OBJECTIVE: To characterize the nature and consequence(s) of interdependent physician electronic health record (EHR) work across inpatient shifts. MATERIALS AND METHODS: Pooled cross-sectional analysis of EHR metadata associated with hospital medicine patients at an academic medical center, January-June 2022. Using patient-day observation data, we use a mixed effects regression model with daytime physician random effects to examine nightshift behavior (handoff time, total EHR time) as a function of behaviors by the preceding daytime team. We also assess whether nighttime patient deterioration is predicted by team coordination behaviors across shifts. RESULTS: We observed 19 671 patient days (N = 2708 encounters). Physicians used the handoff tool consistently, generally spending 8-12 minutes per shift editing patient information. When the day service team was more activated (highest tercile of handoff time, overall EHR time), nightshift experienced increased levels of EHR work and patient risk of overnight decline was elevated. (ie, Busy predicts busy). However, lower levels of dayshift activation were also associated with nightshift spillovers, including higher overnight EHR work and increased likelihood of patient clinical decline. Patient-days in the lowest and highest terciles of dayshift EHR time had a 1 percentage point increased relative risk of overnight decline (baseline prevalence of 4.4%) compared to the middle tercile (P = .04). DISCUSSION: We find evidence of spillovers in EHR work from dayshift to nightshift. Additionally, the lowest and highest levels of dayshift EHR activity are associated with increased risk of overnight patient decline. Results are associational and motivate further examination of additional confounding factors. CONCLUSION: Analyses reveal opportunities to address task interdependence across shifts, using technology to flexibly shape and support collaborative teaming practices in complex clinical environments.

OBJECTIVE: We analyze observed reductions in physician note length and documentation time, 2 contributors to electronic health record (EHR) burden and burnout. MATERIALS AND METHODS: We used EHR metadata from January to May, 2021 for 130 079 ambulatory physician Epic users. We identified cohorts of physicians who decreased note length and/or documentation time and analyzed changes in their note composition. RESULTS: 37 857 physicians decreased either note length (n = 15 647), time in notes (n = 15 417), or both (n = 6793). Note length decreases were primarily attributable to reductions in copy/paste text (average relative change of -18.9%) and templated text (-17.2%). Note time decreases were primarily attributable to reductions in manual text (-27.3%) and increases in note content from other care team members (+21.1%). DISCUSSION: Organizations must consider priorities and tradeoffs in the distinct approaches needed to address different contributors to EHR burden. CONCLUSION: Future research should explore scalable burden-reduction initiatives responsive to both note bloat and documentation time.

Electronic health record (EHR) log data capture clinical workflows and are a rich source of information to understand variation in practice patterns. Variation in how EHRs are used to document and support care delivery is associated with clinical and operational outcomes, including measures of provider well-being and burnout. Standardized measures that describe EHR use would facilitate generalizability and cross-institution, cross-vendor research. Here, we describe the current state of outpatient EHR use measures offered by various EHR vendors, guided by our prior conceptual work that proposed seven core measures to describe EHR use. We evaluate these measures and other reporting options provided by vendors for maturity and similarity to previously proposed standardized measures. Working toward improved standardization of EHR use measures can enable and accelerate high-impact research on physician burnout and job satisfaction as well as organizational efficiency and patient health.

OBJECTIVE: To identify factors that impede payer engagement in a health information exchange (HIE), along with organizational and policy strategies that might effectively address the impediments. MATERIALS AND METHODS: Qualitative analysis of semi-structured interviews with leaders from 17 varied payer organizations from across the country (e.g., large, national payers; state Blues plans; local Medicaid managed care plans). RESULTS: We found a large gap between payers' vision of what optimal HIE should be and the current approach to HIE in the United States. Notably, payers sought to be active participants in HIE efforts--both providing claims data and accessing clinical data to support payer HIE use cases. Instead, payers were often asked by HIE efforts only to provide financial support without the option to participate in data exchange, or, when given the option, their data needs were secondary to those of providers. DISCUSSION: Efforts to engage payers in pursuit of more robust and sustainable HIE need to better align their value proposition with payer HIE use cases. This will require addressing provider concerns about payer access to clinical data. Policymakers should focus on creating the conditions for broader payer engagement by removing common obstacles, such as low provider engagement in HIE. CONCLUSION: Despite variation in the extent to which payers engaged with current HIE efforts, there was agreement on the vision of optimal HIE and the facilitators of greater payer engagement. Specific actions by those leading HIE efforts, complemented by policy efforts nationally, could greatly increase payer engagement and enhance HIE sustainability.

OBJECTIVE: Consensus that enhanced teamwork is necessary for efficient and effective primary care delivery is growing. We sought to identify how electronic health records (EHRs) facilitate and pose challenges to primary care teams as well as how practices are overcoming these challenges. METHODS: Practices in this qualitative study were selected from those recognized as patient-centered medical homes via the National Committee for Quality Assurance 2011 tool, which included a section on practice teamwork. We interviewed 63 respondents, ranging from physicians to front-desk staff, from 27 primary care practices ranging in size, type, geography, and population size. RESULTS: EHRs were found to facilitate communication and task delegation in primary care teams through instant messaging, task management software, and the ability to create evidence-based templates for symptom-specific data collection from patients by medical assistants and nurses (which can offload work from physicians). Areas where respondents felt that electronic medical record EHR functionalities were weakest and posed challenges to teamwork included the lack of integrated care manager software and care plans in EHRs, poor practice registry functionality and interoperability, and inadequate ease of tracking patient data in the EHR over time. DISCUSSION: Practices developed solutions for some of the challenges they faced when attempting to use EHRs to support teamwork but wanted more permanent vendor and policy solutions for other challenges. CONCLUSIONS: EHR vendors in the United States need to work alongside practicing primary care teams to create more clinically useful EHRs that support dynamic care plans, integrated care management software, more functional and interoperable practice registries, and greater ease of data tracking over time.

OBJECTIVE: A core feature of e-prescribing is the electronic exchange of prescription data between physician practices and pharmacies, which can potentially improve the efficiency of the prescribing process and reduce medication errors. Barriers to implementing this feature exist, but they are not well understood. This study's objectives were to explore recent physician practice and pharmacy experiences with electronic transmission of new prescriptions and renewals, and identify facilitators of and barriers to effective electronic transmission and pharmacy e-prescription processing. DESIGN: Qualitative analysis of 114 telephone interviews conducted with representatives from 97 organizations between February and September 2010, including 24 physician practices, 48 community pharmacies, and three mail-order pharmacies actively transmitting or receiving e-prescriptions via Surescripts. RESULTS: Practices and pharmacies generally were satisfied with electronic transmission of new prescriptions but reported that the electronic renewal process was used inconsistently, resulting in inefficient workarounds for both parties. Practice communications with mail-order pharmacies were less likely to be electronic than with community pharmacies because of underlying transmission network and computer system limitations. While e-prescribing reduced manual prescription entry, pharmacy staff frequently had to complete or edit certain fields, particularly drug name and patient instructions. CONCLUSIONS: Electronic transmission of new prescriptions has matured. Changes in technical standards and system design and more targeted physician and pharmacy training may be needed to address barriers to e-renewals, mail-order pharmacy connectivity, and pharmacy processing of e-prescriptions.