Scheduled Hours Research Articles

How Different Distribution of Assortments on Worksites Influences Forwarder Performance in Coniferous Plantations

Forwarders often load logs organized in large piles by modified farm tractors, skidders, animals, other forwarders, etc., but currently, there are no studies on how the different concentrations of logs affect forwarder performance in terms of time consumption, productivity, and costs in forwarding operations. A study was conducted in three locations situated in Bulgaria (sites A and B) and in southern Italy (site C): in site A the logs were spread in the stand, in site B they were concentrated in large piles at the roadside, whereas in site C the logs were organized at the roadside in piles of medium size. The average forwarder productivity in site A obtained at an average forwarding distance of 1780 m, an average payload volume of 9.83 m3, and an average number of grips of logs with the crane grapple, during loading (22.97) and during unloading (8.97) per cycle, is 10.43 m3·PMH-1 (PMH, productive machine hour) and 9.93 m3·SMH-1 (SMH, scheduled machine hour), respectively. In site B the productivity rate was lower than that registered by the forwarder operated in site A: 9.38 m3·PMH-1 and 8.81 m3·SMH-1, respectively, at an average forwarding distance of 3760 m, average payload volume of 15.04 m3, and a mean number of grips of logs with the crane grapple, during loading and during unloading, of 23.57 and 14.10 per cycle, respectively. With regard to site C, the average machine productivitiy was 12.39 m3·PMH-1 and 11.85 m3·SMH-1, travelling a mean forwarding distance of 1630 m, transporting a mean load volume of 13.63 m3, and performing an average number of grips of logs with the crane grapple, during loading of 26.52 and during unloading of 12.36 per cycle. The ratio between the number of grips of logs with the crane grapple during loading and unloading operations in site A is on average 2.56, but in site B it is significantly smaller – mean of 1.67, due to the larger number of logs in the grapple when loading from large piles. Site C shows a loading and unloading number of grips ratio intermediate between the two Bulgarian sites. This ratio is characterized by the concentration of logs in the stand. Concentration in larger piles results in a larger volume of grappled logs by crane, and hence, lower time for loading of the forwarder and higher productivity. The obtained results show that the dispersion of small piles of logs results in a smaller volume grappled, a greater number of crane cycles and a larger loading distance, which generally, increases loading time. The larger volume of logs in the crane grapple and the shorter loading distance, when the loading operation is carried out from larger piles at the roadside, lead to less loading time. Gross costs for forwarders were 65.14 € PMH-1 at Site A, 72.96 €·PMH-1 at Site B, and 85.58 €·PMH-1 at Site C. When the forwarders were productive, the costs were 6.35 €·m-3 in site A, 7.90 €·m-3 in site B, and 6.90 €·m-3 in site C.

Impact of Skidding and Slope on Grapple Skidder Productivity and Costs: A Monte Carlo Simulation in Eucalyptus Plantations

Background: In the context of mechanized timber harvesting, alterations in technical parameters, such as skidding distance and terrain slope, have the potential to influence the productivity and production costs associated with the self-propelled grapple skidder. Furthermore, these variables are inherently uncertain, which could potentially cause forest managers to make inaccurate decisions. The objective was to analyze whether four skidding distances and two slope classes influence the productivity and production costs of the grapple skidder in Eucalyptus planted forests from a stochastic perspective using the Monte Carlo method. Methods: Productivity was estimated using the time study protocol. To calculate the cost per scheduled hour of the grapple skidder, both fixed and variable costs were considered, and subsequently, the production cost was determined. Results: The mean productivity of the grapple skidder on flat slopes was 114.35 m3 h−1, while on wavy to strong wavy slopes it was 80.43 m3 h−1. In flat slopes, considering all skid distance ranges, the mean production cost was 0.82 USD m−3, while in wavy to strong wavy slopes it was 1.48 USD m−3. The mean values for operator labor costs and fuel account for 58.1% of the cost per scheduled hour of the grapple skidder. Conclusions: The mean productivity of the grapple skidder in Eucalyptus planted forests decreased with increasing skidding distance in both slope classes but was 29.7% lower on wavy to strong wavy slopes compared to flat slopes. The mean production cost of the grapple skidder during timber skidding on flat slopes is 80.0% lower than on wavy to strong wavy slopes. For future investigations, the impact of other slope classes, skid distances, and silvicultural aspects on productivity and production costs can be considered from a stochastic perspective using the Monte Carlo method.

The number of patient scheduled hours resulting in a 40-hour work week by physician specialty and setting: a cross-sectional study using electronic health record event log data.

To quantify how many patient scheduled hours would result in a 40-h work week (PSH40) for ambulatory physicians and to determine how PSH40 varies by specialty and practice type. We calculated PSH40 for 186188 ambulatory physicians across 395 organizations from November 2021 through April 2022 stratified by specialty. Median PSH40 for the sample was 33.2 h (IQR: 28.7-36.5). PSH40 was lowest in infectious disease (26.2, IQR: 21.6-31.1), geriatrics (27.2, IQR: 21.5-32.0) and hematology (28.6, IQR: 23.6-32.6) and highest in plastic surgery (35.7, IQR: 32.8-37.7), pain medicine (35.8, IQR: 32.6-37.9) and sports medicine (36.0, IQR: 33.3-38.1). Health system leaders and physicians will benefit from data driven and transparent discussions about work hour expectations. The PSH40 measure can also be used to quantify the impact of variations in the clinical care environment on the in-person ambulatory patient care time available to physicians. PSH40 is a novel measure that can be generated from vendor-derived metrics and used by operational leaders to inform work expectations. It can also support research into the impact of changes in the care environment on physicians' workload and capacity.

From Headache to Handled: Advanced In-Basket Management System in Primary Care Clinics Reduces Provider Workload Burden and Self-Reported Burnout.

The electronic health record (EHR) has been associated with provider burnout, exacerbated by increasing In-Basket burden. We sought to study the impact of implementing a team-based approach to In-Basket management on a series of primary care ambulatory sites. We performed a workflow analysis of the transition to the Advanced In-Basket Management (AIM) nurse team triage for six family medicine clinic locations in a large health system. We abstracted and analyzed associated provider workflow metrics from our EHR. We conducted a postintervention provider survey on satisfaction with the AIM project and provider burnout. The AIM project was implemented in six family medicine clinics after provider townhalls and workgroup development. A nurse team curriculum was created using the principles of "maturing the message" before sending it to a provider and "only handle it once" to improve response efficiency. Provider workload metrics abstracted from the EHR demonstrated 12.2 fewer In-Basket messages per provider per day (p < 0.05), 6.3 fewer minutes per provider per day worked outside scheduled hours (p < 0.05), 3.5 fewer minutes spent in the In-Basket per provider per day (p < 0.05), but 13.7 more seconds spent per completed message per provider (p = 0.017), likely attributable to increased message complexity. Sixty-four percent of providers reported no burnout symptoms in a postintervention survey, 56% agreed that the AIM project reduced their burnout, and approximately 70% of providers agreed that the AIM project was acceptable and appropriate for their clinic. The AIM project demonstrates team-based nurse In-Basket triage is possible to implement across multiple primary care sites, is an acceptable intervention for providers, can reduce provider workload burden and self-reported provider burnout.

Productivity benchmarks for unguyed excavator-based tower yarders

ABSTRACT Detailed productivity studies were conducted on three distinct crews, all operating the modern version of the EMS Harvestline excavator-based yarder working with a motorized grapple carriage for harvesting radiata pine from plantation forests in New Zealand. Data were collected from over 1000 cycles and used to estimate robust productivity benchmarks and models. Mean productivity neared 100 t per productive machine hour (PMH) on short distances (100 m) and decreased to <70 t PMH−1 on longer ones (>200 m). In addition to very fast cycle times, only 1.5 min on average at 100 m, large stem size contributed to those very high productivity figures. Utilization ranged from 50% to 63%, with line-shifts and yarder relocation being a common delay type given the short corridors and quick extraction cycles. Productivity was 40–60 t per scheduled machine hour. This productivity range is comparable with those obtained by heavier and more expensive purpose-built swing yarders, showing great potential for cost-effective future applications.

The clinical pharmacology and therapeutics course for graduating medical students at Dartmouth: Preparation for internship and residency.

This manuscript is a description of the clinical pharmacology and therapeutics (CPT) course that is required to be taken, and passed, by all medical students at the Geisel School of Medicine at Dartmouth during their final year of training, prior to entering their internship/residency. We present a detailed CPT course curriculum, which includes the novel use of simulated expected professional activities (EPAs) and an analysis of the level of confidence the students who took the course had at the beginning and at the end of the course in performing the three simulated EPAs. The course currently consists of 31 h of presentations on what are considered major clinical pharmacology topics and is led by two clinical pharmacologists at Dartmouth (D.W.N. and L.D.L.) supplementedby therapeutic area specialist faculty. In addition, the Dartmouth CPT course incorporates three required simulated entrustable professional activities (EPAs) focused on drug prescribing. These are written exercises, completed outside scheduled class hours, and submitted to and evaluated by the course directors with individual feedback to each medical student. We present preliminary data on the benefits of using these simulated EPAs in undertaking what we consider are three pivotal prescribing skills. The Dartmouth CPT course is unique and is only mirrored by a small number of US medical schools. The students showed a significant improvement in their level of confidence in performing the three simulated EPAs at the end of the course.

Gender Differences in Electronic Health Record Usage Among Surgeons.

Understanding gender differences in electronic health record (EHR) use among surgeons is crucial for addressing potential disparities in workload, compensation, and physician well-being. To investigate gender differences in EHR usage patterns. This cross-sectional study examined data from an EHR system (Epic Signal) at a single academic hospital from January to December 2022. Participants included 224 attending surgeons with patient encounters in the outpatient setting. Statistical analysis was performed from May 2023 to April 2024. Surgeon's gender. The primary outcome variables were progress note length, documentation length, time spent in medical records, and time spent documenting patient encounters. Continuous variables were summarized with median and IQR and assessed via the Kruskal-Wallis test. Categorical variables were summarized using proportion and frequency and compared using the χ2 test. Multivariate linear regression was used with primary EHR usage variables as dependent variables and surgeon characteristics as independent variables. This study included 222 529 patient encounters by 224 attending surgeons, of whom 68 (30%) were female and 156 (70%) were male. The median (IQR) time in practice was 14.0 (7.8-24.3) years. Male surgeons had more median (IQR) appointments per month (78.3 [39.2-130.6] vs 57.8 [25.7-89.8]; P = .005) and completed more medical records per month compared with female surgeons (43.0 [21.8-103.9] vs 29.1 [15.9-48.1]; P = .006). While there was no difference in median (IQR) time spent in the EHR system per month (664.1 [301.0-1299.1] vs 635.0 [315.6-1192.0] minutes; P = .89), female surgeons spent more time logged into the system both outside of 7am to 7pm (36.4 [7.8-67.6] vs 14.1 [5.4-52.2] min/mo; P = .05) and outside of scheduled clinic hours (134.8 [58.9-310.1] vs 105.2 [40.8-214.3] min/mo; P = .05). Female surgeons spent more median (IQR) time per note (4.8 [2.6-7.1] vs 2.5 [0.9-4.2] minutes; P < .001) compared with male surgeons. Male surgeons had a higher number of median (IQR) days logged in per month (17.7 [13.8-21.3] vs 15.7 [10.7-19.7] days; P = .03). Female surgeons wrote longer median (IQR) inpatient progress notes (6025.1 [3692.1-7786.7] vs 4307.7 [2808.9-5868.4] characters/note; P = .001) and had increased outpatient document length (6321.1 [4079.9-7825.0] vs 4445.3 [2934.7-6176.7] characters/note; P < .001). Additionally, female surgeons wrote a higher fraction of the notes manually (17% vs 12%; P = .006). After using multivariable linear regression models, male gender was associated with reduced character length for both documentations (regression coefficient, -1106.9 [95% CI, -1981.5 to -232.3]; P = .01) and progress notes (regression coefficient, -1119.0 [95% CI, -1974.1 to -263.9]; P = .01). Male gender was positively associated with total hospital medical records completed (regression coefficient, 47.3 [95% CI, 28.3-66.3]; P < .001). There was no difference associated with gender for time spent in each note, time spent outside of 7 am to 7 pm, or time spent outside scheduled clinic hours. This cross-sectional study of EHR data found that female surgeons spent more time documenting patient encounters, wrote longer notes, and spent more time in the EHR system compared with male surgeons. These findings have important implications for understanding the differential burdens faced by female surgeons, including potential contributions to burnout and payment disparities.

The Effect of Knife Wear and Sharpening Mode on Chipper Productivity and Delays

The production of wood chips can be achieved using different types of wood chippers whose productivity can be influenced by many factors including proper knife management. Research was conducted to determine the productivity of the new Diamant chipper in chipping air-dried tops stacked at a roadside landing and to compare the efficiency of dry sharpening and wet sharpening in restoring chipper productivity, the time required by dry sharpening with that of knife replacement, and the cost of dry sharpening to knife change in real-life conditions. To clearly define the influence of knife management, a model of the effect of knife wear on chipper productivity was produced. Analysis of variance was used to check the significance of any differences in chipping and total time consumption per cycle. Multiple regression was used to express the relationship between chipping time consumption per cycle and the cumulated mass processed by a set of knives—the latter taken as an indicator of knife wear. The study lasted 10 full workdays, included a total of 136 truckloads or 3560 t of fresh wood chips (or green tons = gt), and resulted in the average productivity of 59.0 gt per productive chipping hour (excluding all delays) or 39.4 gt per machine scheduled hour (including all delays). Delays represented 37% of total worksite time. Knife management (dry sharpening or change) accounted for 30% of the total delay time due to raw material contamination. Dry sharpening took 30% less time than a full knife change. As wear accumulated and knives lost their edge, the chipping time per cycle increased from 25 in the first cycle (full truck load) to 38 min in the third cycle. The presented study offers robust productivity figures, together with a reliable estimate of the productivity losses caused by knife wear, and could help improve knife management in order to increase chipper productivity as well as reduce unnecessary delays.

Assessment of EHR Efficiency Tools and Resources Associated with Physician Time Spent on the Inbox

BackgroundPhysicians are experiencing an increasing burden of messaging within the electronic health record (EHR) inbox. Studies have called for the implementation of tools and resources to mitigate this burden, but few studies have evaluated how these interventions impact time spent on inbox activities.ObjectiveExplore the association between existing EHR efficiency tools and clinical resources on primary care physician (PCP) inbox time.DesignRetrospective, cross-sectional study of inbox time among PCPs in network clinics affiliated with an academic health system.ParticipantsOne hundred fifteen community-based PCPs.Main MeasuresInbox time, in hours, normalized to eight physician scheduled hours (IB-Time8).Key ResultsFollowing adjustment for physician sex as well as panel size, age, and morbidity, we observed no significant differences in inbox time for physicians with and without message triage, custom inbox QuickActions, encounter specialists, and message pools. Moreover, IB-Time8 increased by 0.01 inbox hours per eight scheduled hours for each additional staff member resource in a physician’s practice (p = 0.03).ConclusionsPhysician inbox time was not associated with existing EHR efficiency tools evaluated in this study. Yet, there may be a slight increase in inbox time among physicians in practices with larger teams.

Cumulated time to chart closure: a novel electronic health record-derived metric associated with clinician burnout

Abstract Objective We sought to determine whether average cumulated time to chart closure (CTCC), a novel construct to measure clinician workload burden, and electronic health record (EHR) measures were associated with a validated measure of burnout. Materials and methods Physicians at a large academic institution participated in a well-being survey that was linked to their EHR use data. CTCC was defined as the average time from the start of patient encounters to chart closure over a set of encounters. Established EHR use measures including daily total time in the EHR (EHR-Time8), time in the EHR outside scheduled hours, work outside of work (WOW8), and time spent on inbox (IB-Time8) were calculated. We examined the relationship between CTCC, EHR use metrics, and burnout using descriptive statistics and adjusted logistic regression models. Results We included data from 305 attendings, encompassing 242 432 ambulatory encounters (2021). Among them, 42% (128 physicians) experienced burnout. The median CTCC for all clinicians was 32.5 h. Unadjusted analyses revealed significant associations between CTCC, WOW8, IB-Time8, and burnout. In a final adjusted model, only CTCC remained statistically significant with an odds ratio estimate of 1.42 (95% CI, 1.00-2.01). Discussion These results suggest that CTCC is predictive of burnout and that purely measuring duration of interaction with the EHR itself is not sufficient to capture burnout. Conclusion Workload burden as manifested by average CTCC has the potential to be a practical, quantifiable measure that will allow for identification of clinicians at risk of burnout and to assess the success of interventions designed to address burnout.

Electronic Health Record Usage Patterns Across Surgical Subspecialties.

This study aimed to utilize metrics from physician action logs to analyze surgeon clinical, volume, electronic health record (EHR) efficiency, EHR proficiency, and workload outside scheduled time as impacted by physician characteristics such as years of experience, gender, subspecialty, academic title, and administrative title. We selected 30 metrics from Epic Signal, an analytic tool in Epic that extracts metrics related to clinician documentation. Metrics measuring appointments, messages, and scheduled hours per day were used as a correlate for volume. EHR efficiency, and proficiency were measured by scores built into Epic Signal. Metrics measuring time spent in the EHR outside working hours were used as a correlate for documentation burden. We analyzed these metrics among surgeons at our institution across 4 months and correlated them with physician characteristics. Analysis of 133 surgeons showed that, when stratified by gender, female surgeons had significantly higher EHR metrics for time per day, time per appointment, and documentation burden, and significantly lower EHR metrics for efficiency when compared to male surgeons. When stratified by experience, surgeons with 0 to 5 years of experience had significantly lower EHR metrics for volume, time per day, efficiency, and proficiency when compared to surgeons with 6 to 10 and more than 10 years of experience. On multivariate analysis, having over 10 years of experience was an independent predictor of more appointments per day, greater proficiency, and spending less time per completed message. Female gender was an independent predictor of spending more time in notes per appointment and time spent in the EHR outside working hours. The burden associated with volume, proficiency, efficiency, and workload outside scheduled time related to EHR use varies by gender and years of experience in our cohort of surgeons. Evaluation of physician action logs could help identify those at higher risk of burnout due to burdensome medical documentation.

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.

Assessment of the patient satisfaction level with outpatient department services in a tertiary care hospital of Jammu region

Background: Outpatient department (OPD) is that section of the hospital which is staffed and equipped to provide diagnostic, therapeutic and rehabilitative care to those patients who are not registered as inpatients while receiving the services during scheduled working hours. Objective of the study was to assess the patient satisfaction level with OPD services in a tertiary-care hospital of Jammu region. Methods: A cross-sectional study was conducted among patients visiting the OPD of the SMGS hospital GMC Jammu from January to March 2023. Exit interviews were conducted using a semi-structured questionnaire among patients availing the services from OPD. Results: Average percentage of total satisfaction score among sampled OPD patients has come out to be 68.13% whereas total average dissatisfaction score was 20.87% and the total average mild dissatisfaction score as 11.00%. Conclusions: This study suggests that patients were satisfied to a larger extent with OPD services except a few which are least satisfied especially with waiting time at registration counter.

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.

Developing Nurse Practitioners for Hospitalist Roles: Lessons Learned From an Academic Practice Partnership.

Background: There are numerous benefits to academic practice partnerships. While there is great emphasis on the new graduate nurse transition to practice, there is less intention placed on the new nurse practitioner (NP) role transition. In a rural teaching hospital, leadership perceived a need for more support to successfully transition NPs into hospitalist practice roles. Objective: One academic practice partnership developed and implemented a grant-funded program to support advanced practice registered nurses (APRNs) transition to practice at a rural teaching hospital. Methods: Informed by the results of a needs assessment, faculty and practice partners delivered lecture content in a face-to-face setting during scheduled hours. Results: Although the content was well received, attendance to and engagement with the program were suboptimal. Conclusions: Upon reflection, the program team gained valuable lessons regarding role expectations, intentional interdisciplinary collaboration, timing, alignment, delivery format, and the need for a dedicated program coordinator. Implications for nursing: APRN transition programs can provide much-needed support with dedicated structure, clear communication, and individualized content. It can also be a recruitment and retention strategy for healthcare organizations.

I'm not burned out. This is how I write notes.

We describe an automated transcription system that addresses many documentation problems and fits within scheduled clinical hours. During visits, the provider listens to the patient while maintaining eye contact and making brief notes on paper. Immediately after the visit conclusion and before the next, the provider makes a short voice recording on a smartphone which is transmitted to the system. The system uses a public domain general language model, and a hypertuned provider-specific language model that is iteratively refined as each produced note is edited by the physician, followed by final automated processing steps to add any templated text to the note. The provider leaves the clinic having completed all voice files, median duration 3.4 minutes. Created notes are formatted as preferred and are a median of 363 words (range 125-1175). This approach permits documentation to occur almost entirely within scheduled clinic hours, without copy-forward errors, and without interference with patient-provider interaction. Though no documentation method is likely to appeal to all, this approach may appeal to many physicians and avoid many current problems with documentation.

Employment status and the on-demand economy: a natural experiment on reclassification

Abstract This article uses data from a natural experiment to address one of the most contentious issues in the on-demand platform economy—whether gig work is compatible with standard employment. We analyze a US-based package delivery platform that shifted a subset of its workers from independent contractors to employees, thereby creating a natural experiment that allowed us to exploit variation over time and across locations. We examine the impact of employment status on work scheduling practices, hours of work and the firm’s ability to match workers’ scheduled hours with the amount of time they were actively engaged in parcel delivery. We find that after the transition to employment, flexibility with respect to how work schedules were determined was maintained, and drivers’ total hours of work increased. We also find that the switch to employee status increased the firm’s ability to match scheduled and actual working time, indicating greater operational efficiency. We conclude, contrary to claims commonly made by platform firms, that employment status can coexist with the platform model.

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.

Do emergency medicine residents have access to healthy food options during work hours?

Relatively little data describe how diet and food choices impact trainee well-being despite evidence that diet impacts both physical and mental health. The objective was to describe food options available to emergency medicine (EM) residents when on duty. A survey utilizing closed-ended, binary, rank-order responses was developed by experts in graduate medical education and wellness; it was piloted, revised, and then electronically distributed to 211 EM residency programs over 2 weeks in 2021. The program director (PD) or associate PD was invited to participate. A total of 114 EM programs participated (54%). The primary teaching site included 43 community hospitals, 23 county hospitals, and 48 university hospitals. Resident access to an onsite hospital cafeteria was most common (97%); other onsite options were vending machines (87%), fresh food fridges (34%), national chains (32%), local restaurants (25%), food trucks (30%), and farmer's markets (11%). More than one-third (38%) reported that onsite options did not include healthy food, 26% reported being dissatisfied with onsite food, and 35% rarely or never purchased food onsite. Most programs (89%) do not have a dedicated "meal break" for residents while on duty. Few residency programs include diet or nutrition classes or counseling. When programs sponsor meals during residency events, nutritional value and dietary considerations were ranked less important than cost of food and convenience. Access to healthy food options is not always available during scheduled resident work hours, and dedicated meal breaks are infrequent. These data should inform institutional initiatives to improve the health and well-being of resident physicians.

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

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