Documentation dynamics: Note composition, burden, and physician efficiency

Abstract

Objective: To analyze how physician clinical note length and composition relate to electronic health record (EHR)-based measures of burden and efficiency that have been tied to burnout.

Data sources and study setting: Secondary EHR use metadata capturing physician-level measures from 203,728 US-based ambulatory physicians using the Epic Systems EHR between September 2020 and May 2021.

Study design: In this cross-sectional study, we analyzed physician clinical note length and note composition (e.g., content from manual or templated text). Our primary outcomes were three time-based measures of EHR burden (time writing EHR notes, time in the EHR after-hours, and EHR time on unscheduled days), and one measure of efficiency (percent of visits closed in the same day). We used multivariate regression to estimate the relationship between our outcomes and note length and composition.

Data extraction: Physician-week measures of EHR usage were extracted from Epic's Signal platform used for measuring provider EHR efficiency. We calculated physician-level averages for our measures of interest and assigned physicians to overall note length deciles and note composition deciles from six sources, including templated text, manual text, and copy/paste text.

Principal findings: Physicians in the top decile of note length demonstrated greater burden and lower efficiency than the median physician, spending 39% more time in the EHR after hours (p < 0.001) and closing 5.6 percentage points fewer visits on the same day (p < 0.001). Copy/paste demonstrated a similar dose/response relationship, with top-decile copy/paste users closing 6.8 percentage points fewer visits on the same day (p < 0.001) and spending more time in the EHR after hours and on days off (both p < 0.001). Templated text (e.g., Epic's SmartTools) demonstrated a non-linear relationship with burden and efficiency, with very low and very high levels of use associated with increased EHR burden and decreased efficiency.

Conclusions: "Efficiency tools" like copy/paste and templated text meant to reduce documentation burden and increase provider efficiency may have limited efficacy.

Keywords: documentation; electronic health records; health policy; physician burnout.

FIGURE 1

Average physician burden and efficiency measures by overall note length decile. Source: Authors' analysis of outpatient EHR usage data for 203,728 US‐based physicians using the Epic EHR between September 2020 and May 2021. [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 2

Relationship between overall note length and physician burden and efficiency measures. Each row displays findings from a single multivariable ordinary least‐squares regression model for each outcome adjusting for physician case load and case mix complexity, and organizational factors. The fifth decile is used as the reference category to obtain estimates for physicians in each decile of note length. Each of the four outcome panels represent some aspect of physician burden. Full regression results for all models can be found in Appendix Table 1. [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 3

Relationship between note composition tool use and physician burden and efficiency. Each row displays findings from a single multivariable ordinary least‐squares regression model adjusting for additional deciles of note source (transcription, voice recognition, and NoteWriter), physician case load (average visits per week) and case mix complexity, and organizational factors. For each note text source, the fifth decile is used as the reference category to obtain estimates for physicians in each decile of note content from each of the three featured text sources. Each of the four outcomes on the left side represent some aspect of physician burden. Units for panels (A, B) are minutes per visit; unit for panel (C) is days per week; unit for Panel (D) is percentage points. Full regression results for all models can be found in Appendix Table 2. [Color figure can be viewed at wileyonlinelibrary.com]