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Levy DR, Moy AJ, Apathy N, Adler-Milstein J, Rotenstein L, Nath B, Rosenbloom ST, Kannampallil T, Mishuris RG, Alexanian A, Sieja A, Hribar MR, Patel JS, Sinsky CA, Melnick ER. Identifying and Addressing Barriers to Implementing Core Electronic Health Record Use Metrics for Ambulatory Care: Virtual Consensus Conference Proceedings. Appl Clin Inform 2023; 14:944-950. [PMID: 37802122 PMCID: PMC10686750 DOI: 10.1055/a-2187-3243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023] Open
Abstract
Precise, reliable, valid metrics that are cost-effective and require reasonable implementation time and effort are needed to drive electronic health record (EHR) improvements and decrease EHR burden. Differences exist between research and vendor definitions of metrics. PROCESS: We convened three stakeholder groups (health system informatics leaders, EHR vendor representatives, and researchers) in a virtual workshop series to achieve consensus on barriers, solutions, and next steps to implementing the core EHR use metrics in ambulatory care. CONCLUSION: Actionable solutions identified to address core categories of EHR metric implementation challenges include: (1) maintaining broad stakeholder engagement, (2) reaching agreement on standardized measure definitions across vendors, (3) integrating clinician perspectives, and (4) addressing cognitive and EHR burden. Building upon the momentum of this workshop's outputs offers promise for overcoming barriers to implementing EHR use metrics.
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Affiliation(s)
- Deborah R Levy
- Department of Veterans Affairs, VA Connecticut Healthcare System, West Haven, Connecticut, United States
- Section of Biomedical Informatics and Data Sciences, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Amanda J Moy
- Department of Biomedical Informatics, Columbia University, New York, New York, United States
| | - Nate Apathy
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Iowa, United States
| | - Julia Adler-Milstein
- Department of Medicine, Center for Clinical Informatics and Improvement Research, University of California, San Francisco, California, United States
| | - Lisa Rotenstein
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
| | - S Trent Rosenbloom
- Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, United States
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, United States
- Institute for Informatics, Data Science, and Biostatistics (I2DB), Washington University School of Medicine, St. Louis, Missouri, United States
| | - Rebecca G Mishuris
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
- Digital, Mass General Brigham, Boston, Massachusetts, United States
| | | | - Amber Sieja
- Department of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Michelle R Hribar
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, United States
| | - Jigar S Patel
- Oracle Corporation, Kansas City, Missouri, United States
| | | | - Edward R Melnick
- Section of Biomedical Informatics and Data Sciences, Yale University School of Medicine, New Haven, Connecticut, United States
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
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Rotenstein LS, Apathy N, Edgman-Levitan S, Landon B. Comparison of Work Patterns Between Physicians and Advanced Practice Practitioners in Primary Care and Specialty Practice Settings. JAMA Netw Open 2023; 6:e2318061. [PMID: 37310739 DOI: 10.1001/jamanetworkopen.2023.18061] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
Importance Despite the increasing involvement of advanced practice practitioners (APPs; ie, nurse practitioners and physician assistants) in care delivery across specialties, the work patterns of APPs compared with physicians and how they are integrated into care teams have not been well characterized. Objective To characterize differences between physicians and APPs across specialty types related to days with appointments, visit types seen, and time spent using the electronic health record (EHR). Design, Setting, and Participants This nationwide, cross-sectional study used EHR data from physicians and APPs (ie, nurse practitioners and physician assistants) at all US institutions that used Epic Systems' EHR between January and May 2021. Data analysis was performed from March 2022 to April 2023. Main Outcomes and Measures Appointment scheduling patterns, percentage of new and established and level of evaluation and management (E/M) visits, and EHR use metrics per day and week. Results The sample consisted of 217 924 clinicians across 389 organizations, including 174 939 physicians and 42 985 APPs. Although primary care physicians were more likely than APPs to have more than 3 days per week with appointments (50 921 physicians [79.5%] vs 17 095 APPs [77.9%]), this trend was reversed for medical (38 645 physicians [64.8%] vs 8124 APPs [74.0%]) and surgical (24 155 physicians [47.1%] vs 5198 APPs [51.7%]) specialties. Medical and surgical specialty physicians saw 6.7 and 7.4 percentage points, respectively, more new patient visits than did their APP counterparts, whereas primary care physicians saw 2.8 percentage points fewer new patient visits than did APPs. Physicians saw a greater percentage of level 4 or 5 visits across all specialties. Medical and surgical physicians spent 34.3 and 45.8 fewer minutes per day, respectively, using the EHR than did APPs in their specialties, whereas primary care physicians spent 17.7 minutes per day more. These differences translated to primary care physicians spending 96.3 minutes more per week using the EHR than APPs, whereas medical and surgical physicians spent 149.9 and 140.7 fewer minutes, respectively, than did their APP counterparts. Conclusions and Relevance This cross-sectional, national study of clinicians found significant differences in visit and EHR patterns for physicians compared with APPs across specialty types. By underscoring the different current usage of physicians vs APPs across specialty types, this study helps place into context the work and visit patterns of physicians compared with APPs and serves as a foundation for evaluations of clinical outcomes and quality.
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Affiliation(s)
- Lisa S Rotenstein
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nate Apathy
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Now with MedStar Health Research Institute, Hyattsville, Maryland
| | | | - Bruce Landon
- Department of Healthcare Policy, Harvard Medical School, and Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Rotenstein LS, Apathy N, Holmgren AJ, Bates DW. Physician Note Composition Patterns and Time on the EHR Across Specialty Types: a National, Cross-sectional Study. J Gen Intern Med 2023; 38:1119-1126. [PMID: 36418647 PMCID: PMC10110827 DOI: 10.1007/s11606-022-07834-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/29/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The burden of clinical documentation in electronic health records (EHRs) has been associated with physician burnout. Numerous tools (e.g., note templates and dictation services) exist to ease documentation burden, but little evidence exists regarding how physicians use these tools in combination and the degree to which these strategies correlate with reduced time spent on documentation. OBJECTIVE To characterize EHR note composition strategies, how these strategies differ in time spent on notes and the EHR, and their distribution across specialty types. DESIGN Secondary analysis of physician-level measures of note composition and EHR use derived from Epic Systems' Signal data warehouse. We used k-means clustering to identify documentation strategies, and ordinary least squares regression to analyze the relationship between documentation strategies and physician time spent in the EHR, on notes, and outside scheduled hours. PARTICIPANTS A total of 215,207 US-based ambulatory physicians using the Epic EHR between September 2020 and May 2021. MAIN MEASURES Percent of note text derived from each of five documentation tools: SmartTools, copy/paste, manual text, NoteWriter, and voice recognition and transcription; average total and after-hours EHR time per visit; average time on notes per visit. KEY RESULTS Six distinct note composition strategies emerged in cluster analyses. The most common strategy was predominant SmartTools use (n=89,718). In adjusted analyses, physicians using primarily transcription and dictation (n=15,928) spent less time on notes than physicians with predominant Smart Tool use. (b=-1.30, 95% CI=-1.62, -0.99, p<0.001; average 4.8 min per visit), while those using mostly copy/paste (n=23,426) spent more time on notes (b=2.38, 95% CI=1.92, 2.84, p<0.001; average 13.1 min per visit). CONCLUSIONS Physicians' note composition strategies have implications for both time in notes and after-hours EHR use, suggesting that how physicians use EHR-based documentation tools can be a key lever for institutions investing in EHR tools and training to reduce documentation time and alleviate EHR-associated burden.
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Affiliation(s)
- Lisa S Rotenstein
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Nate Apathy
- Leonard Davis Institute of Health Economics, Wharton School, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, Philadelphia, PA, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - A Jay Holmgren
- University of California at San Francisco, San Francisco, CA, USA
| | - David W Bates
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
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Rotenstein LS, Apathy N, Landon B, Bates DW. Assessment of Satisfaction With the Electronic Health Record Among Physicians in Physician-Owned vs Non-Physician-Owned Practices. JAMA Netw Open 2022; 5:e228301. [PMID: 35446397 PMCID: PMC9024386 DOI: 10.1001/jamanetworkopen.2022.8301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Despite known benefits, electronic health records (EHRs) have had drawbacks for daily practice and the physician experience. There is evidence that physicians practicing in solo or physician-owned practices are more likely to be satisfied with the EHR and experience lower burnout than those practicing in other ownership arrangements; however, it is unclear how practice ownership patterns interact with physicians' experiences with the EHR and documentation in the EHR now that use of these systems is widespread. OBJECTIVE To examine the association between practice ownership and physician perceptions of the EHR. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included non-federally employed physicians who provided office-based patient care in 2019 and completed the 2019 National Electronic Health Records Survey. The 2019 survey sample consisted of 1524 eligible responses (41.0% unweighted response rate representing 301 603 physicians); of those, 1368 physicians who reported having an EHR and answered questions regarding location ownership were included in the analysis. Data for the 2019 National Electronic Health Records Survey were collected by RTI International from June 14 to December 11, 2019; the current cross-sectional analysis was conducted from October 1 to November 30, 2021. MAIN OUTCOMES AND MEASURES Satisfaction with the EHR, perceptions of time spent on clinical documentation, and presence of staff support for documentation. RESULTS Among 1368 respondents (weighted, 270 813 respondents) included in the analysis, 960 respondents (weighted: 185,385 respondents [68.5%]) were male, and 951 respondents (weighted: 200,622 respondents [74.1%]) were over 50 years of age; 766 respondents (weighted, 161 226 respondents [59.5%]) were working in a practice owned by a physician or physician group, and 700 respondents (weighted, 131 284 respondents [48.5%]) were primary care physicians. A total of 602 respondents (weighted, 109 587 physicians [40.5%]) were working in a non-physician-owned practice. Overall, 529 respondents (weighted, 108 093 respondents [68.1%]) working in physician-owned practices reported being satisfied with their EHR vs 320 respondents (weighted, 63 988 respondents [58.5%]) working in non-physician-owned practices (P = .03). Among those working in physician-owned practices, perceptions that time spent on documentation was appropriate (328 physicians [weighted, 71 827 physicians (44.8%)] vs 191 physicians [weighted, 35 447 physicians (32.4%)]; P = .005) and that staff support for documentation was available (289 physicians [weighted, 57 702 physicians (36.0%)] vs 146 physicians [weighted, 29 267 physicians (26.7%)]; P = .02) were significantly higher compared with those working in non-physician-owned practices. Physicians' perceptions of the appropriateness of time spent and the availability of staff support only partially explained the association between practice ownership type and EHR satisfaction. CONCLUSIONS AND RELEVANCE The results of this nationally representative cross-sectional study suggest that physicians working in physician-owned practices are more likely to be satisfied with the EHR, to have positive perceptions of time spent on documentation, and to have staff support for documentation compared with their counterparts working in non-physician-owned practices. The workflow and cultural forces underlying these differences are important to understand in the setting of known differences in burnout by practice ownership type and ongoing physician group consolidation and acquisition by health care systems.
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Affiliation(s)
- Lisa S. Rotenstein
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Nate Apathy
- Leonard Davis Institute of Health Economics, Wharton School, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine, Philadelphia, Pennsylvania
- Regenstrief Institute, Indianapolis, Indiana
| | - Bruce Landon
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Healthcare Policy, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - David W. Bates
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
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Werner RM, Templeton Z, Apathy N, Skira MM, Konetzka RT. Trends in Post-Acute Care in US Nursing Homes: 2001-2017. J Am Med Dir Assoc 2021; 22:2491-2495.e2. [PMID: 34823855 PMCID: PMC8654135 DOI: 10.1016/j.jamda.2021.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe recent trends in post-acute care provision within nursing homes, focusing specifically on nursing homes' degree of specialization in post-acute care. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS All US nursing homes between 2001 and 2017 and all fee-for-service Medicare admissions to nursing homes for post-acute care during that time. METHODS We measured post-acute care specialization as annual Medicare admissions per bed for each nursing home and examined changes in the distribution of specialization across nursing homes over the study period. We described the characteristics of nursing homes and the patients they serve based on degree of specialization. RESULTS The average number of Medicare admissions per bed increased from 1.2 in 2001 to 1.6 in 2017, a relative increase of 41%. This upward trend in the number of Medicare admissions per bed was largest among new nursing homes (those established after 2001), increasing 68% from 2001 to 2017. In contrast, nursing homes that eventually closed during the study period experienced no meaningful growth in the number of admissions per bed. Over time, the number of Medicare admissions per bed increased among highly specialized nursing homes. The number of Medicare admissions per bed grew by 66% at the 95th percentile and by 25% at the 99th percentile. Nursing homes delivering the most post-acute care were more likely to be for-profit or part of a chain, had higher staffing levels, and were less likely to admit patients who were Black, Hispanic, or dually enrolled in Medicare and Medicaid. CONCLUSIONS AND IMPLICATIONS Over the last 2 decades, post-acute care has become increasingly concentrated in a subset of nursing homes, which tend to be for-profit, part of a chain, and less likely to serve racial and ethnic minorities and persons on Medicaid. Although these nursing homes may benefit financially from higher Medicare payment, it may come at the expense of equitable access and patient care.
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Affiliation(s)
- Rachel M Werner
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
| | - Zachary Templeton
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nate Apathy
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Meghan M Skira
- Department of Economics, Terry College of Business, University of Georgia, Athens, GA, USA
| | - R Tamara Konetzka
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
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Comer A, Apathy N, Waite C, Bestmann Z, Bradshaw J, Burchfield E, Harmon B, Legg R, Meyer S, O’Brien P, Sabec M, Sayeed J, Weaver A, D’Cruz L, Bartlett S, Marchand M, Zepeda I, Endri K, Finnell JT, Grannis S, Silverman RD, Embi PJ. Electric Scooters (e-scooters): Assessing the Threat to Public Health and Safety in Setting Policies: Assessing e-scooter policies. CHIA 2020. [DOI: 10.18060/24194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Objective: To determine self-reported incidences of health and safety hazards among persons who ride rentable electric scooters (e-scooters), knowledge of e-scooter laws, and attitudes and perceptions of the health and safety of e-scooter usage.
Methods: A cross-sectional survey of n= 561 e-scooter riders and non-riders was conducted during June of 2019.
Results: Almost half of respondents (44%) report that e-scooters pose a threat to the health and safety of riders. Riders and non-riders disagree regarding the hazards that e-scooters pose to pedestrians. Among riders, 15% report crashing or falling off an e-scooter. Only 2.5% of e-scooter riders self-report that they always wear a helmet while riding.
Conclusions: E-scooter riders report substantial rates of harmful behavior and injuries. Knowledge of e-scooter laws is limited, and e-scooters introduce threats to the health and safety of riders, pedestrians on sidewalks, and automobile drivers. Enhanced public health interventions are needed to educate about potential health risks and laws associated with e-scooter use and to ensure health in all policies. Additionally, greater consideration should be given to public health, safety, and injury prevention when passing relevant state and local e-scooter laws.
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