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. 2022 Oct 3;5(10):e2237086.
doi: 10.1001/jamanetworkopen.2022.37086.

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

Lisa S Rotenstein  1   2 , A Jay Holmgren  3 , Michael J Healey  1   2 , Daniel M Horn  2   4 , David Y Ting  2   5 , Stuart Lipsitz  1 , Hojjat Salmasian  1   2 , Richard Gitomer  1   2 , David W Bates  1   2   6
Affiliations

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

Lisa S Rotenstein et al. JAMA Netw Open. .

Abstract

Importance: 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.

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

Design, setting, and participants: 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.

Exposures: 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).

Main outcomes and measures: 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).

Results: 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.

Conclusions and relevance: 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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Rotenstein reported receiving grants from the American Medical Association outside the submitted work. Dr Holmgren reported receiving grants the from American Medical Association and Healthcare Leadership Council outside the submitted work. Dr Bates reported receiving fees from EarlySense for consulting and speaking, fees from CDI Negev for consulting, equity from ValeraHealth for consulting, equity from Clew for consulting, equity from MDClone for consulting, equity and personal fees from AESOP, equity and personal fees from Guided Clinical Solutions, and grants from IBM Watson Health outside the submitted work. In addition, Dr Bates had a patent for PHC-028564 US PCT pending Mass General Brigham Intraoperative decision support. No other disclosures were reported.

References

    1. Tawfik DS, Profit J, Morgenthaler TI, et al. . Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clin Proc. 2018;93(11):1571-1580. doi:10.1016/j.mayocp.2018.05.014 - DOI - PMC - PubMed
    1. Classen DC, Holmgren AJ, Co Z, et al. . National trends in the safety performance of electronic health record systems from 2009 to 2018. JAMA Netw Open. 2020;3(5):e205547-e205547. doi:10.1001/jamanetworkopen.2020.5547 - DOI - PMC - PubMed
    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. Holmgren AJ, Downing NL, Bates DW, et al. . Assessment of electronic health record use between US and non-US health systems. JAMA Intern Med. 2021;181(2):251-259. doi:10.1001/jamainternmed.2020.7071 - DOI - PMC - PubMed
    1. NCQA. HEDIS measures and technical resources. Accessed May 15, 2022. https://www.ncqa.org/hedis/measures/