Objectives: To understand hospitals’ access to and use of data from electronic health record (EHR) developers that quantify the amount of time clinicians spend documenting clinical care in EHRs.
Study Design: Descriptive analysis of 4 waves of a nationally representative survey of US nonfederal acute care hospitals from 2017 to 2019 and 2021 (N = 10,662 across years).
Methods: We identified the share of hospitals that had access to EHR documentation time measures between 2017 and 2021 and how access varied by hospital and EHR characteristics. We then described how EHR data were used among hospitals with access and whether use varied by developer.
Results: The share of hospitals with access to EHR documentation time measures increased significantly each year between 2017 and 2021, when more than two-thirds of hospitals reported having access to these measures. Despite hospitals’ increased access to measures that track EHR time, lower-resourced hospitals, nonteaching hospitals, and hospitals with non–market-leading EHR developers were less likely to report having access than their counterparts. In 2021, the 2 most common uses of EHR data were “identifying providers in need of training and support” and “identifying areas to improve clinical workflow.” The share of hospitals indicating use of EHR data increased between 2019 and 2021 for all studied uses.
Conclusions: A higher proportion of hospitals with access to EHR documentation time measures used them for more purposes over time, suggesting their increased value. Although hospitals’ access to and use of EHR documentation measures increased significantly in the last 5 years, future research efforts should investigate whether the use of these measures translates into reduced burden for providers.
Am J Manag Care. 2023;29(1):In Press
This study examines trends in hospitals’ access to and use of data from electronic health record (EHR) developers that quantify clinicians’ time spent documenting clinical care in EHRs.
- In 2021, more than two-thirds of hospitals had access to measures from their EHR developer that quantify the amount of time clinicians spend documenting in the EHR.
- A higher proportion of hospitals with access to these measures used them for more purposes over time, suggesting their increased value.
- Although the share of hospitals with non–market-leading EHR developers that provide the ability to track EHR use time increased significantly, their access continues to lag behind that of hospitals with market-leading developers.
- Although hospitals’ access to and use of EHR documentation measures increased in the last 5 years, future research efforts should investigate whether the use of these measures translates into reduced burden for providers.
The adoption and use of electronic health records (EHRs) have been linked to decreased job satisfaction and increased burnout among care providers.1-10 Various methods to reduce burden and optimize the use of EHRs to document clinical care have been suggested.11-13 In 2020, the Office of the National Coordinator for Health Information Technology (ONC) and CMS outlined strategies to improve the usability of EHRs and reduce regulatory and documentation burden.14-16 Recent policy efforts have been made to simplify documentation, including reducing the amount of documentation associated with evaluation and management (E&M) office visits, which became effective in January 2021.
Complementary to these policy efforts, EHR developers have created tools to track the time clinicians spend documenting in their EHRs. Audit logs and other sources of data from EHR systems provide a detailed record of EHR users’ clinical activity, including who has accessed patient data and for how long.17 These data can be mined to measure time or effort associated with specific tasks (eg, note-taking, chart review, messaging), surfacing opportunities to improve clinical workflow and monitor efficiency. Leveraging data from EHR audit logs is one such method that has been used to understand providers’ use of EHRs in inpatient and outpatient settings and identify variation in physician practice patterns.2,18-21
Recent work has demonstrated the use of audit log data by hospitals to measure the time that clinicians spend using EHRs in inpatient settings.21 Early findings indicate that only a few inpatient EHR developers, largely representing the market leaders (top 3 in terms of market share), provided their clients with measures of clinicians’ time spent performing different activities, and the availability and use of these measures varied considerably.19,21 Our study builds on prior work examining hospitals’ and researchers’ use of measures that quantify documentation time in the EHR.21,22 We do so by assessing trends in hospitals’ access to and use of EHR documentation time measures across a common set of applications between the years 2017 and 2021. Understanding how the availability and different uses of these data have evolved over time sheds light on some of the tools and strategies used by hospitals to optimize EHR use and reduce rates of provider burnout and staff turnover, which have become major issues during the COVID-19 pandemic.23
Using the most recent nationally representative survey data available, this study examines trends in the share of hospitals that receive or have access to data from EHR developers that quantify the amount of time clinicians spend documenting clinical care in the EHR. We examine how hospitals’ access to these data varies with geography, hospital characteristics, or health information technology (IT) systems, and whether data access has increased over time. Finally, we explore how EHR data are used and whether use varies by EHR developer. The ultimate objective of this study is to highlight gaps in the availability and use of EHR documentation time measures across hospitals and EHR developers that provide these data. Identifying such gaps can help inform opportunities for hospital leadership, EHR developers, and federal policy makers to ensure that hospitals have access to these data and the necessary resources to leverage this information to improve clinical workflows and reduce documentation burden.
Data come from 4 waves of the American Hospital Association (AHA) IT Supplement to the AHA Annual Survey. The CEO of every US hospital was invited to participate in the survey, regardless of AHA membership status. The survey requested that the individual most knowledgeable of the hospital’s health IT (typically the chief information officer) provide the information. Nonrespondents received follow-up mailings and phone calls to encourage response.
Each survey was administered via mail or a secure online website. The 2017 survey was fielded from January 2018 to May 2018, the 2018 survey was fielded from January 2019 to May 2019, and the 2019 survey was fielded from January 2020 to June 2020. Due to pandemic-related delays, the 2020 survey was not fielded until April 2021 to September 2021. Because the IT supplement survey instructed respondents to answer questions as of the day the survey is completed, we henceforth refer to responses to the 2020 IT supplement survey as happening in 2021.
Data from a combined sample of 10,662 nonfederal acute care hospital surveys were analyzed. The hospital response rate in 2017 was 64%; in 2018, 64%; in 2019, 59%; and in 2021, 52%. A logistic regression model was used to predict the propensity of survey response as a function of hospital characteristics, including size, ownership, teaching status, system membership, availability of a cardiac intensive care unit, urban status, and region. Hospital-level weights were derived by the inverse of the predicted propensity.
We examined the percentage of hospitals reporting that they received or had access to measures of clinician documentation time from their EHR developer. Hospitals were considered to not have access to these measures if they reported “no” or “don’t know” or left the question blank. We also examined the number of different uses of EHR data reported by hospitals and how these uses varied over time. Hospitals with access to EHR measures (ie, those who responded “yes” to receiving or having access to EHR documentation time measures) were asked to indicate whether they used the data for any of the following purposes: (1) vendor product improvement and troubleshooting, (2) identification of providers in need of training and support, (3) provider burden reduction initiatives, (4) physician performance and efficiency monitoring, (5) identification of opportunities for improvement in clinical workflow, and (6) other uses. Some hospitals indicating “other uses” clarified that “other uses” meant “no use” or “not yet used” in their open-ended responses. As such, the number of EHR uses was calculated excluding the “other use” category.
Hospitals’ Access to Measures That Track Provider EHR Documentation Time
As of late 2021, 69% of US nonfederal acute care hospitals reported the ability to track clinicians’ EHR documentation time using measures made available by their EHR developer. The share of hospitals with access to these measures increased significantly between 2017 and 2021 (Figure 1). Rates increased by 8 percentage points to 53% in 2018 (from 45% in 2017; P < .01); by 9 percentage points to 62% in 2019 (from 53% in 2018; P < .01); and by 7 percentage points to 69% in 2021 (from 62% in 2019; P < .01).
Table 1 reports the share of hospitals that track clinicians’ EHR documentation time as a function of hospital and health IT characteristics. Despite increases in the share of hospitals with access to measures that track EHR time, those with fewer resources—critical access hospitals (CAHs) and small, rural, and independent hospitals—as well as nonteaching hospitals were less likely to report having access than their larger, higher-resourced counterparts (Table 1, panel A). In 2021, the ability to track EHR time was reported by 60% of small hospitals (vs 79% of medium to large hospitals), 57% of CAHs (vs 74% of non-CAHs), 56% of rural hospitals (vs 78% of urban hospitals), 48% of independent hospitals (vs 80% of system-affiliated hospitals) and 79% and 59% of minor teaching and nonteaching hospitals, respectively (vs 93% of major teaching hospitals).
The share of hospitals with access to EHR documentation time measures also varied by health IT characteristics. Hospitals without EHRs certified by ONC and with EHRs from smaller, non–market-leading developers (with the top 3 in market share classified as market leading) were less likely to report having access to EHR documentation time data than hospitals with health IT from larger, market-leading developers (Table 1, panel B). In 2021, only 21% of hospitals implementing noncertified health IT reported access to EHR documentation time measures compared with 72% of hospitals with certified EHRs. Similarly, 25% of hospitals with non–market-leading EHR developers reported having access to measures that track EHR time compared with 83% of hospitals with market-leading developers. The share of hospitals with non–market-leading developers that provide the ability to track EHR use time has risen significantly in recent years, increasing 46% between 2018 and 2019 and 49% between 2019 and 2021 (Figure 2).
Utilization of EHR Data
Table 2 reports the share of hospitals with access to EHR documentation measures that use these data for various purposes. The 2 most common uses were to “identify providers in need of training and support” and “identify areas to improve clinical workflow” (reported by 91% and 87% of hospitals, respectively, in 2021). “Performance/efficiency monitoring of clinicians” and informing “provider burden reduction initiatives” were other common uses (reported by 79% and 78% of hospitals, respectively, in 2021).
The share of hospitals indicating use of EHR data increased between 2019 and 2021 for all listed uses. Increases were statistically significant for all uses except “identifying providers in need of training and support”—the most frequently reported use of EHR data across all years in the study period. The mean number of uses increased significantly from 3.5 in 2018 to 3.7 in 2019 and 4.0 in 2021. “Other data uses” or “no use” declined from 9% in 2019 to 5% in 2021.
Figure 3 displays the number of EHR data uses reported by hospitals over time. The share of hospitals reporting all 5 uses listed in Table 2 increased from 30% in 2018 to 34% in 2019 and 44% in 2021. Although the share of hospitals reporting 4 uses remained relatively constant over time, hospitals reporting 3 or fewer uses declined between 2019 and 2021.
The share of hospitals with access to clinician documentation time data increased significantly each year between 2017 and 2021. Hospitals’ use of these measures for clinical improvement, performance efficiency, and burden reduction also increased between 2018 and 2021. Moreover, a higher proportion of hospitals with access to EHR documentation time measures used them for more purposes over time, suggesting their increased value. A majority of hospitals with access to these measures leveraged them to optimize EHR use in ways that may help mitigate burden associated with EHR use and ultimately reduce physician burnout. More than three-fourths of hospitals with access to EHR documentation time measures reported using them to inform initiatives aimed at reducing provider burden and improving clinical workflows. Among hospitals with access to measures, the most cited use over time was identifying providers in need of training and support, with approximately 9 in 10 hospitals reporting this use in 2021. Together, these findings suggest that hospitals with access to measures that track clinicians’ time spent documenting in the EHR are harnessing this information to improve providers’ experiences using EHRs.
Certified EHRs provide the capability to generate audit log data in a standardized manner, which, alongside more detailed activity logs and other EHR data, make it possible to generate reports of clinicians’ EHR use.24 Most hospitals are capable of generating audit log data because adoption of certified EHRs among hospitals is nearly universal.25 However, until recently, EHR developers’ use of these data to generate tools for their customers to monitor time spent documenting and performing other activities in the EHR has primarily been limited to those with a large market share (eAppendix Table 1 [eAppendix available at ajmc.com]).21,26 Encouragingly, we found that the percentage of smaller developers providing access to EHR documentation time measures increased in recent years, more than doubling between 2017 and 2021. This has translated to hospitals with fewer resources—which are more likely to use smaller developers—having increased access to these measures over time.
Despite this progress, the gap in availability of measures between small, critical access, rural, and independent (non–system-affiliated) hospitals and their higher-resourced counterparts has remained static. Lower-resourced hospitals were consistently less likely to track or use EHR documentation time measures compared with their larger, urban counterparts. This may be due, in part, to their use of smaller, non–market-leading developers (eAppendix Table 2). Thus, although the availability of measures grew at a higher rate among hospitals using products from smaller EHR developers, these developers may continue to lag in their ability to provide hospitals access to these measures.
Greater use of advanced standards may make it easier for non–market-leading EHR developers to make EHR documentation time measures accessible to their clients. Currently, conformance to standards for the development and implementation of audit logs for use in health information systems is not required. However, as the use of these more advanced standards for audit logs increases, leveraging audit log data for secondary purposes—such as the development of tools for tracking documentation time and optimizing EHRs—should become simpler.17,26 Such advancements may enable non–market-leading developers to generate and make these types of tools more accessible to their clients, including hospitals with fewer resources that are more likely to be using smaller developers.
Increased client demand for EHR documentation time measures may ultimately drive smaller EHR developers to offer such functionality. The increased utilization of these measures over time suggests there is value to hospitals in having this information available. For example, between 2017 and 2021 there was a significant increase in hospitals’ use of EHR documentation time measures for purposes associated with enhancing efficiency (eg, improving workflow, training and support, performance/efficiency monitoring). There was also a greater use of measures for provider burden reduction initiatives, suggesting that hospital leadership may be championing the use of these measures among their clinical staff as part of broader initiatives to reduce provider burden associated with EHR use within their organizations.
Although the utilization of EHR documentation measures has increased over time, rates of use among hospitals that had access to these measures varied by hospital type. Perhaps unsurprisingly, major teaching hospitals, which tend to be more engaged in research and may facilitate burden reduction initiatives, were significantly more likely to track EHR documentation time compared with minor teaching and nonteaching hospitals. In contrast, lower-resourced hospitals used data they had access to at lower rates, likely due to a lack of support needed to leverage EHR data for burden reduction initiatives. EHR developers may have a role to play in broadening usage of tools they make available to clients by providing additional technical support or making tools easier to use. For example, some EHR developers offer dynamic dashboards, data visualization, and other tools to facilitate interpretation and use of data.21 Such efforts may help bridge the gap for lower-resourced hospitals that have not yet utilized their access to EHR audit log data or associated measures.
Developing specific strategies to support the use of EHR documentation measures is critical to enabling lower-resourced hospitals to take full advantage of these tools. Increasing the availability of such measures may not be sufficient for enabling EHR optimization efforts. Hospitals may be slow to implement changes required to make use of such measures or lack the necessary resources to do so. Future qualitative work could examine hospitals’ experiences with applying these measures to inform the development of best practices for those in need of support.
If efforts are not made to address gaps in access and use of EHR documentation time measures, hospitals that are already facing greater resource constraints will be less likely to have access to the information or resources they need to optimize EHR use and engage in burden reduction initiatives. Hospital and EHR developer efforts to support the availability and use of tools that measure documentation time may not translate to meaningful changes nationally if the efforts are largely limited to hospitals with greater resources. Disparities in the availability and use of these measures may also contribute to the lack of substantial reduction in time spent documenting at the national level despite CMS’ implementation of revised E&M guidelines that sought to ease documentation burden in early 2021.27 Thus, more work is needed to understand which efforts have been linked to desired outcomes in order to better target the availability and use of EHR documentation time data, particularly for hospitals in the greatest need of support.
This study has limitations. First, the self-report survey may underestimate the share of hospitals with access to EHR documentation time data, as respondents may not be aware of the availability of these measures from their EHR developer. For instance, among hospitals with a market-leading developer, 83% of respondents said they had access to measures that track EHR time, whereas 12% reported they did not have access and 4% indicated they “don’t know.” Respondents who were unsure whether their hospital received this information may have had access but were unaware of it.
Conversely, the use of self-reported measures may overestimate the share of hospitals that use EHR data because the uses are not linked to specific actions or outcomes. Moreover, our measures do not capture hospital-level variation in how data are used for different purposes, limiting comparability. These limitations are somewhat mitigated by our ability to examine the change in these measures over time, demonstrating increased access and use of data, regardless of how specifically the data were used.
Overall, trends show that the percentage of hospitals with access to measures of clinician documentation time increased significantly between 2017 and 2021. The percentage of hospitals indicating use of these measures for provider burden reduction also increased. Although smaller, non–market-leading developers lagged behind larger developers in offering these capabilities, more offered these capabilities in the last 4 years. If these trends continue, gaps in access between lower-resourced and greater-resourced hospitals should narrow, enabling more hospitals to engage in data-driven provider burden reduction initiatives. Ultimately, widespread use of EHR documentation time measures among hospitals may help optimize the use of EHRs, improve clinical workflows, and reduce documentation burden for physicians. We also note that use of such data increased for performance/efficiency monitoring, which could have the countervailing effect of adding to clinician burden. Future work in this area should focus on evaluating the effectiveness of EHR optimization and burden reduction efforts and whether they have been successful in reducing provider burnout.
Author Affiliations: Office of the National Coordinator for Health Information Technology (CR, VP), Washington, DC.
Source of Funding: None.
Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (CR, VP); data analysis (CR); interpretation of results (CR, VP); drafting of the manuscript (CR); and critical revision of the manuscript for important intellectual content (CR, VP).
Address Correspondence to: Chelsea Richwine, PhD, MA, Office of the National Coordinator for Health Information Technology, 330 C St SW, Washington, DC 20201. Email: Chelsea.Richwine@hhs.gov.
1. Adler-Milstein J, Zhao W, Willard-Grace R, Knox M, Grumbach K. Electronic health records and burnout: time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians. J Am Med Inform Assoc. 2020;27(4):531-538. doi:10.1093/jamia/ocz220
2. Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med. 2017;15(5):419-426. doi:10.1370/afm.2121
3. Eschenroeder HC Jr, Manzione LC, Adler-Milstein J, et al. Associations of physician burnout with organizational electronic health record support and after-hours charting. J Am Med Inform Assoc. 2021;28(5):960-966. doi:10.1093/jamia/ocab053
4. Peccoralo LA, Kaplan CA, Pietrzak RH, Charney DS, Ripp JA. The impact of time spent on the electronic health record after work and of clerical work on burnout among clinical faculty. J Am Med Inform Assoc. 2021;28(5):938-947. doi:10.1093/jamia/ocaa349
5. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91(7):836-848. doi:10.1016/j.mayocp.2016.05.007
6. Tai-Seale M, Olson CW, Li J, et al. Electronic health record logs indicate that physicians split time evenly between seeing patients and desktop medicine. Health Aff (Millwood). 2017;36(4):655-662. doi:10.1377/hlthaff.2016.0811
7. Yan Q, Jiang Z, Harbin Z, Tolbert PH, Davies MG. Exploring the relationship between electronic health records and provider burnout: a systematic review. J Am Med Inform Assoc. 2021;28(5):1009-1021. doi:10.1093/jamia/ocab009
8. Nguyen OT, Jenkins NJ, Khanna N, et al. A systematic review of contributing factors of and solutions to electronic health record–related impacts on physician well-being. J Am Med Inform Assoc. 2021;28(5):974-984. doi:10.1093/jamia/ocaa339
9. Melnick ER, Fong A, Nath B, et al. Analysis of electronic health record use and clinical productivity and their association with physician turnover. JAMA Netw Open. 2021;4(10):e2128790. doi:10.1001/jamanetworkopen.2021.28790
10. Melnick ER, Dyrbye LN, Sinsky CA, et al. The association between perceived electronic health record usability and professional burnout among US physicians. Mayo Clin Proc. 2020;95(3):476-487. doi:10.1016/j.mayocp.2019.09.024
11. Lourie EM, Utidjian LH, Ricci MF, Webster L, Young C, Grenfell SM. Reducing electronic health record–related burnout in providers through a personalized efficiency improvement program. J Am Med Inform Assoc. 2021;28(5):931-937. doi:10.1093/jamia/ocaa248
12. Simpson JR, Lin CT, Sieja A, Sillau SH, Pell J. Optimizing the electronic health record: an inpatient sprint addresses provider burnout and improves electronic health record satisfaction. J Am Med Inform Assoc. 2021;28(3):628-631. doi:10.1093/jamia/ocaa231
13. Thomas Craig KJ, Willis VC, Gruen D, Rhee K, Jackson GP. The burden of the digital environment: a systematic review on organization-directed workplace interventions to mitigate physician burnout. J Am Med Inform Assoc. 2021;28(5):985-997. doi:10.1093/jamia/ocaa301
14. Strategy on reducing regulatory and administrative burden relating to the use of health IT and EHRs. Office of the National Coordinator for Health Information Technology. February 2020. Accessed March 14, 2022. https://www.healthit.gov/sites/default/files/page/2020-02/BurdenReport_0.pdf
15. Fact sheet – Physician Fee Schedule (PFS) payment for office/outpatient evaluation and management (E/M) visits. CMS. January 11, 2021. Accessed September 28, 2022. https://www.cms.gov/files/document/physician-fee-schedule-pfs-payment-officeoutpatient-evaluation-and-management-em-visits-fact-sheet.pdf
16. CPT evaluation and management: E/M revisions to code descriptors & guidelines 2021-2023. American Medical Association. Updated August 26, 2022. Accessed September 28, 2022. https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
17. Standard specification for audit and disclosure logs for use in health information systems. ASTM International. Updated March 12, 2019. Accessed July 18, 2022. https://www.astm.org/e2147-18.html
18. Sinsky CA, Rule A, Cohen G, et al. Metrics for assessing physician activity using electronic health record log data. J Am Med Inform Assoc. 2020;27(4):639-643. doi:10.1093/jamia/ocz223
19. Baxter SL, Apathy NC, Cross DA, Sinsky C, Hribar MR. Measures of electronic health record use in outpatient settings across vendors. J Am Med Inform Assoc. 2021;28(5):955-959. doi:10.1093/jamia/ocaa266
20. Overhage JM, McCallie D Jr. Physician time spent using the electronic health record during outpatient encounters: a descriptive study. Ann Intern Med. 2020;172(3):169-174. doi:10.7326/M18-3684
21. Cohen GR, Boi J, Johnson C, Brown L, Patel V. Measuring time clinicians spend using EHRs in the inpatient setting: a national, mixed-methods study. J Am Med Inform Assoc. 2021;28(8):1676-1682. doi:10.1093/jamia/ocab042
22. Rule A, Melnick ER, Apathy NC. Using event logs to observe interactions with electronic health records: an updated scoping review shows increasing use of vendor-derived measures. J Am Med Inform Assoc. Published online September 29, 2022. doi:10.1093/jamia/ocac177
23. Sinsky C, Linzer M. Practice and policy reset post–COVID-19: reversion, transition, or transformation? Health Aff (Millwood). 2020;39(8):1405-1411. doi:10.1377/hlthaff.2020.00612
24. §170.315(d)(3) Audit report(s) (Cures). HealthIT.gov. Updated August 2, 2021. Accessed July 18, 2022. https://www.healthit.gov/test-method/audit-reports
25. National trends in hospital and physician adoption of electronic health records. Office of the National Coordinator for Health Information Technology Quick-Stat No. 61. March 2022. Accessed July 18, 2022. https://www.healthit.gov/data/quickstats/national-trends-hospital-and-physician-adoption-electronic-health-records
26. Cohen G, Brown L, Fitzgerald M, Somplasky A. Exploring the feasibility of using audit log data to quantitate burden as providers use electronic health records. Office of the Assistant Secretary for Planning and Evaluation. September 5, 2019. Accessed June 28, 2022. https://aspe.hhs.gov/sites/default/files/private/pdf/263356/jsk-qebhr-final-concept-report.pdf
27. Apathy NC, Hare AJ, Fendrich S, Cross DA. Early changes in billing and notes after evaluation and management guideline change. Ann Intern Med. 2022;175(4):499-504. doi:10.7326/M21-4402.