NUR 8150 Module 1 EHR Burden Paper: Event Log Data, Clerical Load and a Plan to Return Clinician Time Example

Six Hours a Day in the Record: Measuring EHR Burden and Returning Time to Clinicians in an Eight-Clinic Primary Care Network

Student Name

Doctor of Nursing Practice, Thomas Edison State University

NUR-8150: Information Systems and Technology Impacting Healthcare Delivery

Mentor Name

Month Day, Year

Six Hours a Day in the Record: Measuring EHR Burden and Returning Time to Clinicians in an Eight-Clinic Primary Care Network

The Problem in Our Network

The network in this paper is invented: eight family medicine clinics across Burlington County, 46 physicians and nurse practitioners, and about 92,000 patients. In the past two years, four clinicians have left, and exit interviews named the electronic health record as a main reason. Last spring's internal survey had 54 percent of clinicians naming one or more burnout symptoms, and the most common complaint was "pajama time," charting at home after the children are asleep. The chief nursing officer asked the DNP-prepared director of clinical informatics to measure the problem and propose changes.

The question this paper answers is practical: how much time do our clinicians spend in the record, on what tasks, and which changes would return the most time without harming care?

Measuring the Time

Arndt et al. (2017) showed how event logs, the time-stamped records every EHR keeps of each click and screen, can measure clinician work. In a single Wisconsin system, they captured three years of Epic logs for 142 family physicians and checked them against direct observation. Per full-time physician, record time came to 355 minutes each weekday, with 269 of them inside clinic hours and 86 after, in workdays that ran about eleven and a half hours. Clerical and administrative tasks, including documentation, order entry, billing, coding and security, took 44.2 percent of that time, and inbox management took another 23.7 percent.

Our network's informatics team ran the same kind of analysis using the vendor's audit log reports for the past six months. The results were close to the Wisconsin figures: an average of 5.6 hours a day in the record per full-time clinician, with 1.3 hours outside scheduled clinic time. Documentation took 38 percent, inbox work 27 percent and order entry 14 percent. The inbox alone averaged 112 messages a day per clinician, about a third of them automated results notices that required no action.

Why This Matters for Burnout

Shanafelt et al. (2016) surveyed physicians across all specialties nationally in 2014. Of 6,375 practicing physicians who responded, 84.5 percent used EHRs, and of those for whom it applied, 82.5 percent used computerized order entry. Even with age, sex, specialty, setting and weekly hours taken into account, EHR and order entry users still reported less satisfaction with their clerical time, and order entry carried an added link to burnout. The study was cross-sectional and could not prove that the record caused burnout, but it identified clerical burden as a target for change.

For our network, the link matters because each departing clinician costs months of lost visits and recruitment. Our survey's burnout rate, together with the time we measured outside clinic hours, points to the same problem the national study found.

How We Got Here

The record was not built around clinical work. Adler-Milstein and Jha (2017) asked how much of the jump in hospital EHR use could be credited to the 2009 HITECH law. Comparing hospitals eligible for its incentive payments with those that were not, they found eligible hospitals' annual adoption growth climbed from about three points a year to about fourteen, while ineligible hospitals barely moved, a difference-in-differences of 7.9 points. Ambulatory practices saw a similar push. The act succeeded in spreading electronic records quickly, and the paper argues that the speed came with templates and documentation demands designed around billing and reporting rather than clinicians' workflow, which is the burden our clinicians now carry.

Proposed Changes

The paper proposes four changes, ranked by the time they are expected to return and how quickly they can start.

First, inbox triage. Automated normal results will be routed to a medical assistant queue with standard patient letters, and nurses will approve protocol refills under standing orders. Based on our message mix, this is projected to remove about 35 to 40 messages a day from each clinician's inbox.

Second, team documentation. Medical assistants trained as clinical scribes will enter history, review of systems and orders during visits for clinicians who choose it, starting at two clinics.

Third, template cleanup. The informatics team will remove required fields that exist only for billing or reporting and that are not legally required, after review by compliance.

Fourth, protected time. Each clinician will have thirty minutes of scheduled inbox time in the clinic day.

Measures and Evaluation

The same event log reports will be run every quarter. The primary measure is time in the record outside scheduled hours per clinician per day, with a target of reducing it by half within a year. Secondary measures are inbox volume per clinician, time per note, the burnout survey item, clinician turnover and patient access measured by the third next available appointment. A balancing measure, the rate of abnormal results without documented follow-up within seven days, will make sure triage does not let important results slip.

Risks and Limits

Event logs can overcount time when a chart is left open. Our team will apply the same idle-time rule the Wisconsin study used. Scribes cost money, so their effect on visit volume will be measured before they spread. Staff taking on triage work need training and clear protocols. The paper notes that the burnout evidence is associational and that our own measures will show whether these changes help.

Conclusion

The network's clinicians log 5.6 record hours a day, in line with the Wisconsin figures, and 1.3 of them fall outside scheduled clinic time. A national survey links this clerical load to burnout, and the rapid adoption spurred by federal incentives helps explain why records were built around billing. Inbox triage, team documentation, template cleanup and protected time are proposed, each tracked with the same event logs that revealed the problem, with a balancing measure to protect patient safety.

References

Adler-Milstein, J., & Jha, A. K. (2017). HITECH Act drove large gains in hospital electronic health record adoption. Health Affairs, 36(8), 1416-1422. https://doi.org/10.1377/hlthaff.2016.1651

Arndt, B. G., Beasley, J. W., Watkinson, M. D., Temte, J. L., Tuan, W.-J., Sinsky, C. A., & Gilchrist, V. J. (2017). Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time-motion observations. Annals of Family Medicine, 15(5), 419-426. https://doi.org/10.1370/afm.2121

Shanafelt, T. D., Dyrbye, L. N., Sinsky, C., Hasan, O., Satele, D., Sloan, J., & West, C. P. (2016). Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clinic Proceedings, 91(7), 836-848. https://doi.org/10.1016/j.mayocp.2016.05.007