This Primary Care Specialty May Suffer Less EHR Burden

Among three major specialties within primary care, one stood out in a new study of practitioners’ time spent on electronic health records (EHRs).

Whereas family medicine physicians averaged more than 2 hours each day dealing with EHRs, and general internal medicine specialists only slightly less, the mean for pediatricians was under 100 minutes, according to Lisa S. Rotenstein, MD, MBA, of Brigham and Women’s Hospital in Boston, and colleagues.

Time spent both during the regular workday and after hours was significantly lower for pediatric specialists, by about 34 and 8 minutes, respectively, the group reported in a JAMA Network Open research letter from their analysis of 349 U.S. outpatient provider groups using Epic Systems’ EHR platform in 2019. (Ob/gyn physicians, often considered to be primary care, were not part of the study.)

Much of the difference arose from use of EHR systems’ messaging function. Pediatricians’ daily volume averaged 20 messages, versus 42 for internists and 37 for family medicine specialists. That translated to a difference of about 9 minutes daily — not a great deal of time on its own, but nevertheless adding to what many physicians see as a burden and an impediment to patient care.

Meanwhile, time spent on typing notes was nearly identical across the three specialties. That point was important in the authors’ interpretation of their findings.

“Some differences may be attributed to the lesser medical complexity of pediatric patients,” Rotenstein and colleagues wrote. “It is also possible that pediatricians are spending more time on clinical care outside of the EHR. However, it is notable that time spent on notes was similar across specialties, suggesting that documentation burdens may be driven by factors beyond patient complexity.”

Overall, Rotenstein’s group argued, these data point to “opportunities to streamline diverse EHR functions.” For adult primary care specialists, they wrote, one focus should be on EHR messaging — and all primary care specialists would benefit from reduced documentation requirements.

In 2015, the American College of Physicians, which largely represents internists, began an initiative called “Patients Before Paperwork,” followed up in 2017 by a position paper offering a framework for analyzing administrative tasks with an eye to identifying those that could be delegated or eliminated.

Rotenstein, in an email to MedPage Today, listed several possibilities for reducing the EHR burden. Some could be adopted by clinicians and their practices, such as using automated or human scribes, and “team-based approaches to the EHR (i.e., handling in-basket messages, orders, notes).” Others could be taken by EHR developers: better templates and standardized order sets.

Notably, the findings by Rotenstein and colleagues contrasted with a study reported last December in Pediatrics. It found that general pediatricians spent nearly 15 minutes on their EHRs for each patient encounter. “Assuming an average pediatrician might care for 25 patients per day, they would spend 6 hours and 40 minutes using their EHR,” wrote J. Marc Overhage, MD, PhD, and Kevin B. Johnson, MD, MS, both of Vanderbilt University in Nashville.

But when contacted by MedPage Today, Overhage said the discrepancy isn’t as great as those numbers suggest. He pointed out that patient encounters in the new study averaged only 12.9 per day for general pediatricians, barely half the number in his and Johnson’s back-of-the-envelope estimate.

“Given the size of the standard deviations in the studies, the results are not really different,” he wrote in an email.

Rotenstein agreed, noting the different methods for quantifying providers’ EHR usage. The data in her study “looks only at active time (i.e., clicks, active interaction with the EHR),” she said. “For example, if someone is reading a note without actively interacting with the computer, it’s not counted. So, it’s likely that the true estimate is higher.”

Overhage observed that doctors could be using the EHR without detectably interacting with it. “How do you deal with time when data is displayed on the screen but the user is not typing or moving the mouse — are they reading or are they [answering] a question the nurse just asked them?”

Johnson, in an email, highlighted other potential differences in the two groups’ methods: “Epic supports the majority of children’s hospitals, which are teaching institutions. Teaching institutions often have both residents in training and experienced faculty working on the same patient, which may impact both total time in the EHR and how that time is spent.” In addition, the inclusion/exclusion criteria in his study with Overhage may have “biased our sample toward more complex patients” and “fewer handoffs within clinic (all of which impacts both total time and time in message baskets).”

Overhage told MedPage Today that an effort is now underway to standardize EHR research methods and provide better answers to the questions surrounding EHR usage.