More than 94% of pediatricians in the United States now use electronic health records (EHRs).1,2 There is less literature documenting the time pediatricians spend in the EHR for their work than for some other specialties. A recent study found that physicians spent 2 out of every 3 hours using the EHR or completing desk work.3
More recently, a large-scale study of adult physicians found that they spend 16 minutes and 14 seconds per encounter on EHR activities.4
Based on a self-administered survey of 1,619 pediatricians, pediatricians spend an average of 3.4 hours/day documenting care.1 Tai-Seale et al.,5 based on an EHR registry analysis, found that pediatricians spend 2.48 ± 1.3 hours/day using the EHR.
In response to the time physicians spend using their EHR, health systems have dedicated substantial resources to optimizing EHR to improve medical efficiency.6 The use of medical scribes is an example of an approach with some degree of success in reducing time. of documentation.7,8 Optimizing the configuration of the EHR system has also brought benefits.9
The authors conducted a multi-institutional descriptive analysis of EHR usage time to better document the time pediatric outpatient specialties physicians spend performing various tasks using it.
| Methods |
Data were used on outpatient EHR activities from January 1, 2018 to December 31, 2018 by pediatricians or adolescent specialists in any of the 2,191 U.S. Cerner’s Lights On healthcare organization databases. US
Center’s Lights On is a collection of systems that monitor hardware and software activity, clinical application functionality, and other user activities. These data represent nearly the entire population of sites and physicians using Cerner EHRs. For this analysis, time data were summarized for each clinical activity performed by that physician.
A descriptive analysis was performed using log entries from the summarized EHRs reflecting individual software modules and services executed while the provider was using the system. Activities and time data were mapped for specific clinical tasks, such as uploading documentation, placing orders, reviewing historical notes, etc.
To calculate time per encounter, all EHR active time in each category was accumulated during a specific period and then divided by the number of outpatient encounters completed in that period.
The meeting was considered complete on the date and time the note was signed. A 1-year interval was considered for analysis to more directly reflect the total number of encounters. After-hours EHR use was defined as any time spent using EHR between 6:00 pm and 6:00 am Monday through Friday or anytime on weekends.
| Results |
The analysis included data from >20 million encounters performed by 30,000 pediatricians. These physicians practiced in integrated distribution networks (34%), regional hospitals (30%), independent physician groups (22%), and academic medical centers (11%) throughout the US.
The average total active time per encounter that pediatricians spent in front of the EHR was 16 minutes, with 12% of this time occurring after hours. The mean active time for all clinically focused EHR functions combined varied widely within specialty (P < 0.001), with clinically significant differences between several groups.
Graphical review accounted for most of the time spent, followed by documentation, and then ordering. Collectively, these 3 activities represented 75% of EHR activity. Time spent searching for patients, scheduling appointments, or similar activities represented 9% of EHR activity.
| Discussion |
The monitored population of physicians represents a sample of 44% of US pediatricians.11 The mean total active time per encounter for EHR users in all specialties was 16 minutes, varying from 14.5 minutes (generalists) to 30.8 minutes (rheumatologists).
This relatively long time for rheumatologists was not surprising, given the nature of their patients and the volume of chronic diseases they manage.12 General pediatricians used slightly more time than cardiologists but less time than other subspecialists, such as rheumatologists. The proportion of time spent on each activity was remarkably similar between subspecialties.
Assuming that an average pediatrician could see 25 patients per day,13,14 they would spend 6 hours and 40 minutes using their EHR, a substantial portion of the day.
Because these physicians all use the same EHR, the observed variability must arise from other factors, such as differences in setup, implementation details, practice setup (e.g., how the team divides tasks among themselves). ), individual supplier choices and similar factors.
Chart review and documentation accounts for nearly 62% of EHR usage time.4 Clinicians spend half of this time (or 31% of total time) on chart review. Although not conclusive, studies are beginning to reveal an association between the use of EHR and improved adherence to guidelines15 and a lower incidence of adverse effects due to medical errors.16,17 The time physicians spend on Chart review may be early evidence that professionals use EHR to improve the care they provide.
Documentation accounts for 31% of time spent in the EHR and is often the target of physicians’ concerns. Documentation can be more difficult to delegate than some other tasks, in part because physicians would have to transmit complex clinical content to another person or system.
Adler-Milstein and Huckman20 found that physicians delegated only 16% of physical examination documentation and only 29% of current illness documentation, while they delegated other tasks more frequently, such as recording vital signs (92% ) and medical history (82%).
Delegating these latter tasks can be easier because the data is generated and recorded directly. Delegating physical examination findings not directly observed by the person being delegated is more complex and requires careful verification of the record of those findings.
The proportion of time spent using the EHR for patient care by the different subspecialties appears to be similar. However, given the high variability between specialties, little can be concluded about differences or similarities. Recognizing this limitation, the long mean time spent documenting and the short mean time spent coordinating care (messaging) are consistent with the authors’ clinical intuition.
The EHR active times by specialty reported in this study can serve as a reference point for health system leaders, providers, payers, and policymakers. Health system leaders can leverage data to understand the effort required by physicians to complete their work and the value of investing in optimizing the physician’s EHR workflow.
Individual physicians can better understand their performance in the context of other providers by comparing their own EHR usage time to their subspecialty averages and explore opportunities to reorganize their practice or obtain additional training as needed.
Payers can learn about the effort required to complete this important part of a physician’s job when using an EHR and consider adjusting their expectations for data capture based on the direct costs incurred. Finally, policymakers can take this data into account when defining their EHR certification processes and data capture expectations.
The authors acknowledge several limitations. First, the study is focused on a large but comprehensive population of EHR users. Although this allows for analytical consistency across groups, it excludes specific categories of users, such as those in smaller independent practices or those using other large EHR platforms not included.
In particular, the sample had a relatively low rate of physicians identified as specialists in infectious diseases and general pediatrics. Despite this deficiency, results similar to those of studies of EHR use in adult populations were observed. On the other hand, the study was limited to doctors, and in many places, nurses are the busiest care providers. Additional work should be conducted to evaluate EHR use by this group.
Because the authors addressed EHR use on weekends and after hours, the number of hours in these periods may have been overestimated. The analysis also depends on the local health system correctly classifying professional roles and specialties. In this study, they focused on pediatricians and adolescent physicians. Internationally, it is common for pediatric subspecialists to care for adult patients.21
Adult patients may have unique characteristics and unknown issues to address, which may represent increased time spent on chart review or documentation for those specialties. Finally, sources of variation, such as differences in clinical processes or software configuration, could not be analyzed.
| Conclusions |
In this study, the authors estimated the time that pediatricians and adolescent physicians spend using an EHR in the outpatient setting.
The significant proportion of total clinical time that practitioners spend performing tasks using the EHR is significant, and there is certainly a need to continue to identify and eliminate unnecessary and low-value activities throughout the clinician’s workflow.
The wide variability in time that professionals spend using the EHR to care for patients within each specialty is an important finding and warrants extensive investigation.
