Characterizing electronic health record usage patterns of inpatient medicine residents using event log data

Abstract

Amid growing rates of burnout, physicians report increasing electronic health record (EHR) usage alongside decreasing clinical facetime with patients. There exists a pressing need to improve physician-computer-patient interactions by streamlining EHR workflow. To identify interventions to improve EHR design and usage, we systematically characterize EHR activity among internal medicine residents at a tertiary academic hospital across various inpatient rotations and roles from June 2013 to November 2016. Logged EHR timestamps were extracted from Stanford Hospital's EHR system (Epic) and cross-referenced against resident rotation schedules. We tracked the quantity of EHR logs across 24-hour cycles to reveal daily usage patterns. In addition, we decomposed daily EHR time into time spent on specific EHR actions (e.g. chart review, note entry and review, results review).In examining 24-hour usage cycles from general medicine day and night team rotations, we identified a prominent trend in which night team activity promptly ceased at the shift's end, while day team activity tended to linger post-shift. Across all rotations and roles, residents spent on average 5.38 hours (standard deviation = 2.07) using the EHR. PGY1 (post-graduate year one) interns and PGY2+ residents spent on average 2.4 and 4.1 times the number of EHR hours on information review (chart, note, and results review) as information entry (note and order entry).Analysis of EHR event log data can enable medical educators and programs to develop more targeted interventions to improve physician-computer-patient interactions, centered on specific EHR actions.

Fig 1

Mean number of EHR actions logged per user day in half hour increments over a 24-hour cycle for different inpatient rotations, split by PGY1 interns (A) and PGY2+ residents (B). General Medicine Day and Night Teams transition care responsibility at 7 AM and 7 PM. Daytime patient care is regularly interrupted by 10 AM morning report and 12 PM noon teaching conferences. PGY1 interns do not rotate through the ICU. ICU housestaff have a separate noon teaching conference and daily 3 PM care conference. Only the ICU rotation integrates computers-on-wheels (COWs) for physician use in patient care and rounding practices, while other rotations segregate physician (computer) workrooms from patient care areas.