eAppendix. Questions and Response Options in the 2019 National Electronic Health Records Survey
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Gaffney A, Woolhandler S, Cai C, et al. Medical Documentation Burden Among US Office-Based Physicians in 2019: A National Study. JAMA Intern Med. 2022;182(5):564–566. doi:10.1001/jamainternmed.2022.0372
Many physicians perceive that medical documentation is onerous, detracts from face time with patients, and drives burnout.1,2 We assessed the burden of medical documentation on US office-based physicians.
In this cross-sectional study, we analyzed office-based physician responses to the 2019 National Electronic Health Records Survey, which collects nationally representative data on the use and burdens of the electronic health record (EHR).3 The overall participation rate was 37.7%.3 The Cambridge Health Alliance Institutional Review Board deemed this analysis of publicly available, deidentified data exempt from review. Respondents provided informed consent at the time of data collection. Reporting followed the STROBE reporting guideline.
We evaluated the time physicians devoted to documentation outside office hours based on the question, “On average, how many hours per day do you spend outside of normal office hours documenting clinical care in your medical record system?” (none, <1, 1-2, >2-4, or >4 hours). We estimated mean daily hours devoted to documentation outside office hours by recoding categorical responses at the midpoint (for the highest category, the minimum) of response. We also explored 5 measures of satisfaction with the EHR and time spent documenting. For the complete question text and an explanation of how some response categories were combined for this analysis, see the eAppendix in the Supplement. We assessed the proportion of physicians with each outcome stratified by specialty and then the correlation among 3 physician and practice characteristics and mean documentation time outside office hours: (1) EHR use; (2) staff support for documentation (eg, scribes); and (3) participation in an Accountable Care Organization or pay-for-performance program (hereafter, value-based purchasing [VBP] participation).
Physician responses on satisfaction with documentation are summarized as weighted percentages and time spent on documentation as means with 95% CIs. Analyses were performed using Stata SE, version 16.1 (StataCorp LLC) survey procedures module. Two-sided P < .05 indicated statistical significance.
The 1524 respondents (78.6% aged ≥50 years; 69.9% men) represented 301 603 physicians nationwide. Across primary care, surgical, and medical specialties, 64.1% of respondents reported satisfaction with the EHR; 64.5% found documentation to be easy (Table 1). However, 58.1% disagreed that the time spent documenting was appropriate and did not reduce time spent with patients, and 84.7% agreed that documentation solely for billing purposes increased total documentation time. Differences by physician specialty were not significant.
Overall, physicians spent a mean of 1.77 (95% CI, 1.67-1.87) hours daily completing documentation outside office hours (Table 2). Differences by staff support for documentation (eg, scribes) were small and nonsignificant. Physicians who used EHRs spent a mean of 1.84 (95% CI, 1.74-1.94) h/d documenting outside office hours, significantly more than the 1.10 (95% CI, 0.83-1.37) h/d among those who did not use EHRs (P < .001). Physicians participating in VBP spent 2.02 (95% CI, 1.86-2.19) h/d on documentation outside office hours vs 1.58 (95% CI, 1.47-1.69) h/d among those who did not (P < .001). Assuming a 5-day work week and 47-week work year,4 we estimated US physicians spent 125 million hours documenting outside office hours in 2019.
This cross-sectional study reveals that documentation burdens US physicians. Most respondents indicated that documentation time is inappropriate and takes time from patients.
The large majority of US physicians reported that billing-related tasks exacerbate their documentation burden, which suggests that payment strategies specific to the US, vs to EHRs per se, account for some of the overload.5 Relative to EHR users in other nations, US physicians spend more time documenting in the EHR,5 with outpatient notes approximately 4 times longer.1
Per our analysis, VBP participation is associated with a higher documentation burden, a finding consonant with the doubling in length of EHR ambulatory notes in the VBP era (among EHR users).1 Surprisingly, we did not find that scribe use was associated with less overall documentation time; however, this does not address whether scribe users saw more patients.
A limitation of our study is that data were cross-sectional, precluding firm causal inference. Moreover, all data were self-reported by physicians, and the survey did not define documentation.3 Reassuringly, our estimate of time spent documenting outside office hours is comparable with some previous estimates based on other approaches.6 Reconsideration of the US approach to medical documentation may be warranted.
Accepted for Publication: January 30, 2022.
Published Online: March 28, 2022. doi:10.1001/jamainternmed.2022.0372
Corresponding Author: Adam Gaffney, MD, MPH, Cambridge Health Alliance/Harvard Medical School, Pulmonary and Critical Care Medicine, 1943 Cambridge St, Cambridge, MA 02139 (email@example.com).
Author Contributions: Dr Gaffney had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Gaffney, Woolhandler, Bor, McCormick, D. U. Himmelstein.
Acquisition, analysis, or interpretation of data: Gaffney, Cai, J. Himmelstein, McCormick, D. U. Himmelstein.
Drafting of the manuscript: Gaffney.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Gaffney, Woolhandler, D. U. Himmelstein.
Obtained funding: Bor.
Administrative, technical, or material support: Bor.
Supervision: Woolhandler, D. U. Himmelstein.
Conflict of Interest Disclosures: Dr Gaffney reported serving as a leader of the Physicians for a National Health Program (PNHP), a nonprofit organization that favors coverage expansion through a single-payer program; he has not received compensation from PNHP, but some of his travel on behalf of the organization was previously reimbursed by it. His spouse is an employee of Treatment Action Group, a nonprofit research and policy think tank focused on HIV, tuberculosis, and hepatitis C treatment. Dr Woolhandler served as an unpaid policy adviser to Senators Bernie Sanders and Elizabeth Warren and cofounded PNHP but receives no financial compensation from the organization. Dr Cai reported receiving personal fees from the US House of Representatives, Office of Pramila Jayapal, as a summer health policy fellow and nonfinancial support from PNHP as a summer research intern and board member outside the submitted work. Dr J. Himmelstein reported receiving grants from the Institutional National Research Service outside the submitted work. No other disclosures were reported.