Time Requirements for Electronic Health Record Use in an Academic Ophthalmology Center

Abstract

Importance: Electronic health record (EHR) systems have transformed the practice of medicine. However, physicians have raised concerns that EHR time requirements have negatively affected their productivity. Meanwhile, evolving approaches toward physician reimbursement will require additional documentation to measure quality and cost of care. To date, little quantitative analysis has rigorously studied these topics.

Objective: To examine ophthalmologist time requirements for EHR use.

Design, setting, and participants: A single-center cohort study was conducted between September 1, 2013, and December 31, 2016, among 27 stable departmental ophthalmologists (defined as attending ophthalmologists who worked at the study institution for ≥6 months before and after the study period). Ophthalmologists who did not have a standard clinical practice or who did not use the EHR were excluded.

Exposures: Time stamps from the medical record and EHR audit log were analyzed to measure the length of time required by ophthalmologists for EHR use. Ophthalmologists underwent manual time-motion observation to measure the length of time spent directly with patients on the following 3 activities: EHR use, conversation, and examination.

Main outcomes and measures: The study outcomes were time spent by ophthalmologists directly with patients on EHR use, conversation, and examination as well as total time required by ophthalmologists for EHR use.

Results: Among the 27 ophthalmologists in this study (10 women and 17 men; mean [SD] age, 47.3 [10.7] years [median, 44; range, 34-73 years]) the mean (SD) total ophthalmologist examination time was 11.2 (6.3) minutes per patient, of which 3.0 (1.8) minutes (27% of the examination time) were spent on EHR use, 4.7 (4.2) minutes (42%) on conversation, and 3.5 (2.3) minutes (31%) on examination. Mean (SD) total ophthalmologist time spent using the EHR was 10.8 (5.0) minutes per encounter (range, 5.8-28.6 minutes). The typical ophthalmologist spent 3.7 hours using the EHR for a full day of clinic: 2.1 hours during examinations and 1.6 hours outside the clinic session. Linear mixed effects models showed a positive association between EHR use and billing level and a negative association between EHR use per encounter and clinic volume. Each additional encounter per clinic was associated with a decrease of 1.7 minutes (95% CI, -4.3 to 1.0) of EHR use time per encounter for ophthalmologists with high mean billing levels (adjusted R2 = 0.42; P = .01).

Conclusions and relevance: Ophthalmologists have limited time with patients during office visits, and EHR use requires a substantial portion of that time. There is variability in EHR use patterns among ophthalmologists.

Figure 1.. Mean Electronic Health Record (EHR) Time per Patient Encounter vs Median Half-Day Clinic Volume by Mean Billing Level

Mean EHR use time per encounter was 10.8 minutes (dotted horizontal line) (range, 5.8-28.6 minutes). Linear regression fits and 95% CIs are displayed. Low billing level was defined as level 1-2 evaluation and management office visits, preoperative and postoperative encounters, brief or intermediate cosmetic evaluations, vision examinations, or special procedures. Medium billing level was defined as level 3 office visits, comprehensive cosmetic evaluations, intermediate or established comprehensive eye examinations, or refractive surgery consultations. High billing level was defined as level 4-5 office visits, eye examinations that included treatment, or new comprehensive eye examinations.

Figure 2.. Mean Electronic Health Record (EHR) Time per Patient Encounter vs Clinic Volume by Mean Billing Level

A, Low billing level, defined as level 1-2 evaluation and management office visits, preoperative and postoperative encounters, brief or intermediate cosmetic evaluations, vision examinations, or special procedures. B, Medium billing level, defined as level 3 office visits, comprehensive cosmetic evaluations, intermediate or established comprehensive eye examinations, or refractive surgery consultations. C, High billing level, defined as level 4-5 office visits, eye examinations that included treatment, or new comprehensive eye examinations. Linear regression fits and 95% CIs are displayed.