnout.

Importance: Work environments and practice structural features are associated with both burnout and the ability of practices to enhance quality of care. Objective: To characterize factors associated with primary care practices successfully improving quality scores without increasing clinician and staff burnout. Design, Setting, and Participants: This cross-sectional study assessed small- to medium-sized primary care practices that participated in the EvidenceNOW: Advancing Heart Health initiative using surveys that were administered at baseline (September 2015 to April 2017) and after the intervention (January 2017 to October 2018). Data were analyzed from February 2022 to January 2023. Main Outcomes and Measures: The primary outcome of being a quality and well-being positive deviant practice was defined as a practice with a stable or improved percentage of clinicians and staff reporting burnout over the study period and with practice-level improvement in all 3 cardiovascular quality measures: aspirin prescribing, blood pressure control, and smoking cessation counseling. Results: Of 727 practices with complete burnout and aspirin prescribing, blood pressure control, and smoking cessation counseling data, 18.3% (n = 133) met the criteria to be considered quality and well-being positive deviant practices. In analyses adjusted for practice location, accountable care organization and demonstration project participation, and practice specialty composition, clinician-owned practices had greater odds of being a positive deviant practice (odds ratio, 2.02; 95% CI, 1.16-3.54) than practices owned by a hospital or health system. Conclusions and Relevance: In this cross-sectional study, clinician-owned practices were more likely to achieve improvements in cardiovascular quality outcomes without increasing staff member burnout than were practices owned by a hospital or health system. Given increasing health care consolidation, our findings suggest the value of studying cultural features of clinician-owned practices that may be associated with positive quality and experience outcomes.

Adult Primary Care Physician Visits Increasingly Address Mental Health Concerns.

A high prevalence of mental health diagnoses in adults alongside ongoing shortages of mental health specialists and expansion of the patient-centered medical home have increased the involvement of primary care clinicians in treating mental health concerns. Using nationally representative serial cross-sectional data from the 2006-18 National Ambulatory Medical Care Surveys regarding visits to outpatient primary care physicians by patients ages eighteen and older, we sought to characterize temporal trends in primary care visits addressing a mental health concern. Based on a sample of 109,898 visits representing 3,891,233,060 weighted visits, we found that the proportion of visits that addressed mental health concerns increased from 10.7 percent of visits in 2006-07 to 15.9 percent by 2016 and 2018. Black patients were 40 percent less likely than White patients to have a mental health concern addressed during a primary care visit, and Hispanic patients were 40 percent less likely than non-Hispanic patients to have a mental health concern addressed during a primary care visit. These findings emphasize the need for payment and billing approaches (that is, value-based care models and billing codes for integrated behavioral health) as well as organizational designs and supports (that is, colocated therapy or psychiatry providers, availability of e-consultation, and longer visits) that enable primary care physicians to adequately address mental health needs.

Physician Note Composition Patterns and Time on the EHR Across Specialty Types: a National, Cross-sectional Study.

BACKGROUND: The burden of clinical documentation in electronic health records (EHRs) has been associated with physician burnout. Numerous tools (e.g., note templates and dictation services) exist to ease documentation burden, but little evidence exists regarding how physicians use these tools in combination and the degree to which these strategies correlate with reduced time spent on documentation. OBJECTIVE: To characterize EHR note composition strategies, how these strategies differ in time spent on notes and the EHR, and their distribution across specialty types. DESIGN: Secondary analysis of physician-level measures of note composition and EHR use derived from Epic Systems' Signal data warehouse. We used k-means clustering to identify documentation strategies, and ordinary least squares regression to analyze the relationship between documentation strategies and physician time spent in the EHR, on notes, and outside scheduled hours. PARTICIPANTS: A total of 215,207 US-based ambulatory physicians using the Epic EHR between September 2020 and May 2021. MAIN MEASURES: Percent of note text derived from each of five documentation tools: SmartTools, copy/paste, manual text, NoteWriter, and voice recognition and transcription; average total and after-hours EHR time per visit; average time on notes per visit. KEY RESULTS: Six distinct note composition strategies emerged in cluster analyses. The most common strategy was predominant SmartTools use (n=89,718). In adjusted analyses, physicians using primarily transcription and dictation (n=15,928) spent less time on notes than physicians with predominant Smart Tool use. (b=-1.30, 95% CI=-1.62, -0.99, p<0.001; average 4.8 min per visit), while those using mostly copy/paste (n=23,426) spent more time on notes (b=2.38, 95% CI=1.92, 2.84, p<0.001; average 13.1 min per visit). CONCLUSIONS: Physicians' note composition strategies have implications for both time in notes and after-hours EHR use, suggesting that how physicians use EHR-based documentation tools can be a key lever for institutions investing in EHR tools and training to reduce documentation time and alleviate EHR-associated burden.

Association Between Electronic Health Record Time and Quality of Care Metrics in Primary Care.

Importance: Physicians across the US spend substantial time working in the electronic health record (EHR), with primary care physicians (PCPs) spending the most time. The association between EHR time and ambulatory care quality outcomes is unclear. Objective: To characterize measures of EHR use and ambulatory care quality performance among PCPs. Design, Setting, and Participants: A cross-sectional study of PCPs with longitudinal patient panels using a single EHR vendor was conducted at Brigham and Women's Hospital and Massachusetts General Hospital during calendar year 2021. Exposures: Independent variables included PCPs demographic and practice characteristics and EHR time measures (PCP-level mean of daily total EHR time, after-hours time, time from 5:30 pm to 7:00 am and time on weekends, and daily EHR time on notes, sending and receiving patient, staff, results, prescription, or system messages [in-basket], and clinical review). Main Outcomes and Measures: Outcome variables were ambulatory quality measures (year-end, PCP panel-level achievement of targets for hemoglobin A1c level control, lipid management, hypertension control, diabetes screening, and breast cancer screening). Results: The sample included 291 physicians (174 [59.8%] women). Median panel size was 829 (IQR, 476-1157) patients and mean (SD) clinical full-time equivalent was 0.54 (0.27). The PCPs spent a mean (SD) of 145.9 (64.6) daily minutes on the EHR. There were significant associations between EHR time and panel-level achievement of hemoglobin A1c control, hypertension control, and breast cancer screening targets. In adjusted analyses, each additional 15 minutes of total daily EHR time was associated with 0.58 (95% CI, 0.32-0.84) percentage point greater panel-level hemoglobin A1c control, 0.52 (95% CI, 0.33-0.71) percentage point greater hypertension control, and 0.28 (95% CI, 0.05-0.52) higher breast cancer screening rates. Each daily additional 15 minutes of in-basket time was associated with 2.26 (95% CI, 1.05-3.48) greater panel-wide hemoglobin A1c control, 1.65 (95% CI, 0.83-2.47) percentage point greater hypertension control, and 1.26 (95% CI, 0.51-2.02) percentage point higher breast cancer screening rates. Associations were largely concentrated among PCPs with 0.5 clinical full-time equivalent or less. There were no associations between EHR use metrics and diabetes screening or lipid management in patients with cardiovascular disease. Conclusions and Relevance: This cross-sectional study found an association between EHR time and some measures of ambulatory care quality. Although increased EHR time is associated with burnout, it may represent a level of thoroughness or communication that enhances certain outcomes. It may be useful for future studies to characterize payment models, workflows, and technologies that enable high-quality ambulatory care delivery while minimizing EHR burden.