Patient Safety Tip of the Week Archive

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:

June 19, 2007 “Unintended Consequences of Technological Solutions”
May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”
June 17, 2008 “Technology Workarounds Defeat Safety Intent”
August 26, 2008 “Pattern Recognition and CPOE”
September 9, 2008 “Less is More….and Do You Really Need that Decimal?”
December 16, 2008 “Joint Commission Sentinel Event Alert on Hazards of Healthcare IT”
February 2009 “Healthcare IT The Good and The Bad”
March 3, 2009 “Overriding Alerts…Like Surfin’ the Web”
October 2009 “A Cautious View on CPOE”
November 24, 2009 “Another Rough Month for Healthcare IT
April 20, 2010 “HIT’s Limited Impact on Quality To Date”
July 27, 2010 “EMR’s Still Have a Long Way to Go”
March 22, 2011 “An EMR Feature Detrimental to Teamwork and Patient Safety”
January 24, 2012 “Patient Safety in Ambulatory Care”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
June 2012 “Leapfrog CPOE Simulation: Improvement But Still Shortfalls”
July 17, 2012 “More on Wrong-Patient CPOE”
January 2013 “More IT Unintended Consequences”
April 23, 2013 “Plethora of Medication Safety Studies”
April 30, 2013 “Photographic Identification to Prevent Errors”
October 8, 2013 “EMR Problems in the ED”
March 11, 2014 “We Miss the Graphic Flowchart!”
October 2014 “Ebola Exposes Fundamental Flaw”
January 2015 “Beneficial Effect of EMR on Patient Safety”
March 2015 “CPOE Fails to Catch Prescribing Errors”
March 31, 2015 “Clinical Decision Support for Pneumonia”
August 2015 “Newborn Name Confusion”
December 2015 “Opioid Alert Fatigue”
January 12, 2016 “New Resources on Improving Safety of Healthcare IT”
January 19, 2016 “Patient Identification in the Spotlight”
February 9, 2016 “It was just a matter of time…”
April 5, 2016 “Workarounds Overriding Safety”
May 2016 “Name Confusion in the Pharmacy”
May 3, 2016 “Clinical Decision Support Malfunction”
May 24, 2016 “Texting Orders – Is It Really Safe?”
August 23, 2016 “ISMP Canada: Automation Bias and Automation Complacency”
November 22, 2016 “Leapfrog, Picklists, and Healthcare IT Vulnerabilities”
January 2017 “Joint Commission Thinks Twice About Texting Orders”
February 28, 2017 “The Copy and Paste ETTO”
March 2017 “Yes! Another Voice for Medication e-Discontinuation!”
April 2017 “How Much Time Do We Actually Spend on the EMR?”
June 27, 2017 “Texting – We Told You So!”
August 1, 2017 “Progress on Wrong Patient Orders”
January 2018 “Can We Improve Barcoding?”
January 16, 2018 “Just the Fax, Ma’am”
January 30, 2018 “Texting Errors Revealed”
June 19, 2018 “More EHR-Related Problems”
September 2018 “More Clinical Decision Support Successes”
December 11, 2018 “Another NMBA Accident”
January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”
February 5, 2019 “Flaws in Our Medication Safety Technologies”
March 26, 2019 “Patient Misidentification”
May 2019 “Too Much Time on the EMR”
May 21, 2019 “Mixed Message on Number of Open EMR Records”
July 23, 2019 “Order Sets Can Nudge the Right Way or the Wrong Way”
September 10, 2019 “Joint Commission Naming Standard Leaves a Gap”
September 24, 2019 “EHR-related Malpractice Claims”
December 17, 2019 “Tale of Two Tylers”
June 2020 “EMR and Medication Safety: Better But Not Yet There”
June 16, 2020 “Tracking Technologies”
July 2020 “Patient Requests for EHR Corrections”
July 21, 2020 “Is This Patient Allergic to Penicillin?”
September 2020 “More on Workarounds”
November 17, 2020 “A Picture Is Worth a Thousand Words”
March 2021 “ECRI Partnership Whitepaper on Alert Fatigue”

Some of our prior columns on “burnout”:

August 2018 “Burnout and Medical Errors”
October 16, 2018 “Burnout”
February 9, 2021 “Nursing Burnout”

References:

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

https://www.acpjournals.org/doi/10.7326/M16-0961

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

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2777845

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

https://journals.lww.com/lww-medicalcare/Abstract/9000/Electronic_Health_Record_Usability__Associations.98172.aspx

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

https://academic.oup.com/jamia/article/28/5/960/6242740

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