PCP EHR Screen Time Linked to Higher Quality Outcomes

Primary care physician (PCP) EHR screen time spent on in-basket and clinical review was linked to higher quality outcomes for certain metrics, like breast cancer screening rates, according to a JAMA Network Open study.

Researchers conducted a cross-sectional study of PCPs at two large academic health centers.

The study found that each additional 15 minutes of daily EHR time was associated with 0.55 percentage points greater hypertension control. Further, each additional 15 minutes of daily EHR notes time was associated with 0.47 percentage points greater hypertension control.

“These results underscore the need to create team structures, examine PCP and office workflows, and enhance EHR-based technologies and decision support tools in ways that enable high quality of care, while optimizing time spent on the EHR,” the study authors wrote.

Additionally, every 15 minutes of daily in-basket time was associated with 2.26 percentage point greater panel-wide hemoglobin A1c control, 1.65 percentage point greater panel-wide hypertension control, and 1.26 percentage point higher breast cancer screening rates.

The researchers noted that clinicians often perform in-basket work outside scheduled work hours in addition to visit-based, revenue-generating work. Time spent addressing in-basket content has been associated with an increased likelihood of clinician burnout.

“The associations we have identified between increased in-basket time and enhanced ambulatory quality of care highlight the importance of continuing to develop and expand value-based reimbursement systems that adequately reward outside-of-visit care delivery,” the study authors wrote.

“The identified associations also raise also raises the potential for bringing workflow processes and automation technologies to bear to assist PCPs in more efficiently handling their clinical messages,” they added. “Future work may also benefit from identifying the specific types of in-basket messaging activities associated with improved outcomes.”

The study authors said that it is not clear why there were associations between EHR time metrics and quality outcomes for some quality metrics but not for others, like lipid control in cardiovascular disease and diabetes screening.

They said that given the high levels of appropriate diabetes screening across the panels of PCPs, (93.4 percent on average), there may not have been sufficient variation in this measure to show an association with EHR time.

Also, both academic health systems have population health teams that support PCPs in tracking their quality performance.

“Given that a binary action, such as prescription of a high-dose statin, can count as meeting the lipid control in the cardiovascular disease metric, it is possible that these system-level supports more heavily influence lipid control outcomes than individual PCP time spent,” the researchers suggested.

The authors pointed out that the study has several limitations. First, the two academic medical centers may not represent the broader PCP population. In addition, both organizations have established population health programs that likely influence ambulatory quality outcomes for all PCPs in the sample.

“With the current data sources, we were unable to examine PCP EHR use at the level of specific patient visits and interactions,” the researchers said.

“In addition, given the lack of data available at the level of the patient-PCP interaction, we were unable to adjust for other factors, such as continuity of patients’ care, individual patients’ interactions with other staff, or the number of consultants involved in an individual patient’s care,” the authors continued.