OBJECTIVE: Evaluate the association between telemedicine intensity and ambulatory physician electronic health record (EHR) use following the COVID-19 pandemic. MATERIALS AND METHODS: This retrospective study included ambulatory physicians in 11 specialties at 2 large academic medical centers (Washington University in St Louis [WashU], University of California San Francisco [UCSF]). EHR use measures, including time-based and frequency-based, were analyzed in the post-COVID-19 period (March 1, 2021, through March 7, 2022). Multivariable regression models with 2-way fixed effects were used to assess the association between telemedicine intensity and EHR use. RESULTS: Fully telemedicine physician-weeks were associated with higher EHR (hours per 8 patient scheduled hours; β = 3.2 at WashU, β = 1.4 at UCSF; P < .001) and documentation time (β = 2.7 at WashU, β = 1.4 at UCSF; P < .001). Several differences in discrete EHR-based tasks were observed: fully telemedicine physician-days were associated with lesser ordering, and there were mixed patterns for information seeking and clinical communication tasks. DISCUSSION: Expanded use of telemedicine was associated with significant changes in physician EHR use post-COVID-19 onset. Increased EHR time may suggest a shift in workload, whereas decreased ordering may suggest constraints in virtual care, such as ability to perform physical examination and the reliance on patient-reported symptoms. Institutional differences usage patterns suggest that telemedicine's impact is context-specific and provides opportunities for understanding how to optimize EHRs to support telemedicine. CONCLUSION: Telemedicine shifts physician EHR. Supporting physicians through optimized EHR tools, tailored workflows, and team-based interventions is essential for sustainable virtual care delivery without exacerbating EHR burden.

INTRODUCTION: Research on how people interact with electronic health records (EHRs) increasingly involves the analysis of metadata on EHR use. These metadata can be recorded unobtrusively and capture EHR use at a scale unattainable through direct observation or self-reports. However, there is substantial variation in how metadata on EHR use are recorded, analyzed and described, limiting understanding, replication, and synthesis across studies. RECOMMENDATIONS: In this perspective, we provide guidance to those working with EHR use metadata by describing 4 common types, how they are recorded, and how they can be aggregated into higher-level measures of EHR use. We also describe guidelines for reporting analyses of EHR use metadata-or measures of EHR use derived from them-to foster clarity, standardization, and reproducibility in this emerging and critical area of research.

OBJECTIVE: To determine whether novel measures of contextual factors from multi-site electronic health record (EHR) audit log data can explain variation in clinical process outcomes. MATERIALS AND METHODS: We selected one widely-used process outcome: emergency department (ED)-based team time to deliver tissue plasminogen activator (tPA) to patients with acute ischemic stroke (AIS). We evaluated Epic audit log data (that tracks EHR user-interactions) for 3052 AIS patients aged 18+ who received tPA after presenting to an ED at three Northern California health systems (Stanford Health Care, UCSF Health, and Kaiser Permanente Northern California). Our primary outcome was door-to-needle time (DNT) and we assessed bivariate and multivariate relationships with six audit log-derived measures of treatment team busyness and prior team experience. RESULTS: Prior team experience was consistently associated with shorter DNT; teams with greater prior experience specifically on AIS cases had shorter DNT (minutes) across all sites: (Site 1: -94.73, 95% CI: -129.53 to 59.92; Site 2: -80.93, 95% CI: -130.43 to 31.43; Site 3: -42.95, 95% CI: -62.73 to 23.17). Teams with greater prior experience across all types of cases also had shorter DNT at two sites: (Site 1: -6.96, 95% CI: -14.56 to 0.65; Site 2: -19.16, 95% CI: -36.15 to 2.16; Site 3: -11.07, 95% CI: -17.39 to 4.74). Team busyness was not consistently associated with DNT across study sites. CONCLUSIONS: EHR audit log data offers a novel, scalable approach to measure key contextual factors relevant to clinical process outcomes across multiple sites. Audit log-based measures of team experience were associated with better process outcomes for AIS care, suggesting opportunities to study underlying mechanisms and improve care through deliberate training, team-building, and scheduling to maximize team experience.