Analysis of Electronic Health Record Use and Clinical Productivity and Their Association With Physician Turnover

Edward R Melnick,Raj M Ratwani,Christine A Sinsky,Ryan T O'Connell,Mihriye Mete,Bidisha Nath,Allan Fong,Richard Goldstein,Brian Williams,Daniel Marchalik

doi:10.1001/jamanetworkopen.2021.28790

Abstract

Physician turnover takes a heavy toll on patients, physicians, and health care organizations. Survey research has established associations of electronic health record (EHR) use with professional burnout and reduction in professional effort, but these findings are subject to response fatigue and bias. To evaluate the association of physician productivity and EHR use patterns, as determined by vendor-derived EHR use data platforms, with physician turnover. This retrospective cohort study was conducted among nonteaching ambulatory physicians at a large ambulatory practice network based in New England. Data were collected from March 2018 to February 2020. Physician departure from the practice network; 4 time-based core measures of EHR use, normalized to 8 hours of scheduled clinical time; teamwork, percentage of a physician's orders that are placed by other members of the care team; and productivity measures of patient volume, intensity, and demand. Among 335 physicians assessed for eligibility, 314 unique physicians (89.2%) were included in the analysis (123 [39%] women; 100 [32%] aged 45-54 years), with 5663 physician-months of data. The turnover rate was 5.1%/year (32 of 314 physicians). Physicians completed a mean 2.6 appointments/hour (95% CI, 2.5-2.6 appointments/hour) and 206 appointments/month (95% CI, 197-215 appointments/month) with 5.5 hours (95% CI, 5.3-5.8 hours) of EHR time for every 8 hours of scheduled patient time. After controlling for gender, medical specialty, and time, the following variables were associated with turnover: inbox time (odds ratio [OR], 0.70; 95% CI, 0.61-0.82; P < .001), teamwork (OR, 0.68; 95% CI, 0.52-0.87; P = .003), demand (ie, proportion of available appointments filled: OR, 0.49; 95% CI, 0.35-0.70; P < .001), and age 45 to 54 years vs 25 to 34 years (OR, 0.19; 95% CI, 0.04-0.93; P = .04). In this study, physician productivity and EHR use metrics were associated with physician departure. Prospectively tracking these metrics could identify physicians at high risk of departure who would benefit from early, team-based, targeted interventions. The counterintuitive finding that less time spent on the EHR (in particular inbox management) was associated with physician departure warrants further investigation.

Highlights

Physician turnover disrupts patients’ continuity of care, the lives of physicians and their families, and strains health care organizations’ culture, climate, and finances
In this study, physician productivity and electronic health record (EHR) use metrics were associated with physician departure
The counterintuitive finding that less time spent on the EHR was associated with physician departure warrants further investigation

Summary

Introduction

Physician turnover disrupts patients’ continuity of care, the lives of physicians and their families, and strains health care organizations’ culture, climate, and finances. Cross-sectional analyses have established associations between professional satisfaction, burnout, intention to leave,[6,7,8,9,10] and actual reduction in professional effort.[11] Given excessive physician time spent on electronic health record (EHR) activities[12,13,14,15] and its association with professional burnout,[16,17,18] it is not surprising that physician dissatisfaction with the EHR has been associated with intention to reduce clinical work in the 12 months (in national sample of 6880 physicians: OR, 1.44; 95% CI, 1.16-1.80; P = .001) and to leave one’s current position in the 24 months (OR, 1.57; 95% CI, 1.27-1.93; P < .001).[8] In particular, EHR inbox message volume has been strongly associated with physician burnout.[19,20]

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Discussion

Conclusion