Original Investigation
Physician Work Environment and Well-Being
August 26, 2024
Physician EHR Time and Visit Volume Following Adoption of Team-Based Documentation Support
Nate C. Apathy, A. Jay Holmgren, Dori A. Cross
JAMA Intern Med. Published online August 26, 2024. doi:10.1001/jamainternmed.2024.4123
Question How do physician visit volume, documentation time in the electronic health record (EHR), overall EHR time, and EHR time outside scheduled hours change for physicians adopting team-based documentation support?
Findings In this national longitudinal cohort study of 18 265 ambulatory physicians, the adoption of team-based documentation support (ie, coauthored notes) was associated with significant increases in visit volume and decreases in documentation time in the EHR, including after-hours EHR time. Physicians with less than 40% of note text authored by another team member did not realize any time savings following documentation support.
Meaning For high-intensity adopters, documentation support can increase visit volume while substantially reducing physician EHR burden.
Abstract
Importance Physicians spend the plurality of active electronic health record (EHR) time on documentation. Excessive documentation limits time spent with patients and is associated with burnout. Organizations need effective strategies to reduce physician documentation burden; however, evidence on team-based documentation (eg, medical scribes) has been limited to small, single-institution studies lacking rigorous estimates of how documentation support changes EHR time and visit volume.
Objectives To analyze how EHR documentation time and visit volume change following the adoption of team-based documentation approaches.
Design, Setting, and Participants This national longitudinal cohort study analyzed physician-week EHR metadata from September 2020 through April 2021. A 2-way fixed-effects difference-in-differences regression approach was used to analyze changes in the main outcomes after team-based documentation support adoption. Event study regression models were used to examine variation in changes over time and stratified models to analyze the moderating role of support intensity. The sample included US ambulatory physicians using the EHR. Data were analyzed between October 2022 and September 2023.
Exposure Team-based documentation support, defined as new onset and consistent use of coauthored documentation with another clinical team member.
Main Outcomes and Measures The main outcomes included weekly visit volume, EHR documentation time, total EHR time, and EHR time outside clinic hours.
Results Of 18 265 physicians, 1024 physicians adopted team-based documentation support, with 17 241 comparison physicians who did not adopt such support. The sample included 57.2% primary care physicians, 31.6% medical specialists, and 11.2% surgical specialists; 40.0% practiced in academic settings and 18.4% in outpatient safety-net settings. For adopter physicians, visit volume increased by 6.0% (2.5 visits/wk [95% CI, 1.9-3.0]; P < .001), and documentation time decreased by 9.1% (23.3 min/wk [95% CI, −30.3 to −16.2]; P < .001). Following a 20-week postadoption learning period, visits per week increased by 10.8% and documentation time decreased by 16.2%. Only high-intensity adopters (>40% of note text authored by others) realized reductions in documentation time, both for the full postadoption period (−53.9 min/wk [95% CI, −65.3 to −42.4]; 21.0% decrease; P < .001) and following the learning period (−72.2 min/wk; 28.1% decrease). Low adopters saw no meaningful change in EHR time but realized a similar increase in visit volume.
Conclusions and Relevance In this national longitudinal cohort study, physicians who adopted team-based documentation experienced increased visit volume and reduced documentation and EHR time, especially after a learning period.
