Evaluating Electronic Health Record Limitations and Time Expenditure in a German Medical Center

 

 Permissions and Reprints

Abstract

Objectives This study set out to obtain a general profile of physician time expenditure and electronic health record (EHR) limitations in a large university medical center in Germany. We also aim to illustrate the merit of a tool allowing for easier capture and prioritization of specific clinical needs at the point of care for which the current study will inform development in subsequent work.

Methods Nineteen physicians across six different departments participated in this study. Direct clinical observations were conducted with 13 out of 19 physicians for a total of 2,205 minutes, and semistructured interviews were conducted with all participants. During observations, time was measured for larger activity categories (searching information, reading information, documenting information, patient interaction, calling, and others). Semistructured interviews focused on perceived limitations, frustrations, and desired improvements regarding the EHR environment.

Results Of the observed time, 37.1% was spent interacting with the health records (9.0% searching, 7.7% reading, and 20.5% writing), 28.0% was spent interacting with patients corrected for EHR use (26.9% of time in a patient's presence), 6.8% was spent calling, and 28.1% was spent on other activities. Major themes of discontent were a spread of patient information, high and often repeated documentation burden, poor integration of (new) information into workflow, limits in information exchange, and the impact of such problems on patient interaction. Physicians stated limited means to address such issues at the point of care.

Conclusion In the study hospital, over one-third of physicians' time was spent interacting with the EHR, environment, with many aspects of used systems far from optimal and no convenient way for physicians to address issues as they occur at the point of care. A tool facilitating easier identification and registration of issues, as they occur, may aid in generating a more complete overview of limitations in the EHR environment.

Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, and was waived by the Institutional Review Board of the university medical center Leipzig.

Publication History

Received: 12 July 2021

Accepted: 11 October 2021

Article published online:
22 December 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

• References

• 1 Chaudhry B, Wang J, Wu S. et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006; 144 (10) 742-752
  CrossrefPubMedGoogle Scholar
• 2 Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff (Millwood) 2011; 30 (03) 464-471
  CrossrefPubMedGoogle Scholar
• 3 Silow-Carroll S, Edwards JN, Rodin D. Using electronic health records to improve quality and efficiency: the experiences of leading hospitals. Issue Brief (Commonw Fund) 2012; 17: 1-40
  PubMedGoogle Scholar
• 4 Adler-Milstein J, Huckman RS. The impact of electronic health record use on physician productivity. Am J Manag Care 2013; 19 (10 spec no): SP345-SP352
  PubMedGoogle Scholar
• 5 Lorenzi NM, Kouroubali A, Detmer DE, Bloomrosen M. How to successfully select and implement electronic health records (EHR) in small ambulatory practice settings. BMC Med Inform Decis Mak 2009; 9: 15
  CrossrefPubMedGoogle Scholar
• 6 Graber ML, Byrne C, Johnston D. The impact of electronic health records on diagnosis. Diagnosis (Berl) 2017; 4 (04) 211-223
  CrossrefPubMedGoogle Scholar
• 7 Melnick ER, Harry E, Sinsky CA. et al. Perceived electronic health record usability as a predictor of task load and burnout among US physicians: mediation analysis. J Med Internet Res 2020; 22 (12) e23382
  CrossrefPubMedGoogle Scholar
• 8 Hanauer DA, Branford GL, Greenberg G. et al. Two-year longitudinal assessment of physicians' perceptions after replacement of a longstanding homegrown electronic health record: does a J-curve of satisfaction really exist?. J Am Med Inform Assoc 2017; 24 (e1): e157-e165
  CrossrefPubMedGoogle Scholar
• 9 Overhage JM, McCallie Jr D. Physician time spent using the electronic health record during outpatient encounters: a descriptive study. Ann Intern Med 2020; 172 (03) 169-174
  CrossrefPubMedGoogle Scholar
• 10 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 (11) 753-760
  CrossrefPubMedGoogle Scholar
• 11 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 (04) 655-662
  CrossrefPubMedGoogle Scholar
• 12 Flanagan ME, Militello LG, Rattray NA, Cottingham AH, Frankel RM. The thrill is gone: burdensome electronic documentation takes its toll on physicians' time and attention. J Gen Intern Med 2019; 34 (07) 1096-1097
  CrossrefPubMedGoogle Scholar
• 13 Perry JJ, Sutherland J, Symington C, Dorland K, Mansour M, Stiell IG. Assessment of the impact on time to complete medical record using an electronic medical record versus a paper record on emergency department patients: a study. Emerg Med J 2014; 31 (12) 980-985
  CrossrefPubMedGoogle Scholar
• 14 Asan O, D Smith P, Montague E. More screen time, less face time - implications for EHR design. J Eval Clin Pract 2014; 20 (06) 896-901
  CrossrefPubMedGoogle Scholar
• 15 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 (05) 419-426
  CrossrefPubMedGoogle Scholar
• 16 Pizziferri L, Kittler AF, Volk LA. et al. Primary care physician time utilization before and after implementation of an electronic health record: a time-motion study. J Biomed Inform 2005; 38 (03) 176-188
  CrossrefPubMedGoogle Scholar
• 17 Lo HG, Newmark LP, Yoon C. et al. Electronic health records in specialty care: a time-motion study. J Am Med Inform Assoc 2007; 14 (05) 609-615
  CrossrefPubMedGoogle Scholar
• 18 Zheng K, Haftel HM, Hirschl RB, O'Reilly M, Hanauer DA. Quantifying the impact of health IT implementations on clinical workflow: a new methodological perspective. J Am Med Inform Assoc 2010; 17 (04) 454-461
  CrossrefPubMedGoogle Scholar
• 19 Edwards MB, Gronlund SD. Task interruption and its effects on memory. Memory 1998; 6 (06) 665-687
  CrossrefPubMedGoogle Scholar
• 20 Kellogg KM, Puthumana JS, Fong A, Adams KT, Ratwani RM. Understanding the types and effects of clinical interruptions and distractions recorded in a multihospital patient safety reporting system. J Patient Saf 2018; DOI: 10.1097/PTS.0000000000000513.
  CrossrefPubMedGoogle Scholar
• 21 Pollack AH, Tweedy CG, Blondon K, Pratt W. Knowledge crystallization and clinical priorities: evaluating how physicians collect and synthesize patient-related data. AMIA Annu Symp Proc 2014; 2014: 1874-1883
  PubMedGoogle Scholar
• 22 Weiner M. Forced inefficiencies of the electronic health record. J Gen Intern Med 2019; 34 (11) 2299-2301
  CrossrefPubMedGoogle Scholar
• 23 Ruppel H, Bhardwaj A, Manickam RN. et al. Assessment of electronic health record search patterns and practices by practitioners in a large integrated health care system. JAMA Netw Open 2020; 3 (03) e200512
  CrossrefPubMedGoogle Scholar
• 24 Kroth PJ, Morioka-Douglas N, Veres S. et al. The electronic elephant in the room: Physicians and the electronic health record. JAMIA Open 2018; 1 (01) 49-56
  CrossrefPubMedGoogle Scholar
• 25 Usher M, Sahni N, Herrigel D. et al. Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study. J Gen Intern Med 2018; 33 (09) 1447-1453
  CrossrefPubMedGoogle Scholar
• 26 Or C, Tong E, Tan J, Chan S. Exploring factors affecting voluntary adoption of electronic medical records among physicians and clinical assistants of small or solo private general practice clinics. J Med Syst 2018; 42 (07) 121
  CrossrefPubMedGoogle Scholar
• 27 Everson J, Kocher KE, Adler-Milstein J. Health information exchange associated with improved emergency department care through faster accessing of patient information from outside organizations. J Am Med Inform Assoc 2017; 24 (e1): e103-e110
  CrossrefPubMedGoogle Scholar
• 28 Olson K, Sinsky C, Rinne ST. et al. Cross-sectional survey of workplace stressors associated with physician burnout measured by the Mini-Z and the Maslach Burnout Inventory. Stress Health 2019; 35 (02) 157-175
  CrossrefPubMedGoogle Scholar
• 29 West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med 2018; 283 (06) 516-529
  CrossrefPubMedGoogle Scholar
• 30 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 (07) 836-848
  CrossrefPubMedGoogle Scholar
• 31 Shanafelt TD, Hasan O, Dyrbye LN. et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc 2015; 90 (12) 1600-1613
  CrossrefPubMedGoogle Scholar
• 32 Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009; 374 (9702): 1714-1721
  CrossrefPubMedGoogle Scholar
• 33 Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017; 92 (01) 129-146
  CrossrefPubMedGoogle Scholar
• 34 Willard-Grace R, Knox M, Huang B, Hammer H, Kivlahan C, Grumbach K. Burnout and health care workforce turnover. Ann Fam Med 2019; 17 (01) 36-41
  CrossrefPubMedGoogle Scholar
• 35 Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health Care Manage Rev 2007; 32 (03) 203-212
  CrossrefPubMedGoogle Scholar
• 36 Kroth PJ, Morioka-Douglas N, Veres S. et al. Association of electronic health record design and use factors with clinician stress and burnout. JAMA Netw Open 2019; 2 (08) e199609
  CrossrefPubMedGoogle Scholar
• 37 Washington V, DeSalvo K, Mostashari F, Blumenthal D. The HITECH era and the path forward. N Engl J Med 2017; 377 (10) 904-906
  CrossrefPubMedGoogle Scholar
• 38 Helmons PJ, Suijkerbuijk BO, Nannan Panday PV, Kosterink JG. Drug-drug interaction checking assisted by clinical decision support: a return on investment analysis. J Am Med Inform Assoc 2015; 22 (04) 764-772
  CrossrefPubMedGoogle Scholar
• 39 Sutton RT, Pincock D, Baumgart DC, Sadowski DC, Fedorak RN, Kroeker KI. An overview of clinical decision support systems: benefits, risks, and strategies for success. NPJ Digit Med 2020; 3: 17
  Google Scholar
• 40 Zheng K, Guo MH, Hanauer DA. Using the time and motion method to study clinical work processes and workflow: methodological inconsistencies and a call for standardized research. J Am Med Inform Assoc 2011; 18 (05) 704-710
  CrossrefPubMedGoogle Scholar
• 41 Overhage JM, Perkins S, Tierney WM, McDonald CJ. Controlled trial of direct physician order entry: effects on physicians' time utilization in ambulatory primary care internal medicine practices. J Am Med Inform Assoc 2001; 8 (04) 361-371
  CrossrefPubMedGoogle Scholar
• 42 Chapman AL, Hadfield M, Chapman CJ. Qualitative research in healthcare: an introduction to grounded theory using thematic analysis. J R Coll Physicians Edinb 2015; 45 (03) 201-205
  CrossrefPubMedGoogle Scholar
• 43 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3: 77-101
  CrossrefPubMedGoogle Scholar
• 44 Holmgren AJ, Lindeman B, Ford EW. Resident physician experience and duration of electronic health record use. Appl Clin Inform 2021; 12 (04) 721-728
  Article in Thieme ConnectPubMedGoogle Scholar
• 45 Montague E, Asan O. Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor-patient communication and attention. Int J Med Inform 2014; 83 (03) 225-234
  CrossrefPubMedGoogle Scholar
• 46 Artis KA, Bordley J, Mohan V, Gold JA. Data omission by physician trainees on ICU rounds. Crit Care Med 2019; 47 (03) 403-409
  CrossrefPubMedGoogle Scholar
• 47 Ratwani RM, Reider J, Singh H. A decade of health information technology usability challenges and the path forward. JAMA 2019; 321 (08) 743-744
  CrossrefPubMedGoogle Scholar
• 48 Clynch N, Kellett J. Medical documentation: part of the solution, or part of the problem? A narrative review of the literature on the time spent on and value of medical documentation. Int J Med Inform 2015; 84 (04) 221-228
  CrossrefPubMedGoogle Scholar
• 49 Friedberg MW, Chen PG, Van Busum KR. et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Rand Health Q 2014; 3 (04) 1
  PubMedGoogle Scholar
• 50 Koopman RJ, Steege LM, Moore JL. et al. Physician information needs and electronic health records (EHRs): time to reengineer the clinic note. J Am Board Fam Med 2015; 28 (03) 316-323
  CrossrefPubMedGoogle Scholar
• 51 Hultman GM, Marquard JL, Lindemann E, Arsoniadis E, Pakhomov S, Melton GB. Challenges and opportunities to improve the clinician experience reviewing electronic progress notes. Appl Clin Inform 2019; 10 (03) 446-453
  Article in Thieme ConnectPubMedGoogle Scholar
• 52 Sheehy AM, Weissburg DJ, Dean SM. The role of copy-and-paste in the hospital electronic health record. JAMA Intern Med 2014; 174 (08) 1217-1218
  CrossrefPubMedGoogle Scholar
• 53 Downing NL, Bates DW, Longhurst CA. Physician burnout in the electronic health record era: are we ignoring the real cause?. Ann Intern Med 2018; 169 (01) 50-51
  CrossrefPubMedGoogle Scholar
• 54 Adler-Milstein J, Pfeifer E. Information blocking: is it occurring and what policy strategies can address it?. Milbank Q 2017; 95 (01) 117-135
  CrossrefPubMedGoogle Scholar
• 55 Reisman M. EHRs: the challenge of making electronic data usable and interoperable. P&T 2017; 42 (09) 572-575
  PubMedGoogle Scholar
• 56 Zhang J. Human-centered computing in health information systems. Part 1: analysis and design. J Biomed Inform 2005; 38 (01) 1-3
  CrossrefPubMedGoogle Scholar
• 57 Sittig DF, Wright A, Osheroff JA. et al. Grand challenges in clinical decision support. J Biomed Inform 2008; 41 (02) 387-392
  CrossrefPubMedGoogle Scholar
• 58 Zandieh SO, Yoon-Flannery K, Kuperman GJ, Langsam DJ, Hyman D, Kaushal R. Challenges to EHR implementation in electronic- versus paper-based office practices. J Gen Intern Med 2008; 23 (06) 755-761
  CrossrefPubMedGoogle Scholar
• 59 Beeler PE, Bates DW, Hug BL. Clinical decision support systems. Swiss Med Wkly 2014; 144: w14073
  PubMedGoogle Scholar
• 60 Or C. Pre-implementation case studies evaluating workflow and informatics challenges in private primary care clinics for electronic medical record implementation. Int J Healthc Inf Syst Inform 2015; 10 (04) 56-64
  CrossrefPubMedGoogle Scholar
• 61 Or C, Wong K, Tong E, Sek A. Private primary care physicians' perspectives on factors affecting the adoption of electronic medical records: a qualitative pre-implementation study. Work 2014; 48 (04) 529-538
  CrossrefPubMedGoogle Scholar
• 62 Zahabi M, Kaber DB, Swangnetr M. Usability and safety in electronic medical records interface design: a review of recent literature and guideline formulation. Hum Factors 2015; 57 (05) 805-834
  CrossrefPubMedGoogle Scholar
• 63 Howe JL, Adams KT, Hettinger AZ, Ratwani RM. Electronic health record usability issues and potential contribution to patient harm. JAMA 2018; 319 (12) 1276-1278
  CrossrefPubMedGoogle Scholar
• 64 Khairat S, Coleman C, Newlin T. et al. A mixed-methods evaluation framework for electronic health records usability studies. J Biomed Inform 2019; 94: 103175
  CrossrefPubMedGoogle Scholar
• 65 Lasko TA, Owens DA, Fabbri D, Wanderer JP, Genkins JZ, Novak LL. User-centered clinical display design issues for inpatient providers. Appl Clin Inform 2020; 11 (05) 700-709
  Article in Thieme ConnectPubMedGoogle Scholar
• 66 Gawande A. Why doctors hate their computers. Accessed June 10, 2021 at: https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers
  PubMedGoogle Scholar

• Supplementary Material