More Tethered to the EHR: EHR Workload Trends Among Academic Primary Care Physicians, 2019-2023

Primary care staff members' experiences with managing electronic health record inbox messages

OBJECTIVE

Clinical staff often help clinicians review and respond to messages from patients. This study aimed to characterize primary care staff members' experiences with inbox work.

MATERIALS AND METHODS

In this qualitative study, we conducted direct observations and focus groups with clinical staff at 4 academic primary care clinics. We used inductive thematic analysis to code the resulting notes and transcripts for themes in staff members' experience with inbox work.

RESULTS

Nine medical assistants and 3 nurses participated in the study. Staff described inbox work as fragmented, feeling like an assembly line, requiring frequent communication with other team members to clarify and manage tasks, and requiring navigation of expectations that varied between patients, clinicians, and clinics. Staff described some messages as being more difficult to manage due to how requests were posed, challenges with subsequent communication, and mismatches between data from different sources. Staff also described how tools that structured or automated message management aided inbox work.

DISCUSSION

Staff addressed routine messages by following known protocols and appreciated tools that structured their inbox work. However, staff also regularly encountered messages with information that conflicted with clinic records or that contained multiple, redundant, or vague requests. Addressing these messages required additional work to clarify information (ie, data work) and manage resulting tasks (ie, articulation work).

CONCLUSION

Clinic workflows and health information technology should support not only the readily standardized work of addressing routine messages but also the more varied work of preparing messages to be addressed in the first place.

High-Frequency Utilization of the Outpatient Messaging System in a Specialized Outpatient Catatonia Clinic for Individuals with Autism Spectrum Disorder

Purpose: Catatonia is a highly morbid psychomotor disorder that impacts autistic adults and children. There is very little literature that describes outpatient catatonia management practices, none of which discusses the use of the electronic health record (EHR). Thus, we conducted this study to analyze patient messages in a specialized catatonia clinic. Methods: We conducted a retrospective analysis of messaging practices in the EHR for patients in a specialized clinic with autism and catatonia from July 1, 2021, to May 31, 2024. Catatonic symptom severity was recorded via the Bush Francis Catatonia Rating Scale (BFCRS), Kanner Catatonia Severity Scale (KCS), and Kanner Catatonia Examination (KCE). We conducted Spearman and Pearson correlation coefficients to determine whether a relationship exists between the frequency of patient messages, catatonic symptoms, and length of follow-up. Results: A total of 12,972 messages were sent to the health system or received by the patient or their family. Of those, 6375 (49.1%) messages were sent from the family to the health system. Relationships between message frequency to the health system and all baseline catatonia severity scores (BFCRS, KCS, KCE) were not statistically significant, although message frequency was strongly associated with length of follow-up (r = 0.65, p < 0.001). A total of 5555 (42.8%) messages were sent directly to or received from providers in the catatonia specialty clinic. The rate of messages to providers in the catatonia clinic was 2.9 messages/day. Conclusion: The frequency of patient messaging was high in this catatonia specialty clinic. Health systems should consider this possibility when planning for similar service lines.

Trends in Physician Electronic Health Record Time and Message Volume

This cohort study uses national electronic health record data to assess patient medical advice request message volume and the time physicians spend in the records.

Instruments evaluating the duration and pace of clinical encounters: A scoping review

OBJECTIVE

Hurried encounters in clinical settings contribute to dissatisfaction among both patients and clinicians and may indicate and contribute to low-quality care. We sought to identify patient- or clinician-reported instruments concerning this experience of time in clinical encounters.

METHODS

We searched multiple databases from inception through July 2023. Working in duplicate without restrictions by language or clinical context, we identified published instruments or single items measuring perceptions of time adequacy in clinical encounters. We characterized these by time domain (perceived duration or pace of the encounter), responder (patient or clinician), and reference (experience of care in general or of a particular encounter).

RESULTS

Of the 96 instruments found, none focused exclusively on perception of time adequacy in clinical encounters. Nonetheless, these instruments contained 107 time-related items. Of these, 81 items (77 %) measured the perception of the encounter duration, assessing whether there was adequate consultation time overall or for specific tasks (e.g., listening to the patient, exploring psychosocial issues, formulating the care plan). Another 19 (18 %) assessed encounter pace, and 7 (7 %) assessed both duration and pace. Pace items captured actions perceived as rushed or hurried or the perception that patients and clinicians felt pressed for time or rushed. Patients were the respondents for 76 (71 %) and clinicians for 24 (22 %) items. Most patient-reported items (48 of 76) referred to the patient's general care experience.

CONCLUSION

There are existing items to capture patient and clinician perceptions of the duration and/or pace of clinical encounters. Further work should ascertain their ability to identify hurried consultations and to detect the effect of interventions to foster unhurried encounters.

PRACTICE IMPLICATIONS

The available items assessing patient and clinician perceptions of duration and pace can illuminate the experience of time adequacy in clinical encounters as a target for quality improvement interventions. These items may capture unintended consequences on perceived time for care of interventions to improve healthcare access and efficiency.

Ambient artificial intelligence scribes: utilization and impact on documentation time

OBJECTIVES

To quantify utilization and impact on documentation time of a large language model-powered ambient artificial intelligence (AI) scribe.

MATERIALS AND METHODS

This prospective quality improvement study was conducted at a large academic medical center with 45 physicians from 8 ambulatory disciplines over 3 months. Utilization and documentation times were derived from electronic health record (EHR) use measures.

RESULTS

The ambient AI scribe was utilized in 9629 of 17 428 encounters (55.25%) with significant interuser heterogeneity. Compared to baseline, median time per note reduced significantly by 0.57 minutes. Median daily documentation, afterhours, and total EHR time also decreased significantly by 6.89, 5.17, and 19.95 minutes/day, respectively.

DISCUSSION

An early pilot of an ambient AI scribe demonstrated robust utilization and reduced time spent on documentation and in the EHR. There was notable individual-level heterogeneity.

CONCLUSION

Large language model-powered ambient AI scribes may reduce documentation burden. Further studies are needed to identify which users benefit most from current technology and how future iterations can support a broader audience.

The number of patient scheduled hours resulting in a 40-hour work week by physician specialty and setting: a cross-sectional study using electronic health record event log data

OBJECTIVE

To quantify how many patient scheduled hours would result in a 40-h work week (PSH40) for ambulatory physicians and to determine how PSH40 varies by specialty and practice type.

METHODS

We calculated PSH40 for 186 188 ambulatory physicians across 395 organizations from November 2021 through April 2022 stratified by specialty.

RESULTS

Median PSH40 for the sample was 33.2 h (IQR: 28.7-36.5). PSH40 was lowest in infectious disease (26.2, IQR: 21.6-31.1), geriatrics (27.2, IQR: 21.5-32.0) and hematology (28.6, IQR: 23.6-32.6) and highest in plastic surgery (35.7, IQR: 32.8-37.7), pain medicine (35.8, IQR: 32.6-37.9) and sports medicine (36.0, IQR: 33.3-38.1).

DISCUSSION

Health system leaders and physicians will benefit from data driven and transparent discussions about work hour expectations. The PSH40 measure can also be used to quantify the impact of variations in the clinical care environment on the in-person ambulatory patient care time available to physicians.

CONCLUSIONS

PSH40 is a novel measure that can be generated from vendor-derived metrics and used by operational leaders to inform work expectations. It can also support research into the impact of changes in the care environment on physicians' workload and capacity.

Relationships Among Physician Vendor-Derived Proficiency Score, Gender, and Time in the Electronic Health Record

BACKGROUND AND OBJECTIVES

Electronic health record (EHR) customization is proposed to mitigate EHR-related burnout. Gender disparities in EHR usage are established, though less is known regarding differences in customization and its impact on EHR time. This study examined gender differences in vendor-derived proficiency score (PS) and its relationship to EHR time.

METHODS

This was a retrospective observational study of ambulatory EHR use for adult primary care and medical subspecialty physicians at an academic safety-net health care system. The EHR vendor provided a physician PS (0-10), derived from customization and efficiency tool utilization. Primary outcomes were PS, time in system per day, and time in system per appointment stratified by gender. We used multiple variable linear regression to determine whether gender differences persisted with the inclusion of other factors.

RESULTS

A total of 228 physicians were included in the study; 122 were women, and 106 were men. Women had higher median PS (7.6 vs 6.6, P=.021) and EHR time per day (150.5 vs 119.9 minutes, P=.013), but no difference in time per appointment (24.7 vs 26.1 minutes, P=.665). After adjusting for potential confounders, gender remained a significant predictor of PS, but not time in EHR. Higher PS was significantly associated with greater time in the system per appointment, but not per day.

CONCLUSIONS

While women had higher PS than men, gender was not significantly associated with measures of EHR time after adjusting for potential confounders. Higher PS was associated with greater time in the EHR per appointment, suggesting factors that influence EHR time are complex and varied.

Beyond the Exam Room: Teaching Intervisit Care to Internal Medicine Residents

Introduction

Intervisit care, asynchronous care provided between patient visits, represents an essential part of patient care. Despite the importance of intervisit care, residency programs have not traditionally taught residents how to effectively manage intervisit care within the formal curriculum. We aimed to improve resident preparedness in providing intervisit care with an intervisit workshop.

Methods

We developed a 2-hour, small-group, interactive workshop on intervisit care for categorical internal medicine interns at the University of Utah in Fall of 2023. The workshop consisted of a didactic session introducing a novel framework for intervisit care medical decision-making, case-based application, and practical site-specific applications using the electronic health record. We evaluated the workshop with an electronic survey following the session.

Results

Thirty-two internal medicine residents (100% participation rate) participated in the workshop and 26/32 (81%) completed the survey. Residents felt intervisit care education was extremely important (median = 5, interquartile range [IQR] = 1). Residents felt more prepared to provide intervisit care after the workshop (median = 2, IQR = 2, vs. median = 4, IQR = 0; p < .001). Residents felt the framework for medical decision-making was helpful (median = 4, IQR = 1).

Discussion

By employing a framework to guide medical decision-making and guided application, our intervisit care workshop improved residents' perceived preparedness in providing intervisit care for their patients. This workshop addresses a major gap in medical education and can be adapted by other institutions and specialties. Further work is needed to reinforce content and develop metrics of intervisit care.

Effects of COVID-19 on Irish general practice activity from 2019 to 2021: a retrospective analysis of 500,000 consultations using electronic medical record data

BACKGROUND

General practice (GP) is crucial to primary care delivery in the Republic of Ireland and is almost fully computerised. General practice teams were the first point of contact for much COVID-19-related care and there were concerns routine healthcare activities could be disrupted due to COVID-19 and related restrictions.

AIMS

The study aimed to assess effects of the pandemic on GP activity through analysis of electronic medical record data from general practice clinics in the Irish Midwest.

METHODS

A retrospective, descriptive study of electronic medical record data relating to patient record updates, appointments and medications prescribed across 10 GP clinics over the period 2019-2021 inclusive.

RESULTS

Data relating to 1.18 million record transactions for 32 k patients were analysed. Over 500 k appointments were examined, and demographic trends presented. Overall appointment and prescribing activity increased over the study period, while a dip was observed immediately after the pandemic's arrival in March 2020. Delivery of non-childhood immunisations increased sixfold as a result of COVID-19, childhood immunisation activity was maintained, while cervical smears decreased in 2020 as the screening programme was halted. A quarter of consultations in 2020 and 2021 were teleconsultations, and these were more commonplace for younger patients.

CONCLUSIONS

General practice responded robustly to the pandemic by taking on additional activities while maintaining routine services where possible. The shift to teleconsulting was a significant change in workflow. Analysing routinely collected electronic medical record data can provide valuable insights for service planning, and access to these insights would be beneficial for future pandemic responses.

Use of the Patient Portal to Discuss Medications Among People with Dementia and Their Care Partners

BACKGROUND

People with dementia (PWD) often use potentially inappropriate medications (PIM), exposing them to harm. Patient portals are a promising platform for delivering deprescribing educational interventions to reduce PIM use, yet little is known about how PWD and their care partners use patient portals to communicate with clinicians about medications.

OBJECTIVE

To characterize the content of patient portal messages relating to medications among PWD, care partners, and clinicians, to inform development of a portal-based intervention to reduce use of PIM among PWD.

DESIGN

Descriptive analysis of data from the electronic health record and qualitative analysis of patient portal messages.

PARTICIPANTS

Adults 65 and older, categorized as having dementia based on EHR algorithm, who received care in an academic health system from 2017 to 2022.

APPROACH

Electronic health record data were analyzed using descriptive statistics. Qualitative coding identified topics raised in portal messages.

KEY RESULTS

A total of 399 message threads from 159 unique patients were analyzed. Patients were on average 78.4 years old (SD 8.0). Most (65%) were female, White (76%), and non-Hispanic/Latinx (96%); 15% had a registered proxy portal user. The most common topics raised in portal messages were logistics (42%), concerns about adverse effects/treatment burden (25%), asking for new medications (23%), and openness to stopping medications (21%). Qualitative analysis revealed three main themes related to deprescribing: (1) Opportunities to deprescribe, (2) challenges to deprescribing, and (3) medication-related counseling in the portal.

CONCLUSIONS

PWD and their care partners frequently raise medication concerns in the portal, suggesting it is a promising platform for delivering deprescribing interventions for this population. Future research should identify characteristics of portal-based interventions that would best support deprescribing for PWD and develop pragmatic workflows.

Measuring Documentation Burden in Healthcare

BACKGROUND

The enactment of the Health Information Technology for Economic and Clinical Health Act and the wide adoption of electronic health record (EHR) systems have ushered in increasing documentation burden, frequently cited as a key factor affecting the work experience of healthcare professionals and a contributor to burnout. This systematic review aims to identify and characterize measures of documentation burden.

METHODS

We integrated discussions with Key Informants and a comprehensive search of the literature, including MEDLINE, Embase, Scopus, and gray literature published between 2010 and 2023. Data were narratively and thematically synthesized.

RESULTS

We identified 135 articles about measuring documentation burden. We classified measures into 11 categories: overall time spent in EHR, activities related to clinical documentation, inbox management, time spent in clinical review, time spent in orders, work outside work/after hours, administrative tasks (billing and insurance related), fragmentation of workflow, measures of efficiency, EHR activity rate, and usability. The most common source of data for most measures was EHR usage logs. Direct tracking such as through time-motion analysis was fairly uncommon. Measures were developed and applied across various settings and populations, with physicians and nurses in the USA being the most frequently represented healthcare professionals. Evidence of validity of these measures was limited and incomplete. Data on the appropriateness of measures in terms of scalability, feasibility, or equity across various contexts were limited. The physician perspective was the most robustly captured and prominently focused on increased stress and burnout.

DISCUSSION

Numerous measures for documentation burden are available and have been tested in a variety of settings and contexts. However, most are one-dimensional, do not capture various domains of this construct, and lack robust validity evidence. This report serves as a call to action highlighting an urgent need for measure development that represents diverse clinical contexts and support future interventions.

Primary Care in the United States: Past, Present and Future

Even though a well-functioning primary care system is widely acknowledged as critical to population health, the number of primary care physicians (PCPs) practicing in the United States has steadily declined, and PCPs are in short supply. The reasons are multiple and include inadequate income relative to other specialties, excessive administrative demands on PCPs and the lack of respect given to primary care specialties during medical school and residency. Advanced practice nurses can augment the services of primary care physicians but cannot substitute for them. To change this situation, we need action on several fronts. Medical schools should give preference to students who are more likely to enter the primary care specialties. The income gap between primary care and other specialties should be narrowed. The administrative load placed on PCPs, including cumbersome electronic medical records, must be lessened. Insurers, including Medicare and Medicaid, must provide the resources to allow primary care physicians to act as leaders of multidisciplinary teams.

Accuracy, thoroughness, and quality of outpatient primary care documentation in the U.S. Department of Veterans Affairs

BACKGROUND

Electronic health records (EHRs) can accelerate documentation and may enhance details of notes, or complicate documentation and introduce errors. Comprehensive assessment of documentation quality requires comparing documentation to what transpires during the clinical encounter itself. We assessed outpatient primary care notes and corresponding recorded encounters to determine accuracy, thoroughness, and several additional key measures of documentation quality.

METHODS

Patients and primary care clinicians across five midwestern primary care clinics of the US Department of Veterans Affairs were recruited into a prospective observational study. Clinical encounters were video-recorded and transcribed verbatim. Using the Physician Documentation Quality Instrument (PDQI-9) added to other measures, reviewers scored quality of the documentation by comparing transcripts to corresponding encounter notes. PDQI-9 items were scored from 1 to 5, with higher scores indicating higher quality.

RESULTS

Encounters (N = 49) among 11 clinicians were analyzed. Most issues that patients initiated in discussion were omitted from notes, and nearly half of notes referred to information or observations that could not be verified. Four notes lacked concluding assessments and plans; nine lacked information about when patients should return. Except for thoroughness, PDQI-9 items that were assessed achieved quality scores exceeding 4 of 5 points.

CONCLUSIONS

Among outpatient primary care electronic records examined, most issues that patients initiated in discussion were absent from notes, and nearly half of notes referred to information or observations absent from transcripts. EHRs may contribute to certain kinds of errors. Approaches to improving documentation should consider the roles of the EHR, patient, and clinician together.

Assessment of the workload of general practitioners in outpatient clinics in Almaty

OBJECTIVE

Aim: The purpose of this study is to comprehensively assess the workload of general practitioners using the time study and the WISN method..

PATIENTS AND METHODS

Materials and Methods: Time studies are used to assess the objective workload of physicians, by measuring the duration of physicians' activities, and the WISN method, which is based on the workload of a health care professional and determines how many health care professionals of a certain type are needed to cope with the workload of a given health care facility.

RESULTS

Results: The results show that general practitioners spend short period of time for one patient visits, which may be conditioned by high patient attendance. In addition, general practitioners perform unusual functional duties. When calculated based on the Republican standard, the needs assessment by the WISN method showed that there is a shortage of general practitioners in outpatient clinics.

CONCLUSION

Conclusions: The needs assessment for the first and second scenarios shows that general practitioners cope with the workload of receiving patients, so the WISN assessment shows that there is a surplus of general practitioners.