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Original Investigation
Physician Work Environment and Well-Being
December 14, 2020

Assessment of Electronic Health Record Use Between US and Non-US Health Systems

Author Affiliations
  • 1Interfaculty Initiative in Health Policy, Harvard University, Cambridge, Massachusetts
  • 2Harvard Business School, Boston, Massachusetts
  • 3Department of Medicine, Stanford University, Stanford, California
  • 4Clinical Excellence Research Center, Stanford University, Stanford, California
  • 5Department of General Internal Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
  • 6Harvard Medical School, Boston, Massachusetts
  • 7Division of Hematology, Department of Medicine, Stanford University, Palo Alto, California
  • 8Department of Economics, Harvard University, Cambridge, Massachusetts
  • 9Graduate School of Business, Stanford University, Stanford, California
JAMA Intern Med. 2021;181(2):251-259. doi:10.1001/jamainternmed.2020.7071
Key Points

Question  Does the use of the electronic health record (EHR) differ between clinicians in the US and those in other countries?

Findings  In this cross-sectional study of the EHR metadata of 371 health systems in the US and abroad, US clinicians vs non-US clinicians were found to spend more time per day actively using the EHR, receive more system-generated messages, write a higher proportion of automatically generated note text, and spend more time using the EHR after hours.

Meaning  Findings from this study suggest that US clinicians compared with non-US clinicians had a higher EHR burden, which could be alleviated by minimizing EHR uncertainties and consolidating documentation requirements.


Importance  Understanding how the electronic health record (EHR) system changes clinician work, productivity, and well-being is critical. Little is known regarding global variation in patterns of use.

Objective  To provide insights into which EHR activities clinicians spend their time doing, the EHR tools they use, the system messages they receive, and the amount of time they spend using the EHR after hours.

Design, Setting, and Participants  This cross-sectional study analyzed the deidentified metadata of ambulatory care health systems in the US, Canada, Northern Europe, Western Europe, the Middle East, and Oceania from January 1, 2019, to August 31, 2019. All of these organizations used the EHR software from Epic Systems and represented most of Epic Systems’s ambulatory customer base. The sample included all clinicians with scheduled patient appointments, such as physicians and advanced practice practitioners.

Exposures  Clinician EHR use was tracked by deidentified and aggregated metadata across a variety of clinical activities.

Main Outcomes and Measures  Descriptive statistics for clinician EHR use included time spent on clinical activities, note documentation (as measured by the percentage of characters in the note generated by automated or manual data entry source), messages received, and time spent after hours.

Results  A total of 371 health systems were included in the sample, of which 348 (93.8%) were located in the US and 23 (6.2%) were located in other countries. US clinicians spent more time per day actively using the EHR compared with non-US clinicians (mean time, 90.2 minutes vs 59.1 minutes; P < .001). In addition, US clinicians vs non-US clinicians spent significantly more time performing 4 clinical activities: notes (40.7 minutes vs 30.7 minutes; P < .001), orders (19.5 minutes vs 8.75 minutes; P < .001), in-basket messages (12.5 minutes vs 4.80 minutes; P < .001), and clinical review (17.6 minutes vs 14.8 minutes; P = .01). Clinicians in the US composed more automated note text than their non-US counterparts (77.5% vs 60.8% of note text; P < .001) and received statistically significantly more messages per day (33.8 vs 12.8; P < .001). Furthermore, US clinicians used the EHR for a longer time after hours, logging in 26.5 minutes per day vs 19.5 minutes per day for non-US clinicians (P = .01). The median US clinician spent as much time actively using the EHR per day (90.1 minutes) as a non-US clinician in the 99th percentile of active EHR use time per day (90.7 minutes) in the sample. These results persisted after controlling for organizational characteristics, including structure, type, size, and daily patient volume.

Conclusions and Relevance  This study found that US clinicians compared with their non-US counterparts spent substantially more time actively using the EHR for a wide range of clinical activities or tasks. This finding suggests that US clinicians have a greater EHR burden that may be associated with nontechnical factors, which policy makers and health system leaders should consider when addressing clinician wellness.

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