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What’s New in the Patient Safety World

May 2021

More on Time Spent on the EMR



Clinicians spend an awful lot of time on the electronic medical record (EMR) and this has been an important factor contributing to burnout. See our What's New in the Patient Safety World columns for April 2017 “How Much Time Do We Actually Spend on the EMR?” and May 2019 “Too Much Time on the EMR”.


Many of the studies have looked at time spent on the EMR in the hospital setting. But a few have looked at EMR use in the ambulatory setting. A time-motion study of physicians in ambulatory practices (Sinsky 2016) found that, during the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on EHR and desk work. In addition, outside of office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work. Thus, for every hour physicians provide direct clinical face time to patients, they spent nearly 2 additional hours on EHR and desk work within the clinic day. Of the time spent on EHR and desk work, 38.5% was spent on documentation and review tasks, 6.3% on test results, 2.4% on medication orders, and 2.0% on other orders. They spent 1.1% of their time on administrative tasks (0.6% involved insurance-related tasks and 0.5% involved scheduling).


But it turns out that time spent on the EMR is far from uniform across ambulatory specialties. A new study looked at time spent on the EMR both during the day and after hours (Rotenstein 2021). Those researchers found that mean total active daily EMR time was 45.6 vs 85.7 vs. 115.0 minutes for surgical vs. medical vs. primary care specialties, respectively. Mean after hours active use time on the EMR was 16.0 vs 26.2 vs. 29.8 minutes, respectively.


The most time was spent on notes (22.0 minutes vs. 40.8 minutes vs. 51.5 minutes for surgical specialties, medical specialties, and primary care specialties, respectively). Clinical review and orders represented the next biggest areas of time expenditure. Time dealing with messages showed major differences. Compared with surgical colleagues, primary care clinicians received more than twice as many team-derived messages, 5 times as many patient messages, and 15 times as many prescription messages each day.


The authors call for further investigation to identify interventions to reduce the administrative and EMR burden to help avoid clinician burnout.


A second recent study (Eschenroeder 2021) confirmed the impact of after-hours EMR activity on burnout. The researchers found that physicians reporting ≤ 5 hours weekly of after-hours charting were twice as likely to report lower burnout scores compared to those charting ≥6 hours (aOR 2.43).


Of course, the EMR burden impact on burnout is not limited to physicians. Nurses are also impacted. A new study (Kutney-Lee 2021) found that nurses who worked in hospitals with poorer EHR (electronic health record) usability had significantly higher odds of burnout (odds ratio 1.41),  job dissatisfaction (OR 1.61) and intention to leave (OR 1.31) compared with nurses working in hospitals with better usability.


Not only did poor EHR usability impact nurse burnout, it also impacted patient safety and outcomes. Surgical patients treated in hospitals with poorer EHR usability had significantly higher odds of inpatient mortality (OR 1.21) and 30-day readmission (OR 1.06) compared with patients in hospitals with better usability.



See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:



Some of our prior columns on “burnout”:








Sinsky C, Colligan L, Li L, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med 2016; 165: 753-760



Rotenstein LS, Holmgren AJ, Downing NL, Bates DW. Differences in Total and After-hours Electronic Health Record Time Across Ambulatory Specialties. JAMA Intern Med 2021; Published online March 22, 2021



Kutney-Lee A, Brooks Carthon M, Sloane DM, Bowles KH, McHugh MD, Aiken LH. Electronic Health Record Usability: Associations With Nurse and Patient Outcomes in Hospitals. Med Care 2021; Apr 1, 2021



Eschenroeder E, Manzione LC, Adler-Milstein J, et al. Associations of physician burnout with organizational electronic health record support and after-hours charting, Journal of the American Medical Informatics Association 2021; 28(5): 960-966






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