Challenges in reliable preoperative blood ordering: A qualitative interview study.

BACKGROUND: Presurgical blood orders are important for patient safety during surgery, but excess orders can be costly to patients and the healthcare system. We aimed to assess clinician perceptions on the presurgical blood ordering process and perceived barriers to reliable decision-making. METHODS: This descriptive qualitative study was conducted at a single large academic medical center. Semi-structured interviews were conducted with surgeons, anesthesiologists, nurse anesthetists, nurse practitioners working in preoperative assessment clinics, and transfusion medicine physicians to assess perceptions of current blood ordering processes. Interview responses were analyzed using an inductive open coding approach followed by thematic analysis. RESULTS: Twenty-three clinicians were interviewed. Clinicians felt that the current blood ordering process was frequently inconsistent. One contributor was a lack of information on surgical transfusion risk, related to lack of experience in ordering clinicians, insufficient communication between stakeholders, high turnover in academic settings, and lack of awareness of the maximum surgical blood ordering schedule. Other contributors included differing opinions about the benefits and harms of over- and under-preparing blood products, leading to variation in transfusion risk thresholds between clinicians, and disagreement about the safety of emergency-release blood. CONCLUSION: Several barriers to reliable decision-making for presurgical blood orders exist. Future efforts to improve ordering consistency may benefit from improved information sharing between stakeholders and education on safe transfusion practices.

Reducing perioperative red blood cell unit issue orders, returns, and waste using failure modes and effects analysis.

BACKGROUND: Surgical transfusion has an outsized impact on hospital-based transfusion services, leading to blood product waste and unnecessary costs. The objective of this study was to design and implement a streamlined, reliable process for perioperative blood issue ordering and delivery to reduce waste. STUDY DESIGN AND METHODS: To address the high rates of surgical blood issue requests and red blood cell (RBC) unit waste at a large academic medical center, a failure modes and effects analysis was used to systematically examine perioperative blood management practices. Based on identified failure modes (e.g., miscommunication, knowledge gaps), a multi-component action plan was devised involving process changes, education, electronic clinical decision support, audit, and feedback. Changes in RBC unit issue requests, returns, waste, labor, and cost were measured pre- and post-intervention. RESULTS: The number of perioperative RBC unit issue requests decreased from 358 per month (SD 24) pre-intervention to 282 per month (SD 16) post-intervention (p < .001), resulting in an estimated savings of 8.9 h per month in blood bank staff labor. The issue-to-transfusion ratio decreased from 2.7 to 2.1 (p < .001). Perioperative RBC unit waste decreased from 4.5% of units issued pre-intervention to 0.8% of units issued post-intervention (p < .001), saving an estimated $148,543 in RBC unit acquisition costs and $546,093 in overhead costs per year. DISCUSSION: Our intervention, designed based on a structured failure modes analysis, achieved sustained reductions in perioperative RBC unit issue orders, returns, and waste, with associated benefits for blood conservation and transfusion program costs.

Measuring the cognitive effort associated with task switching in routine EHR-based tasks.

OBJECTIVE: Clinical work involves performing overlapping, time-sensitive tasks that frequently require clinicians to switch their attention between multiple tasks. We developed a methodological approach using EHR-based audit logs to determine switch costs-the cognitive burden associated with task switching-and assessed its magnitude during routine EHR-based clinical tasks. METHOD: Physician trainees (N = 75) participated in a longitudinal study where they provided access to their EHR-based audit logs. Physicians' audit log actions were used to create a taxonomy of EHR tasks. These tasks were transformed into task sequences and the time spent on each task in a sequence was computed. Within these task sequences, instances of task switching (i.e., switching from one task to the next) and non-switching were identified. The primary outcome of interest was the time spent on a post-switch task. Using a mixed-effects regression model, we compared the durations of post-switch and non-switch tasks. RESULTS: 2,781,679 audit log events over 117,822 sessions from 75 physicians were analyzed. Physicians spent most time on chart review (Median (IQR) = 5,439 (2,492-8,336) seconds), note review (1,936 (827-3,321) seconds), and navigating the EHR interface (1,048 (365.5-2,006) seconds) daily. Post task switch activity times were greater for documentation (Median increase = 5 s), order entry (Median increase = 3 s) and results review (Median increase = 3 s). Mixed-effects regression showed that time spent on tasks were longer following a task switch (ß = 0.03; 95% CIlower = 0.027, CIupper = 0.034), with greater post-swtich task times for imaging, order entry, note review, handoff, note entry, chart review and best practice advisory tasks. DISCUSSION: Increased task switching time-an indicator of the cognitive burden associated with switching between tasks-is prevalent in routine EHR-based tasks. We discuss the cumulative impact of incremental switch costs have on overall EHR workload, wellness, and error rates. Relying on theoretical cognitive foundations, we suggest pragmatic design considerations for mitigating the effects of cognitive burden associated with task switching.

Characterizing the Patterns of Electronic Health Record-Integrated Secure Messaging Use: Cross-Sectional Study.

BACKGROUND: Communication among health care professionals is essential for the delivery of safe clinical care. Secure messaging has rapidly emerged as a new mode of asynchronous communication. Despite its popularity, relatively little is known about how secure messaging is used and how such use contributes to communication burden. OBJECTIVE: This study aims to characterize the use of an electronic health record-integrated secure messaging platform across 14 hospitals and 263 outpatient clinics within a large health care system. METHODS: We collected metadata on the use of the Epic Systems Secure Chat platform for 6 months (July 2022 to January 2023). Information was retrieved on message volume, response times, message characteristics, messages sent and received by users, user roles, and work settings (inpatient vs outpatient). RESULTS: A total of 32,881 users sent 9,639,149 messages during the study. Median daily message volume was 53,951 during the first 2 weeks of the study and 69,526 during the last 2 weeks, resulting in an overall increase of 29% (P=.03). Nurses were the most frequent users of secure messaging (3,884,270/9,639,149, 40% messages), followed by physicians (2,387,634/9,639,149, 25% messages), and medical assistants (1,135,577/9,639,149, 12% messages). Daily message frequency varied across users; inpatient advanced practice providers and social workers interacted with the highest number of messages per day (median 19). Conversations were predominantly between 2 users (1,258,036/1,547,879, 81% conversations), with a median of 2 conversational turns and a median response time of 2.4 minutes. The largest proportion of inpatient messages was from nurses to physicians (972,243/4,749,186, 20% messages) and physicians to nurses (606,576/4,749,186, 13% messages), while the largest proportion of outpatient messages was from physicians to nurses (344,048/2,192,488, 16% messages) and medical assistants to other medical assistants (236,694/2,192,488, 11% messages). CONCLUSIONS: Secure messaging was widely used by a diverse range of health care professionals, with ongoing growth throughout the study and many users interacting with more than 20 messages per day. The short message response times and high messaging volume observed highlight the interruptive nature of secure messaging, raising questions about its potentially harmful effects on clinician workflow, cognition, and errors.

Effects of Persistent Exposure to COVID-19 on Mental Health Outcomes Among Trainees: a Longitudinal Survey Study.

BACKGROUND: The rapid spread of the coronavirus disease 2019 (COVID-19) has created considerable strain on the physical and mental health of healthcare workers around the world. The effects have been acute for physician trainees-a unique group functioning simultaneously as learners and care providers with limited autonomy. OBJECTIVE: To investigate the longitudinal effects of physician trainee exposure to patients being tested for COVID-19 on stress, anxiety, depression, and burnout using three surveys conducted during the early phase of the pandemic. DESIGN: Longitudinal survey study. PARTICIPANTS: All physician trainees (N = 1375) at an academic medical center. MAIN MEASURE: Assess the relationship between repeated exposure to patients being tested for COVID-19 and stress, anxiety, depression, and burnout. KEY RESULTS: Three hundred eighty-nine trainees completed the baseline survey (28.3%). Of these, 191 and 136 completed the ensuing surveys. Mean stress, anxiety, and burnout decreased by 21% (95% confidence interval (CI): - 28 to - 12%; P < 0.001), 25% (95% CI: - 36 to - 11%; P < 0.001), and 13% (95% CI: - 18 to - 7%; P < 0.001), respectively, per survey. However, for each survey time point, there was mean increase in stress, anxiety, and burnout per additional exposure: stress [24% (95% CI: + 12 to + 38%; P < 0.001)], anxiety [22% (95% CI: + 2 to + 46%; P = 0.026)], and burnout [18% (95% CI: + 10 to + 28%; P < 0.001)]. For depression, the association between exposure was strongest for the third survey, where mean depression scores increased by 33% per additional exposure (95% CI: + 18 to + 50%; P < 0.001). CONCLUSIONS: Training programs should adapt to address the detrimental effects of the "pileup" of distress associated with persistent exposure through adaptive programs that allow flexibility for time off and recovery.

Temporal Associations Between EHR-Derived Workload, Burnout, and Errors: a Prospective Cohort Study.

BACKGROUND: The temporal progression and workload-related causal contributors to physician burnout are not well-understood. OBJECTIVE: To characterize burnout's time course and evaluate the effect of time-varying workload on burnout and medical errors. DESIGN: Six-month longitudinal cohort study with measurements of burnout, workload, and wrong-patient orders every 4 weeks. PARTICIPANTS: Seventy-five intern physicians in internal medicine, pediatrics, and anesthesiology at a large academic medical center. MAIN MEASURES: Burnout was measured using the Professional Fulfillment Index survey. Workload was collected from electronic health record (EHR) audit logs and summarized as follows: total time spent on the EHR, after-hours EHR time, patient load, inbox time, chart review time, note-writing time, and number of orders. Wrong-patient orders were assessed using retract-and-reorder events. KEY RESULTS: Seventy-five of 104 interns enrolled (72.1%) in the study. A total of 337 surveys and 8,863,318 EHR-based actions were analyzed. Median burnout score across the cohort across all time points was 1.2 (IQR 0.7-1.7). Individual-level burnout was variable (median monthly change 0.3, IQR 0.1-0.6). In multivariable analysis, increased total EHR time (ß=0.121 for an increase from 54.5 h per month (25th percentile) to 123.0 h per month (75th percentile), 95%CI=0.016-0.226), increased patient load (ß=0.130 for an increase from 4.9 (25th percentile) to 7.1 (75th percentile) patients per day, 95%CI=0.053-0.207), and increased chart review time (ß=0.096 for an increase from 0.39 (25th percentile) to 0.59 (75th percentile) hours per patient per day, 95%CI=0.015-0.177) were associated with an increased burnout score. After adjusting for the total number of ordering sessions, burnout was not statistically associated with an increased rate of wrong-patient orders (rate ratio=1.20, 95%CI=0.76-1.89). CONCLUSIONS: Burnout and recovery were associated with recent clinical workload for a cohort of physician trainees, highlighting the elastic nature of burnout. Wellness interventions should focus on strategies to mitigate sustained elevations of work responsibilities.

Personalized Surgical Transfusion Risk Prediction Using Machine Learning to Guide Preoperative Type and Screen Orders.

BACKGROUND: Accurate estimation of surgical transfusion risk is essential for efficient allocation of blood bank resources and for other aspects of anesthetic planning. This study hypothesized that a machine learning model incorporating both surgery- and patient-specific variables would outperform the traditional approach that uses only procedure-specific information, allowing for more efficient allocation of preoperative type and screen orders. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Participant Use File was used to train four machine learning models to predict the likelihood of red cell transfusion using surgery-specific and patient-specific variables. A baseline model using only procedure-specific information was created for comparison. The models were trained on surgical encounters that occurred at 722 hospitals in 2016 through 2018. The models were internally validated on surgical cases that occurred at 719 hospitals in 2019. Generalizability of the best-performing model was assessed by external validation on surgical cases occurring at a single institution in 2020. RESULTS: Transfusion prevalence was 2.4% (73,313 of 3,049,617), 2.2% (23,205 of 1,076,441), and 6.7% (1,104 of 16,053) across the training, internal validation, and external validation cohorts, respectively. The gradient boosting machine outperformed the baseline model and was the best- performing model. At a fixed 96% sensitivity, this model had a positive predictive value of 0.06 and 0.21 and recommended type and screens for 36% and 30% of the patients in internal and external validation, respectively. By comparison, the baseline model at the same sensitivity had a positive predictive value of 0.04 and 0.144 and recommended type and screens for 57% and 45% of the patients in internal and external validation, respectively. The most important predictor variables were overall procedure-specific transfusion rate and preoperative hematocrit. CONCLUSIONS: A personalized transfusion risk prediction model was created using both surgery- and patient-specific variables to guide preoperative type and screen orders and showed better performance compared to the traditional procedure-centric approach.

Predicting physician burnout using clinical activity logs: Model performance and lessons learned.

BACKGROUND: Burnout is a significant public health concern affecting more than half of the healthcare workforce; however, passive screening tools to detect burnout are lacking. We investigated the ability of machine learning (ML) techniques to identify burnout using passively collected electronic health record (EHR)-based audit log data. METHOD: Physician trainees participated in a longitudinal study where they completed monthly burnout surveys and provided access to their EHR-based audit logs. Using the monthly burnout scores as the target outcome, we trained ML models using combinations of features derived from audit log data-aggregate measures of clinical workload, time series-based temporal measures of EHR use, and the baseline burnout score. Five ML models were constructed to predict burnout as a continuous score: penalized linear regression, support vector machine, neural network, random forest, and gradient boosting machine. RESULTS: 88 trainee physicians participated and completed 416 surveys; greater than10 million audit log actions were collected (Mean [Standard Deviation] = 25,691 [14,331] actions per month, per physician). The workload feature set predicted burnout score with a mean absolute error (MAE) of 0.602 (95% Confidence Interval (CI), 0.412-0.826), and was able to predict burnout status with an average AUROC of 0.595 (95% CI 0.355-0.808) and average accuracy 0.567 (95% CI 0.393-0.742). The temporal feature set had a similar performance, with MAE 0.596 (95% CI 0.391-0.826), and AUROC 0.581 (95% CI 0.343-0.790). The addition of the baseline burnout score to the workload features improved the model performance to a mean AUROC of 0.829 (95% CI 0.607-0.996) and mean accuracy of 0.781 (95% CI 0.587-0.936); however, this performance was not meaningfully different than using the baseline burnout score alone. CONCLUSIONS: Current findings illustrate the complexities of predicting burnout exclusively based on clinical work activities as captured in the EHR, highlighting its multi-factorial and individualized nature. Future prediction studies of burnout should account for individual factors (e.g., resilience, physiological measurements such as sleep) and associated system-level factors (e.g., leadership).

Elastic wrinkling of keratocyte lamellipodia driven by myosin-induced contractile stress.

During actin-based cell migration, the actin cytoskeleton in the lamellipodium both generates and responds to force, which has functional consequences for the ability of the cell to extend protrusions. However, the material properties of the lamellipodial actin network and its response to stress on the timescale of motility are incompletely understood. Here, we describe a dynamic wrinkling phenotype in the lamellipodium of fish keratocytes, in which the actin sheet buckles upward away from the ventral membrane of the cell, forming a periodic pattern of wrinkles perpendicular to the cell's leading edge. Cells maintain an approximately constant wrinkle wavelength over time despite new wrinkle formation and the lateral movement of wrinkles in the cell frame of reference, suggesting that cells have a preferred or characteristic wrinkle wavelength. Generation of wrinkles is dependent upon myosin contractility, and their wavelength scales directly with the density of the actin network and inversely with cell adhesion. These results are consistent with a simple physical model for wrinkling in an elastic sheet under compression and suggest that the lamellipodial cytoskeleton behaves as an elastic material on the timescale of cell migration despite rapid actin turnover.

Risk factors associated with physician trainee concern over missed educational opportunities during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic resulted in a transformation of clinical care practices to protect both patients and providers. These changes led to a decrease in patient volume, impacting physician trainee education due to lost clinical and didactic opportunities. We measured the prevalence of trainee concern over missed educational opportunities and investigated the risk factors leading to such concerns. METHODS: All residents and fellows at a large academic medical center were invited to participate in a web-based survey in May of 2020. Participants responded to questions regarding demographic characteristics, specialty, primary assigned responsibility during the previous 2 weeks (clinical, education, or research), perceived concern over missed educational opportunities, and burnout. Multivariable logistic regression was used to assess the relationship between missed educational opportunities and the measured variables. RESULTS: 22% (301 of 1375) of the trainees completed the survey. 47% of the participants were concerned about missed educational opportunities. Trainees assigned to education at home had 2.85 [95%CI 1.33-6.45] greater odds of being concerned over missed educational opportunities as compared with trainees performing clinical work. Trainees performing research were not similarly affected [aOR = 0.96, 95%CI (0.47-1.93)]. Trainees in pathology or radiology had 2.51 [95%CI 1.16-5.68] greater odds of concern for missed educational opportunities as compared with medicine. Trainees with greater concern over missed opportunities were more likely to be experiencing burnout (p = 0.038). CONCLUSIONS: Trainees in radiology or pathology and those assigned to education at home were more likely to be concerned about their missed educational opportunities. Residency programs should consider providing trainees with research or at home clinical opportunities as an alternative to self-study should future need for reduced clinical hours arise.

Measuring cognitive effort using tabular transformer-based language models of electronic health record-based audit log action sequences.

OBJECTIVES: To develop and validate a novel measure, action entropy, for assessing the cognitive effort associated with electronic health record (EHR)-based work activities. MATERIALS AND METHODS: EHR-based audit logs of attending physicians and advanced practice providers (APPs) from four surgical intensive care units in 2019 were included. Neural language models (LMs) were trained and validated separately for attendings' and APPs' action sequences. Action entropy was calculated as the cross-entropy associated with the predicted probability of the next action, based on prior actions. To validate the measure, a matched pairs study was conducted to assess the difference in action entropy during known high cognitive effort scenarios, namely, attention switching between patients and to or from the EHR inbox. RESULTS: Sixty-five clinicians performing 5 904 429 EHR-based audit log actions on 8956 unique patients were included. All attention switching scenarios were associated with a higher action entropy compared to non-switching scenarios (P < .001), except for the from-inbox switching scenario among APPs. The highest difference among attendings was for the from-inbox attention switching: Action entropy was 1.288 (95% CI, 1.256-1.320) standard deviations (SDs) higher for switching compared to non-switching scenarios. For APPs, the highest difference was for the to-inbox switching, where action entropy was 2.354 (95% CI, 2.311-2.397) SDs higher for switching compared to non-switching scenarios. DISCUSSION: We developed a LM-based metric, action entropy, for assessing cognitive burden associated with EHR-based actions. The metric showed discriminant validity and statistical significance when evaluated against known situations of high cognitive effort (ie, attention switching). With additional validation, this metric can potentially be used as a screening tool for assessing behavioral action phenotypes that are associated with higher cognitive burden. CONCLUSION: An LM-based action entropy metric-relying on sequences of EHR actions-offers opportunities for assessing cognitive effort in EHR-based workflows.

Contributors to Electronic Health Record-Integrated Secure Messaging Use: A Study of Over 33,000 Health Care Professionals.

OBJECTIVES: Electronic health record (EHR)-integrated secure messaging is extensively used for communication between clinicians. We investigated the factors contributing to secure messaging use in a large health care system. METHODS: This was a cross-sectional study that included 14 hospitals and 263 outpatient clinic locations. Data on EHR-integrated secure messaging use over a 1-month period (February 1, 2023, through February 28, 2023) were collected. A multilevel mixed effects model was used to assess the contribution of clinical role, clinical unit (i.e., specific inpatient ward or outpatient clinic), hospital or clinic location (i.e., Hospital X or Outpatient Clinic Building Y), and inpatient versus outpatient setting toward secure messaging use. RESULTS: Of the 33,195 health care professionals who worked during the study period, 20,576 (62%) were secure messaging users. In total, 25.3% of the variability in messaging use was attributable to the clinical unit and 30.5% was attributable to the hospital or clinic location. Compared with nurses, advanced practice providers, pharmacists, and physicians were more likely to use secure messaging, whereas medical assistants, social workers, and therapists were less likely (p < 0.001). After adjusting for other factors, inpatient versus outpatient setting was not associated with secure messaging use. CONCLUSION: Secure messaging was widely used; however, there was substantial variation by clinical role, clinical unit, and hospital or clinic location. Our results suggest that interventions and policies for managing secure messaging behaviors are likely to be most effective if they are not only set at the organizational level but also communicated and tailored toward individual clinical units and clinician workflows.

National Multi-Institutional Validation of a Surgical Transfusion Risk Prediction Model.

BACKGROUND: Accurate estimation of surgical transfusion risk is important for many aspects of surgical planning, yet few methods for estimating are available for estimating such risk. There is a need for reliable validated methods for transfusion risk stratification to support effective perioperative planning and resource stewardship. STUDY DESIGN: This study was conducted using the American College of Surgeons NSQIP datafile from 2019. S-PATH performance was evaluated at each contributing hospital, with and without hospital-specific model tuning. Linear regression was used to assess the relationship between hospital characteristics and area under the receiver operating characteristic (AUROC) curve. RESULTS: A total of 1,000,927 surgical cases from 414 hospitals were evaluated. Aggregate AUROC was 0.910 (95% CI 0.904 to 0.916) without model tuning and 0.925 (95% CI 0.919 to 0.931) with model tuning. AUROC varied across individual hospitals (median 0.900, interquartile range 0.849 to 0.944), but no statistically significant relationships were found between hospital-level characteristics studied and model AUROC. CONCLUSIONS: S-PATH demonstrated excellent discriminative performance, although there was variation across hospitals that was not well-explained by hospital-level characteristics. These results highlight the S-PATH's viability as a generalizable surgical transfusion risk prediction tool.

Classifying clinical work settings using EHR audit logs: a machine learning approach.

OBJECTIVES: We used electronic health record (EHR)-based raw audit logs to classify the work settings of anesthesiology physicians providing care in both surgical intensive care units (ICUs) and operating rooms. STUDY DESIGN: Observational study. METHODS: Attending anesthesiologists who worked at least 1 shift in 1 of 4 surgical ICUs in calendar year 2019 were included. Time-stamped EHR-based audit log events for each week were used to create event frequencies and represented as a term frequency-inverse document frequency matrix. Primary classification outcome of interest was a physician's clinical work setting. Performance of multiple supervised machine learning classifiers were evaluated. RESULTS: A total of 24 attending physicians were included; physicians performed a median (IQR) of 2545 (906-5071) EHR-based actions per week and worked a median (IQR) of 5 (3-7) weeks in a surgical ICU. A random forest classifier yielded the best discriminative performance (mean [SD] area under receiver operating characteristic curve, 0.88 [0.05]; mean [SD] area under precision-recall curve, 0.72 [0.13]). Model explanations illustrated that clinical activities related to signing of clinical notes, printing handoff data, and updating diagnosis information were associated with the positive prediction of working in a surgical ICU setting. CONCLUSIONS: A random forest classifier using a frequency-based feature engineering approach successfully predicted work settings of physicians with multiple clinical responsibilities with high accuracy. These findings highlight opportunities for using audit logs for automated assessment of clinician activities and their work settings, thereby affording the ability to accurately assess context-specific work characteristics (eg, workload).

Characterizing the macrostructure of electronic health record work using raw audit logs: an unsupervised action embeddings approach.

Raw audit logs provide a comprehensive record of clinicians' activities on an electronic health record (EHR) and have considerable potential for studying clinician behaviors. However, research using raw audit logs is limited because they lack context for clinical tasks, leading to difficulties in interpretation. We describe a novel unsupervised approach using the comparison and visualization of EHR action embeddings to learn context and structure from raw audit log activities. Using a dataset of 15 767 634 raw audit log actions performed by 88 intern physicians over 6 months of EHR use across inpatient and outpatient settings, we demonstrated that embeddings can be used to learn the situated context for EHR-based work activities, identify discrete clinical workflows, and discern activities typically performed across diverse contexts. Our approach represents an important methodological advance in raw audit log research, facilitating the future development of metrics and predictive models to measure clinician behaviors at the macroscale.

Anesthesia Clinical Workload Estimated From Electronic Health Record Documentation vs Billed Relative Value Units.

Importance: Accurate measurements of clinical workload are needed to inform health care policy. Existing methods for measuring clinical workload rely on surveys or time-motion studies, which are labor-intensive to collect and subject to biases. Objective: To compare anesthesia clinical workload estimated from electronic health record (EHR) audit log data vs billed relative value units. Design, Setting, and Participants: This cross-sectional study of anesthetic encounters occurring between August 26, 2019, and February 9, 2020, used data from 8 academic hospitals, community hospitals, and surgical centers across Missouri and Illinois. Clinicians who provided anesthetic services for at least 1 surgical encounter were included. Data were analyzed from January 2022 to January 2023. Exposure: Anesthetic encounters associated with a surgical procedure were included. Encounters associated with labor analgesia and endoscopy were excluded. Main Outcomes and Measures: For each encounter, EHR-derived clinical workload was estimated as the sum of all EHR actions recorded in the audit log by anesthesia clinicians who provided care. Billing-derived clinical workload was measured as the total number of units billed for the encounter. A linear mixed-effects model was used to estimate the relative contribution of patient complexity (American Society of Anesthesiology [ASA] physical status modifier), procedure complexity (ASA base unit value for the procedure), and anesthetic duration (time units) to EHR-derived and billing-derived workload. The resulting ß coefficients were interpreted as the expected effect of a 1-unit change in each independent variable on the standardized workload outcome. The analysis plan was developed after the data were obtained. Results: A total of 405 clinicians who provided anesthesia for 31 688 encounters were included in the study. A total of 8 288 132 audit log actions corresponding to 39 131 hours of EHR use were used to measure EHR-derived workload. The contributions of patient complexity, procedural complexity, and anesthesia duration to EHR-derived workload differed significantly from their contributions to billing-derived workload. The contribution of patient complexity toward EHR-derived workload (ß = 0.162; 95% CI, 0.153-0.171) was more than 50% greater than its contribution toward billing-derived workload (ß = 0.106; 95% CI, 0.097-0.116; P < .001). In contrast, the contribution of procedure complexity toward EHR-derived workload (ß = 0.033; 95% CI, 0.031-0.035) was approximately one-third its contribution toward billing-derived workload (ß = 0.106; 95% CI, 0.104-0.108; P < .001). Conclusions and Relevance: In this cross-sectional study of 8 hospitals, reimbursement for anesthesiology services overcompensated for procedural complexity and undercompensated for patient complexity. This method for measuring clinical workload could be used to improve reimbursement valuations for anesthesia and other specialties.

Conceptual considerations for using EHR-based activity logs to measure clinician burnout and its effects.

Electronic health records (EHR) use is often considered a significant contributor to clinician burnout. Informatics researchers often measure clinical workload using EHR-derived audit logs and use it for quantifying the contribution of EHR use to clinician burnout. However, translating clinician workload measured using EHR-based audit logs into a meaningful burnout metric requires an alignment with the conceptual and theoretical principles of burnout. In this perspective, we describe a systems-oriented conceptual framework to achieve such an alignment and describe the pragmatic realization of this conceptual framework using 3 key dimensions: standardizing the measurement of EHR-based clinical work activities, implementing complementary measurements, and using appropriate instruments to assess burnout and its downstream outcomes. We discuss how careful considerations of such dimensions can help in augmenting EHR-based audit logs to measure factors that contribute to burnout and for meaningfully assessing downstream patient safety outcomes.