The Impact of Team-Based Ordering Workflows on Ambulatory Physician EHR Time, Order Volume, and Visit Volume

To analyze national rates of team-based ordering and evaluate changes in key outcomes following adoption.

We conducted an observational pre-post intervention-comparison study of 249,463 ambulatory physicians across 401 organizations using the Epic EHR. Our intervention was the adoption of team-based ordering, measured as the proportion of orders involving team support. Outcomes include active ordering time, overall EHR time, order volume, and visit volume among adopter physicians.

We analyzed the distribution and trends in team-based ordering rates from Epic Signal (September 2019-March 2022). We used multi-variable regression in a difference-in-differences framework to evaluate changes in our outcomes among 115 adopters of team-based ordering and 3115 non-adopters. We defined adopters as physicians who demonstrated a one-time shift from 0% of orders to a consistent non-zero share of orders, and non-adopters as those who demonstrated constant 0% teamwork for at least 18 months.

Across our study period, 26.2% of orders involved team support, with surgical specialists averaging greater team-based ordering (43.1%) than primary care (22.2%) and medical specialists (23.0%). There was no association between team-based ordering adoption and time spent ordering (-0.13 min/visit, 95% CI: [-0.48 to 0.22]) or total EHR time (-1.42 min/visit, [-3.79 to 0.95]). Adoption was associated with a 26.8% relative increase in order volume (0.47 orders/visit, [0.14-0.80]) and a 22.3% relative increase in visit volume (6.50 visits/week [2.81-10.19]).

Team-based ordering rates are relatively low, and new adoption of team-based ordering was not associated with physicians' time spent ordering or in the EHR overall. Teamwork may facilitate substantial increases in both order and visit volume, but a greater level of team-based ordering may be required to realize EHR time savings.