Greater EHR Use Among Adult PCPs Draws Clinician Burden Concerns

Adult primary care providers (PCPs) may be susceptible to clinician burden as their EHR use is significantly greater than pediatric clinicians, according to a study published in JAMA Network Open.

The study analyzed clinician EHR use at 349 ambulatory healthcare organizations that leveraged an Epic Systems EHR. Researchers collected data from January through August 2019.

While previous research has revealed that PCPs spend significantly more time using the EHR than their medical specialty and surgical colleagues, little has been known about potential disparities in EHR use across primary care specialties until now.

The study revealed that general pediatric clinicians and family medicine clinicians had 12.9 and 12.8 EHR encounters per day, respectively, while general internal medicine clinicians had 11.5 encounters per day.

For pediatric clinicians, the average daily total active EHR time was 94.7 minutes compared to 121.5 minutes and 127.9 minutes among general internal medicine clinicians and family medicine clinicians, respectively.

After-hours EHR use revealed a similar pattern; general pediatric clinicians spent an average of 23.6 minutes on the EHR after-hours, compared to 34.4 minutes and 31.2 minutes among general internal medicine clinicians and family medicine clinicians, respectively.

Additionally, pediatric clinicians spent approximately half as long on in-basket messages (9.4 minutes) as family medicine (18.0 minutes) and general medicine (18.4 minutes) clinicians. Pediatric clinicians also spent two-thirds as much time on clinical review and orders as the other primary care specialties.

Pediatric clinicians received one-fifth as many prescription messages, one-third as many patient messages, and one-half as many team messages compared to family medicine and general medicine clinicians.

The researchers found that time spent on notes was comparable across primary care specialties.

“Some differences may be attributed to the lesser medical complexity of pediatric patients,” the study authors 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.”

The study’s findings suggest disproportionate clinician burden for general internal medicine and family medicine clinicians compared to pediatric PCPs, demonstrating the need for EHR optimization to streamline EHR functions for adult primary care clinicians.   

"How primary care clinicians spend time with the record affects care in several ways," Lisa Rotenstein, MD, MBA, of the Department of Medicine at the Brigham and Women’s Hospital said in a public statement.

"If physicians can be more efficient, there will likely be less burnout; and if less time is spent on the EHR, there is more time to interact with patients, and to ensure that the truly important things get done,” the corresponding author continued.

Co-author David Bates, MD, MSc, chief of the Division of General Internal Medicine and Primary Care at Brigham and Women’s echoed Rosenstein, noting how improved clinician experience lends itself to higher quality care.

"The physician and patient experience are inextricably linked, as we know that burnout has consequences for quality of care and patient outcomes in addition to its important consequences for individual physicians," said Bates.

"Future studies should help us better understand why pediatric clinicians are spending less time on the EHR than other primary care clinicians, and whether there are any lessons about how pediatric EHRs are designed that could be applied to other specialties,” he continued.

A separate study, published recently in the Human Factors and Ergonomics Society’s journal Human Factors, revealed EHR usability challenges within primary care.  

The study reviewed and analyzed research about PCP EHR use conducted from 2012 through 2020.

Researchers from the Regenstrief Institute mapped their review’s findings onto a three-level framework to measure PCP situation awareness (SA), which refers to a provider’s understanding of her environment. Level one indicates basic perception, two indicates comprehension, and three signals projection.

“In primary care, reduced SA among physicians increases errors in clinical decision-making and, correspondingly, patients’ risk of experiencing adverse outcomes,” the study authors noted.

According to the findings, PCPs did not have access to the necessary data to achieve level one SA.

"The human mind can do many things well,” April Savoy, PhD, human factors engineer, Regenstrief Institute research scientist, and lead author of the study, said in a press release. “Digesting vast amounts of patient information while multitasking in time-constrained situations exposes a limitation. EHR technology should be able to complement or enhance physicians' abilities in these scenarios.”