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Physician Note Composition Patterns and Time on the EHR Across Specialty Types: a National, Cross-sectional Study
Lisa S Rotenstein1,2, Nate Apathy3,4,5, A Jay Holmgren6
1Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA. lrotenstein@partners.org.
Journal of General Internal Medicine
|November 23, 2022
Summary
Physician documentation strategies in electronic health records (EHRs) vary significantly. Using transcription and dictation tools reduces time spent on notes, while copy-paste methods increase it, impacting physician burnout.
Area of Science:
- Medical Informatics
- Health Services Research
- Clinical Documentation
Background:
- Clinical documentation in electronic health records (EHRs) contributes to physician burnout.
- Existing tools aim to reduce documentation burden, but their combined use and impact on time are not well understood.
Purpose of the Study:
- To characterize EHR note composition strategies among physicians.
- To analyze how these strategies affect time spent on documentation and EHR use.
- To examine the distribution of strategies across medical specialties.
Main Methods:
- Secondary analysis of physician-level EHR data from Epic Systems.
- K-means clustering to identify distinct note composition strategies.
- Ordinary least squares regression to assess the relationship between strategies and time spent in EHRs.
Main Results:
- Six distinct note composition strategies were identified.
- Predominant use of SmartTools was the most common strategy.
- Physicians using transcription/dictation spent less time on notes (4.8 min/visit) compared to SmartTools users, while copy/paste users spent more time (13.1 min/visit).
Conclusions:
- Physician note composition strategies significantly influence documentation time and after-hours EHR use.
- Optimizing the use of EHR documentation tools and training can reduce physician workload and burnout.
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