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. 2023 Nov 1;6(11):e2344713.
doi: 10.1001/jamanetworkopen.2023.44713.

System-Level Factors and Time Spent on Electronic Health Records by Primary Care Physicians

Lisa S Rotenstein  1   2 , A Jay Holmgren  2 , Daniel M Horn  3   4 , Stuart Lipsitz  1   3 , Russell Phillips  3   5 , Richard Gitomer  1   3 , David W Bates  1   3
Affiliations

System-Level Factors and Time Spent on Electronic Health Records by Primary Care Physicians

Lisa S Rotenstein et al. JAMA Netw Open. .

Abstract

Importance: Primary care physicians (PCPs) spend the most time on the electronic health record (EHR) of any specialty. Thus, it is critical to understand what factors contribute to varying levels of PCP time spent on EHRs.

Objective: To characterize variation in EHR time across PCPs and primary care clinics, and to describe how specific PCP, patient panel, clinic, and team collaboration factors are associated with PCPs' time spent on EHRs.

Design, setting, and participants: This cross-sectional study included 307 PCPs practicing across 31 primary care clinics at Massachusetts General Hospital and Brigham and Women's Hospital during 2021. Data were analyzed from October 2022 to October 2023.

Main outcomes and measures: Total per-visit EHR time, total per-visit pajama time (ie, time spent on the EHR between 5:30 pm to 7:00 am and on weekends), and total per-visit time on the electronic inbox as measured by activity log data derived from an EHR database.

Results: The sample included 307 PCPs (183 [59.6%] female). On a per-visit basis, PCPs spent a median (IQR) of 36.2 (28.9-45.7) total minutes on the EHR, 6.2 (3.1-11.5) minutes of pajama time, and 7.8 (5.5-10.7) minutes on the electronic inbox. When comparing PCP time expenditure by clinic, median (IQR) total EHR time, median (IQR) pajama time, and median (IQR) electronic inbox time ranged from 23.5 (20.7-53.1) to 47.9 (30.6-70.7) minutes per visit, 1.7 (0.7-10.5) to 13.1 (7.7-28.2) minutes per visit, and 4.7 (4.1-5.2) to 10.8 (8.9-15.2) minutes per visit, respectively. In a multivariable model with an outcome of total per-visit EHR time per visit, an above median percentage of teamwork on orders was associated with 3.81 (95% CI, 0.49-7.13) minutes per visit fewer and having a clinic pharmacy technician was associated with 7.87 (95% CI, 2.03-13.72) minutes per visit fewer. Practicing in a community health center was associated with fewer minutes of total EHR time per visit (5.40 [95% CI, 0.06-10.74] minutes).

Conclusions and relevance: There is substantial variation in EHR time among individual PCPs and PCPs within clinics. Organization-level factors, such as team collaboration on orders, support for medication refill functions, and practicing in a community health center, are associated with lower EHR time for PCPs. These findings highlight the importance of addressing EHR burden at a systems level.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Rotenstein reported receiving grants from Physicians Foundation, American Medical Association, and FeelBetter and serving on the advisory board at Augmedix outside the submitted work. Dr Holmgren reported grants from American Medical Association and Healthcare Leadership Council outside the submitted work. Dr Phillips reported receiving grants from AHRQ during the conduct of the study and having equity in Bicycle Health Small and Grow Therapy and being an expert witness for Morrison Mahoney LLP outside the submitted work. Dr Bates reported receiving a grant from EarlySense and personal fees from EarlySense, CDI Negev, AESOP, Guided Clinical Solutions, and FeelBetter, and having equity in Clew, MDClone, AESOP, Guided Clinical Solutions, and FeelBetter outside the submitted work; additionally, Dr Bates had a patent for PHC-028654 pending from Massachusetts General Hospital. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Distribution of PCPs’ Time Spent on Electronic Health Record (EHR) per Visit
Lines within boxes indicate medians, boxes indicate IQRs, whiskers denote 1.5 IQR of the lower and higher quartiles, and circles denote outliers.
Figure 2.
Figure 2.. Distribution of Electronic Health Record (EHR) Time per Visit by Clinic
Lines within boxes indicate medians, boxes indicate IQRs, whiskers denote 1.5 IQR of the lower and higher quartiles, and circles denote outliers.
See this image and copyright information in PMC

References

    1. Rotenstein LS, Holmgren AJ, Downing NL, Bates DW. Differences in total and after-hours electronic health record time across ambulatory specialties. JAMA Intern Med. 2021;181(6):863-865. doi:10.1001/jamainternmed.2021.0256 - DOI - PMC - PubMed
    1. Rotenstein LS, Holmgren AJ, Healey MJ, et al. . Association between electronic health record time and quality of care metrics in primary care. JAMA Netw Open. 2022;5(10):e2237086. doi:10.1001/jamanetworkopen.2022.37086 - DOI - PMC - PubMed
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    1. Rotenstein LS, Holmgren AJ, Downing NL, Longhurst CA, Bates DW. Differences in clinician electronic health record use across adult and pediatric primary care specialties. JAMA Netw Open. 2021;4(7):e2116375. doi:10.1001/jamanetworkopen.2021.16375 - DOI - PMC - PubMed

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