Electronic Health Record Burden Research Articles

Physicians in ACOs report greater documentation burden.

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. Retrospective analyses of US office-based physicians in 2019 and 2021. 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. 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). 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.

More Tethered to the EHR: EHR Workload Trends Among Academic Primary Care Physicians, 2019-2023.

The purpose of this study is to evaluate recent trends in primary care physician (PCP) electronic health record (EHR) workload. This longitudinal study observed the EHR use of 141 academic PCPs over 4 years (May 2019 to March 2023). Ambulatory full-time equivalency (aFTE), visit volume, and panel size were evaluated. Electronic health record time and inbox message volume were measured per 8 hours of scheduled clinic appointments. From the pre-COVID-19 pandemic year (May 2019 to February 2020) to the most recent study year (April 2022 to March 2023), the average time PCPs spent in the EHR per 8 hours of scheduled clinic appointments increased (+28.4 minutes, 7.8%), as did time in orders (+23.1 minutes, 58.9%), inbox (+14.0 minutes, 24.4%), chart review (+7.2 minutes, 13.0%), notes (+2.9 minutes, 2.3%), outside scheduled hours on days with scheduled appointments (+6.4 minutes, 8.2%), and on unscheduled days (+13.6 minutes, 19.9%). Primary care physicians received more patient medical advice requests (+5.4 messages, 55.5%) and prescription messages (+2.3, 19.5%) per 8 hours of scheduled clinic appointments, but fewer patient calls (-2.8, -10.5%) and results messages (-0.3, -2.7%). While total time in the EHR continued to increase in the final study year (+7.7 minutes, 2.0%), inbox time decreased slightly from the year prior (-2.2 minutes, -3.0%). Primary care physicians' average aFTE decreased 5.2% from 0.66 to 0.63 over 4 years. Primary care physicians' time in the EHR continues to grow. While PCPs' inbox time may be stabilizing, it is still substantially higher than pre-pandemic levels. It is imperative health systems develop strategies to change the EHR workload trajectory to minimize PCPs' occupational stress and mitigate unnecessary reductions in effective physician workforce resulting from the increased EHR burden.

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

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. 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. 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. 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. 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). 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.

Changes in Physician Electronic Health Record Use With the Expansion of Telemedicine

Understanding the drivers of electronic health record (EHR) burden, including EHR time and patient messaging, may directly inform strategies to address physician burnout. Given the COVID-19-induced expansion of telemedicine-now used for a substantial proportion of ambulatory encounters-its association with EHR burden should be evaluated. To measure the association of the telemedicine expansion with time spent working in the EHR and with patient messaging among ambulatory physicians before and after the onset of the COVID-19 pandemic. This longitudinal cohort study analyzed weekly EHR metadata of ambulatory physicians at UCSF Health, a large academic medical center. The same EHR measures were compared for 1 year before the COVID-19 pandemic (August 2018-September 2019) with the same period 1 year after its onset (August 2020-September 2021). Multivariable regression models evaluating the association between level of telemedicine use and EHR use were then assessed after the onset of the pandemic. The sample included all physician-weeks with at least 1 scheduled half-day clinic in the 11 largest ambulatory specialties at UCSF Health. Data analyses were performed from March 1, 2022, through July 1, 2023. Physicians' weekly modality mix of either entirely face-to-face visits, mixed modalities, or entirely telemedicine. The EHR time during and outside of patient scheduled hours (PSHs), time spent documenting (normalized per 8 PSHs), and electronic messages sent to and received from patients. The study sample included 1052 physicians (437 [41.5%] men and 615 [58.5%] women) during 115 weeks, which provided 35 697 physician-week observations. Comparing the period before to the period after pandemic onset showed that physician time spent working in the EHR during PSHs increased from 4.53 to 5.46 hours per 8 PSH (difference, 0.93; 95% CI, 0.87-0.98; P < 0.001); outside of PSHs, increased from 4.29 to 5.34 hours (difference, 1.04; 95% CI, 0.95-1.14; P < 0.001); and time documenting during and outside of PSHs increased from 6.35 to 8.18 hours (difference, 1.83; 95% CI, 1.72-1.94; P < 0.001). Mean weekly messages received from patients increased from 16.76 to 30.33, and messages sent to patients increased from 13.82 to 29.83. In multivariable models, weeks with a mix of face-to-face and telemedicine (β, 0.43; 95% CI, 0.31-0.55; P < .001) visits or entirely telemedicine (β, 0.91; 95% CI, 0.74-1.09; P < .001) had more EHR time during PSHs than all face-to-face weeks, with similar results for EHR time outside of PSHs. There was no association between telemedicine use and messages received from patients, whereas mixed modalities (β, -0.90; 95% CI, -1.73 to -0.08; P = .03) and all telemedicine (β, -4.06; 95% CI, -5.19 to -2.93; P < .001) were associated with fewer messages sent to patients compared with entirely face-to-face weeks. The findings of this longitudinal cohort study suggest that telemedicine is associated with greater physician time spent working in the EHR, both during and outside of scheduled hours, mostly documenting visits and not messaging patients. Health systems may need to adjust productivity expectations for physicians and develop strategies to address EHR documentation burden for physicians.

Identifying and Addressing Barriers to Implementing Core Electronic Health Record Use Metrics for Ambulatory Care: Virtual Consensus Conference Proceedings.

Precise, reliable, valid metrics that are cost-effective and require reasonable implementation time and effort are needed to drive electronic health record (EHR) improvements and decrease EHR burden. Differences exist between research and vendor definitions of metrics. PROCESS: We convened three stakeholder groups (health system informatics leaders, EHR vendor representatives, and researchers) in a virtual workshop series to achieve consensus on barriers, solutions, and next steps to implementing the core EHR use metrics in ambulatory care. CONCLUSION: Actionable solutions identified to address core categories of EHR metric implementation challenges include: (1) maintaining broad stakeholder engagement, (2) reaching agreement on standardized measure definitions across vendors, (3) integrating clinician perspectives, and (4) addressing cognitive and EHR burden. Building upon the momentum of this workshop's outputs offers promise for overcoming barriers to implementing EHR use metrics.

Using K-Means Clustering to Identify Physician Clusters by Electronic Health Record Burden and Efficiency.

Objectives: Electronic health records (EHRs) have transformed the way modern medicine is practiced, but they remain a major source of documentation burden among physicians. This study aims to use data from Signal, a tool provided by the Epic EHR, to analyze physician metadata in the Montefiore Health System via cluster analysis to assess EHR burden and efficiency. Methods: Data were obtained for a one-month period (July 2020) representing a return to normal operation post-telemedicine implementation. Six metrics from Signal were used to phenotype physicians: time on unscheduled days, pajama time, time outside of 7 AM to 7 PM, turnaround time, proficiency score, and visits closed the same day. k-Means clustering was employed to group physicians, and the clusters were assessed overall and by sex and specialty. Results: Our results demonstrate the partitioning of physicians into a higher-efficiency, lower-time outside of scheduled hours (TOSH) cluster and a lower-efficiency, higher-TOSH cluster even when stratified by sex and specialty. Intra-cluster comparisons showed general homogeneity of physician metrics with the exception of the higher-efficiency, lower-TOSH cluster when stratified by sex. Conclusions: Taken together, the clusters uniquely reflect the EHR efficiency-burden of the Montefiore Health System. Applying k-means clustering to readily available EHR data allows for a scalable, efficient, and adaptable approach of assessing physician EHR burden and efficiency, allowing health systems to examine documentation trends and target wellness interventions.

COVID Exacerbated the Gender Disparity in Physician Electronic Health Record Inbox Burden.

The COVID-19 pandemic was associated with significant changes to the delivery of ambulatory care, including a dramatic increase in patient messages to physicians. While asynchronous messaging is a valuable communication modality for patients, a greater volume of patient messages is associated with burnout and decreased well-being for physicians. Given that women physicians experienced greater EHR burden and received more patient messages pre-pandemic, there is concern that COVID may have exacerbated this disparity. Using EHR audit log data of ambulatory physicians at an academic medical center, we used a difference-in-differences framework to evaluate the impact of the pandemic on patient message volume and compare differences between men and women physicians. We found patient message volume increased post-COVID for all physicians, and women physicians saw an additional increase compared to men. Our results contribute to the growing evidence of different communication expectations for women physicians that contribute to the gender disparity in EHR burden.

416 On-Call Junior Neurosurgery Residents Spend 9 Hours of Their On-Call Shift Actively Using the Electronic Health Record

INTRODUCTION: The Electronic Health Record (EHR) is central to clinical workflow, yet few studies to date have explored EHR usage patterns among neurosurgery trainees. METHODS: We utilized the EHR audit logs, time-stamped records of user activities, to review EHR usage of PGY-2 and 3 neurosurgery residents scheduled for 1 or more on-call days across 2 calendar years at the University of California San Francisco. We focused on the PGY-2 and 3 years, which in our training program represent the primary participants in the in-house on-call pool. RESULTS: Over 723 call days, 12 different residents took at least one on-call shift. The median (IQR) number of minutes that residents spent per on-call shift actively using the EHR was 536.8 (203.5), while interacting with an average (SD) of 68.1 (14.7) patient charts. There was no significant difference between active EHR time between residents as PGY-2 and PGY-3 on paired t-tests. Residents spent the most time on the following EHR activities: patient reports, notes, order management, patient list, and chart review. CONCLUSIONS: Residents spent, on average, 9 hours of their on-call shift actively using the EHR, and there was no improved efficiency as residents gained experience. We noted several areas of administrative EHR burden which could be reduced.

Electronic Health Record Burden Among Gastroenterology Providers Associated With Subspecialty and Training.

Use of the electronic health record (EHR) has become increasingly widespread. Higher EHR burden is associated with burnout, but this has not been specifically investigated among gastroenterology (GI) providers. We retrospectively collected measures of EHR use for outpatient GI providers during a 6-month period. We compared metrics across provider sex, subspecialty, and training (physicians vs nonphysician providers [NPPs]). Data collected represented more than 16,000 appointments from 41 providers across the Division of Gastroenterology and Hepatology. Inflammatory bowel disease (IBD) and hepatology specialists spent more time per appointment in the EHR, clinical review, and outside regular hours compared with other subspecialists. NPPs spent more EHR time than physicians. IBD and hepatology specialists and NPPs may have disproportionally high EHR burden. More work is needed to understand differences in provider workload to combat burnout.

On-Call Junior Neurosurgery Residents Spend 9 hours of Their On-Call Shift Actively Using the Electronic Health Record.

The electronic health record (EHR) is central to clinical workflow, yet few studies to date have explored EHR usage patterns among neurosurgery trainees. To describe the amount of EHR time spent by postgraduate year (PGY)-2 and PGY-3 neurosurgery residents during on-call days and the distribution of EHR activities in which they engage. This cohort study used the EHR audit logs, time-stamped records of user activities, to review EHR usage of PGY-2 and PGY-3 neurosurgery residents scheduled for 1 or more on-call days across 2 calendar years at the University of California San Francisco. We focused on the PGY-2 and PGY-3, which, in our training program, represent the primary participants in the in-house on-call pool. Over 723 call days, 12 different residents took at least one on-call shift. The median (IQR) number of minutes that residents spent per on-call shift actively using the EHR was 536.8 (203.5), while interacting with an average (SD) of 68.1 (14.7) patient charts. There was no significant difference between Active EHR Time between residents as PGY-2 and PGY-3 on paired t -tests. Residents spent the most time on the following EHR activities: patient reports, notes, order management, patient list, and chart review. Residents spent, on average, 9 hours of their on-call shift actively using the EHR, and there was no improved efficiency as residents gained experience. We noted several areas of administrative EHR burden, which could be reduced.

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

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. 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. 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. 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. 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. "Efficiency tools" like copy/paste and templated text meant to reduce documentation burden and increase provider efficiency may have limited efficacy.

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

We analyze observed reductions in physician note length and documentation time, 2 contributors to electronic health record (EHR) burden and burnout. We used EHR metadata from January to May, 2021 for 130079 ambulatory physician Epic users. We identified cohorts of physicians who decreased note length and/or documentation time and analyzed changes in their note composition. 37857 physicians decreased either note length (n = 15647), time in notes (n = 15417), 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%). Organizations must consider priorities and tradeoffs in the distinct approaches needed to address different contributors to EHR burden. Future research should explore scalable burden-reduction initiatives responsive to both note bloat and documentation time.

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

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. To characterize measures of EHR use and ambulatory care quality performance among PCPs. 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. 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). 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). 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. 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.

S1480 Clinical Burden of Electronic Health Record Use Amongst Gastroenterology Providers Associated With Differences in Sex, Provider Subspecialty, and Provider Training

Introduction: The electronic health record (EHR) has increased time spent outside of face-to-face encounters, with higher EHR burden associated with differences in provider sex, specialty, and rates of burnout. However, the EHR burden specific to gastroenterology (GI) providers is not fully understood. Methods: Measures of EHR use calculated through Epic Systems were retrospectively collected for GI providers from a tertiary referral center during a 6-month period starting January 1, 2021. Primary measures used to characterize EHR use included time spent performing clinical review, documentation, and in-basket management as well as quantification of efficiency, messaging, and time logged into the EHR, including time outside regularly scheduled hours (5:30 p.m. to 7:00 a.m. and weekends). EHR use patterns were compared across provider sex, sub-specialty (inflammatory bowel disease [IBD], motility/irritable bowel syndrome, advanced endoscopy [AE], and esophagus [ESO]), and training (physician vs non-physician provider [NPP]). Data was analyzed in aggregate using t-tests and analysis of variance with post-hoc Boniferri correction. Results: Data from 33 providers compromising 3,743 clinic days and 16,572 appointments was collected. Overall, 69.7% (23/33) were physicians, 30.3% (10/33) NPPs and 48.5% (16/33) were women, with women comprising all NPPs. Comparing EHR burden across sexes, women spent more daily time in clinical review than men (42.4 minutes vs 26.0, P = 0.02), though this result lost statistical significance when excluding NPPs. Comparing sub-specialties, IBD specialists spent more daily time in clinical review per appointment than AEs or ESOs (13.7 minutes vs 3.9 and 3.7, respectively; P < 0.001) yet had higher efficiency scores compared to these sub-specialties (P < 0.001). Compared to AEs, IBD specialists spent more overall daily time in the EHR (131.5 minutes vs 39.7, P < 0.005) as well as more daily time outside of regular work hours (60.0 minutes vs 8.9, P < 0.01). Comparing provider training, NPPs spent more daily time in the in-basket (P = 0.03), clinical review (P = 0.02), and overall EHR (P < 0.001) than physicians. Additionally, NPPs received more patient medical advice request messages per day than physicians (P = 0.03). Conclusion: IBD specialists and NPPs have an increased EHR burden. More work is needed to better understand sex, sub-specialty, and training-based differences in workload to combat factors contributing to provider burnout.

The Impact of the COVID-19 Pandemic on Physician Electronic Health Record Use and Burden at a Canadian Mental Health Hospital.

The COVID-19 Pandemic has significantly changed the delivery of care through new workflows and models of care. However, the impact of these changes on the usage of electronic health record (EHR) systems remains unclear. This mixed method study aims to understand how EHR usage patterns changed between the pandemic onset and the pre-pandemic period at a Canadian mental health hospital, using an analysis of EHR usage log data and a qualitative focus group. An increase in after-hours EHR usage and documentation time per patient was observed, as well as a decrease in order time. Virtual care (VC) use also had an impact on time spent per patient within the EHR and after-hours EHR usage. Qualitative results highlighted physician concerns related to VC workflows and documentation, which contributed to additional EHR burden. Future work should focus on different contexts and developing relevant interventions to address these issues.

Time and Clerical Burden Posed by the Current Electronic Health Record for Orthopaedic Surgeons.

The electronic health record (EHR) has become an integral part of modern medical practice. The balance of benefit versus burden of a required EHR remains inconclusive, with many studies identifying increasing physician burnout and less face-to-face patient contact because of increasing documentation demands. Few studies have investigated EHR burden in orthopaedic surgery practice. This study aimed to characterize and compare EHR usage patterns and time allocation within EHR between orthopaedic surgeons, other surgeons, and medicine physicians at an academic medical center. EHR usage was digitally tracked within a large academic medical center. EHR usage data were compiled for all physicians seeing outpatients from April 2018 to June 2019. The tracking metrics included time spent answering messages, typing notes, reviewing laboratories and imaging, reading notes, and placing orders. Physicians were subdivided between orthopaedic surgeons, other surgeons, and nonsurgeon/medical specialties. Statistical comparisons using a two-sample t-test were done between orthopaedic surgeon EHR usage patterns and other surgeons, in addition to orthopaedic surgeons versus nonsurgeons. One thousand sixty physicians including 28 full-time orthopaedic surgeons, 134 other surgeons, and 898 nonsurgical medicine physicians met inclusion criteria. Orthopaedic surgeons saw on average 31 patients per office day compared with other surgeons at 18 patients per office day (P < 0.01) and nonsurgeons at 12 patients per office day (P < 0.01). Orthopaedic surgeons received more EHR messages while also being more efficient at answering EHR messages compared with other surgeons and nonsurgeons (P < 0.01). EHR tasks, including answering messages, placing orders, chart review, writing notes, and reviewing imaging, consumed 58% of an orthopaedic surgeon's scheduled office day with the largest contribution from required note writing. In academic orthopaedic practice, EHR use has surpassed face-to-face patient time, consuming 58% of orthopaedic surgeons' clinical days. With the previously shown correlation between EHR burden and physician burnout, targeted interventions to increase efficiency and off-load EHR burden are necessary to sustain a successful orthopaedic practice.

The Effect of Electronic Health Record Burden on Pediatricians' Work-Life Balance and Career Satisfaction.

To examine pediatricians' perspectives on administrative tasks including electronic health record (EHR) documentation burden and their effect on work-life balance and life and career satisfaction. We analyzed 2018 survey data from the American Academy of Pediatrics (AAP) Pediatrician Life and Career Experience Study (PLACES), a longitudinal cohort study of early and midcareer pediatricians. Cohorts graduated from residency between 2002 and 2004 or 2009 and 2011. Participants were randomly selected from an AAP database (included all pediatricians who completed U.S. pediatric residency programs). Four in 10 pediatricians (1,796 out of 4,677) were enrolled in PLACES in 2012 and considered participants in 2018. Data were weighted to adjust for differences between study participants and the overall population of pediatricians. Chi-square and multivariable logistic regression examined the association of EHR burden on work-life balance (three measures) and satisfaction with work, career, and life (three measures). Responses to an open-ended question on experiences with administrative tasks were reviewed. A total of 66% of pediatrician participants completed the 2018 surveys (1,192 of 1,796; analytic sample = 1,069). Three-fourths reported EHR documentation as a major or moderate burden. Half reported such burden for billing and insurance and 42.7% for quality and performance measurement. Most pediatricians reported satisfaction with their jobs (86.7%), careers (84.5%), and lives (66.2%). Many reported work-life balance challenges (52.5% reported stress balancing work and personal responsibilities). In multivariable analysis, higher reported EHR burden was associated with lower scores on career and life satisfaction measures and on all three measures of work-life balance. Open-ended responses (n = 467) revealed several themes. Two predominant themes especially supported the quantitative findings-poor EHR functionality and lack of support for administrative burdens. Most early to midcareer pediatricians experience administrative burdens with EHRs. These experiences are associated with worse work-life balance including more stress in balancing responsibilities and less career and life satisfaction.

Building the evidence-base to reduce electronic health record-related clinician burden.

Clinicians face competing pressures of being clinically productive while using imperfect electronic health record (EHR) systems and maximizing face-to-face time with patients. EHR use is increasingly associated with clinician burnout and underscores the need for interventions to improve clinicians' experiences. With an aim of addressing this need, we share evidence-based informatics approaches, pragmatic next steps, and future research directions to improve 3 of the highest contributors to EHR burden: (1) documentation, (2) chart review, and (3) inbox tasks. These approaches leverage speech recognition technologies, natural language processing, artificial intelligence, and redesign of EHR workflow and user interfaces. We also offer a perspective on how EHR vendors, healthcare system leaders, and policymakers all play an integral role while sharing responsibility in helping make evidence-based sociotechnical solutions available and easy to use.

Assessment of Electronic Health Record Use Between US and Non-US Health Systems

Understanding how the electronic health record (EHR) system changes clinician work, productivity, and well-being is critical. Little is known regarding global variation in patterns of use. To provide insights into which EHR activities clinicians spend their time doing, the EHR tools they use, the system messages they receive, and the amount of time they spend using the EHR after hours. This cross-sectional study analyzed the deidentified metadata of ambulatory care health systems in the US, Canada, Northern Europe, Western Europe, the Middle East, and Oceania from January 1, 2019, to August 31, 2019. All of these organizations used the EHR software from Epic Systems and represented most of Epic Systems's ambulatory customer base. The sample included all clinicians with scheduled patient appointments, such as physicians and advanced practice practitioners. Clinician EHR use was tracked by deidentified and aggregated metadata across a variety of clinical activities. Descriptive statistics for clinician EHR use included time spent on clinical activities, note documentation (as measured by the percentage of characters in the note generated by automated or manual data entry source), messages received, and time spent after hours. A total of 371 health systems were included in the sample, of which 348 (93.8%) were located in the US and 23 (6.2%) were located in other countries. US clinicians spent more time per day actively using the EHR compared with non-US clinicians (mean time, 90.2 minutes vs 59.1 minutes; P < .001). In addition, US clinicians vs non-US clinicians spent significantly more time performing 4 clinical activities: notes (40.7 minutes vs 30.7 minutes; P < .001), orders (19.5 minutes vs 8.75 minutes; P < .001), in-basket messages (12.5 minutes vs 4.80 minutes; P < .001), and clinical review (17.6 minutes vs 14.8 minutes; P = .01). Clinicians in the US composed more automated note text than their non-US counterparts (77.5% vs 60.8% of note text; P < .001) and received statistically significantly more messages per day (33.8 vs 12.8; P < .001). Furthermore, US clinicians used the EHR for a longer time after hours, logging in 26.5 minutes per day vs 19.5 minutes per day for non-US clinicians (P = .01). The median US clinician spent as much time actively using the EHR per day (90.1 minutes) as a non-US clinician in the 99th percentile of active EHR use time per day (90.7 minutes) in the sample. These results persisted after controlling for organizational characteristics, including structure, type, size, and daily patient volume. This study found that US clinicians compared with their non-US counterparts spent substantially more time actively using the EHR for a wide range of clinical activities or tasks. This finding suggests that US clinicians have a greater EHR burden that may be associated with nontechnical factors, which policy makers and health system leaders should consider when addressing clinician wellness.

A National Survey of Burnout and Depression Among Fellows Training in Pulmonary and Critical Care Medicine: A Special Report by the Association of Pulmonary and Critical Care Medicine Program Directors

The prevalence of burnout and depressive symptoms is high among physician trainees. What is the burden of burnout and depressive symptoms among fellows training in pulmonary and critical care medicine (PCCM) and what are associated individual fellow, program, and institutional characteristics? We conducted a cross-sectional electronic survey of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States to assess burnout and depressive symptoms. Burnout symptoms were measured using the Maslach Burnout Index two-item measure. The two-item Primary Care Evaluation of Mental Disorders Procedure was used to screen for depressive symptoms. For each of the two outcomes (burnout and depressive symptoms), we constructed three multivariate logistic regression models to assess individual fellow characteristics, program structure, and institutional polices associated with either burnout or depressive symptoms. Five hundred two of the 976 fellows who received the survey completed it-including both outcome measures-giving a response rate of 51%. Fifty percent of fellows showed positive results for either burnout or depressive symptoms, with 41%showing positive results for depressive symptoms, 32%showing positive results for burnout, and 23%showing positive results for both. Reporting a coverage system in the case of personal illness or emergency (adjusted OR [aOR], 0.44; 95%CI, 0.26-0.73) and access to mental health services (aOR, 0.14; 95%CI, 0.04-0.47) were associated with lower odds of burnout. Financial concern was associated with higher odds of depressive symptoms (aOR, 1.13; 95%CI, 1.05-1.22). Working more than 70 hours in an average clinical week and the burdens of electronic health record (EHR) documentation were associated with a higher odds of both burnout and depressive symptoms. Given the high prevalence of burnout and depressive symptoms among fellows training in PCCM, an urgent need exists to identify solutions that address this public health crisis. Strategies such as providing an easily accessible coverage system, access to mental health resources, reducing EHR burden, addressing work hours, and addressing financial concerns among trainees may help to reduce burnout or depressive symptoms and should be studied further by the graduate medical education community.