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Comparative Study
. 2021 Feb 1;181(2):251-259.
doi: 10.1001/jamainternmed.2020.7071.

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

A Jay Holmgren  1   2 , N Lance Downing  3   4 , David W Bates  5   6 , Tait D Shanafelt  7 , Arnold Milstein  4 , Christopher D Sharp  3 , David M Cutler  8 , Robert S Huckman  2 , Kevin A Schulman  3   4   9
Affiliations
Comparative Study

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

A Jay Holmgren et al. JAMA Intern Med. .

Erratum in

  • Omission in the Author Contributions Section.
    [No authors listed] [No authors listed] JAMA Intern Med. 2021 Feb 1;181(2):296. doi: 10.1001/jamainternmed.2020.8964. JAMA Intern Med. 2021. PMID: 33523124 Free PMC article. No abstract available.

Abstract

Importance: 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.

Objective: 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.

Design, setting, and participants: 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.

Exposures: Clinician EHR use was tracked by deidentified and aggregated metadata across a variety of clinical activities.

Main outcomes and measures: 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.

Results: 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.

Conclusions and relevance: 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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Bates reported receiving grants and personal fees from EarlySense; personal fees from Center for Digital Innovation (Negev) Ltd; equity from Valera Health, CLEW, and MDClone Ltd; personal fees and other from AESOP; and grants from IBM Watson outside the submitted work. Dr Shanafelt reported being a coinventor of the Well-Being Index instruments and the Participatory Management Leadership Index, for which he receives a portion of any royalties paid to the copyright owner, Mayo Clinic, and reported receiving honoraria for providing grand rounds, keynote lectures, and advice to health care organizations. Dr Milstein reported being a co-founding scientist and paid scientific adviser of Dawnlight Technology and Prealize Health. Dr Huckman reported receiving personal fees from Kaiser Permanente, Partners Healthcare, MD Anderson Cancer Center, OhioHealth, and Ochsner Health; serving as an advisory board member for RubiconMD, Arena, and Carrum Health; and being an uncompensated trustee of Brigham Health and the Brigham and Women's Physicians Organization. Dr Schulman reported being a board member and shareholder for Grid Therapeutics and Reserve Therapeutics; being a managing member and shareholder for Faculty Connection LLC; being a shareholder for Prealize; being an investor in Altitude Ventures Inc and Excelerate Health Ventures; being a consultant for Novartis, Cytokinetics, Business Roundtable, Motley Rice LLC, and Frazier Healthcare Partners; being a speaker for Health Quest LLC and ISMIE Inc; being president of Business School Alliance for Health Management; being senior associate editor of Health Services Research; and being on the advisory board of Civica RX. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Comparing Electronic Health Record Use Between US and Non-US Clinicians From 371 Health Systems
EHR indicates electronic health record.
Figure 2.
Figure 2.. Distribution of Total Electronic Health Record (EHR) Time per Day Between US and Non-US Clinicians From 371 Health Systems
The brown color represents the overlap between the US and non-US health systems in this overlaid histogram.
See this image and copyright information in PMC

Comment in

References

    1. Adler-Milstein J, Holmgren AJ, Kralovec P, Worzala C, Searcy T, Patel V. Electronic health record adoption in US hospitals: the emergence of a digital “advanced use” divide. J Am Med Inform Assoc. 2017;24(6):1142-1148. doi:10.1093/jamia/ocx080 - DOI - PMC - PubMed
    1. Adler-Milstein J, Jha AK. HITECH Act drove large gains in hospital electronic health record adoption. Health Aff (Millwood). 2017;36(8):1416-1422. doi:10.1377/hlthaff.2016.1651 - DOI - PubMed
    1. Centers for Medicare & Medicaid Services Promoting interoperability (Pl) program. Published October 2018. Accessed June 8, 2020. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePro...
    1. Lin SC, Jha AK, Adler-Milstein J. Electronic health records associated with lower hospital mortality after systems have time to mature. Health Aff (Millwood). 2018;37(7):1128-1135. doi:10.1377/hlthaff.2017.1658 - DOI - PubMed
    1. McCullough JS, Casey M, Moscovice I, Prasad S. The effect of health information technology on quality in U.S. hospitals. Health Aff (Millwood). 2010;29(4):647-654. doi:10.1377/hlthaff.2010.0155 - DOI - PubMed

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