Health Information Technology

Study uncovers the time spent on writing and viewing hospital electronic health records

Clinical documentation of a patient's condition and treatment form the core of the electronic health record (EHR). A new study measured how much of their working time hospital physicians and other providers spend on clinical documentation in the EHR. Using detailed audit logs for EHRs, researchers measured the rate and time of authoring and viewing clinical documentation, as well as associations among users. They found that users spent 20-103 minutes per day authoring notes and 7-56 minutes per day viewing notes, with physicians spending less than 90 minutes per day total.

Overall, 16 percent of notes were never read by anybody. However, 38 percent of nurses' notes went unread by other users. Possible reasons for this are the use of oral communications between successive nursing shifts and the use of flowsheets instead of nursing notes to report critical information. Medical student notes were read by physicians at a relatively high rate of 81 percent, implying that supervision is substantial. The use of notes dropped off rapidly after the first day, but even old notes (up to almost 2 years in this study) were viewed at a low but consistent rate. The study was supported in part by the Agency for Healthcare Research and Quality (HS18250).

See "Use of electronic clinical documentation: Time spent and team interactions," by George Hripcsak, M.D., David K. Vawdrey, Ph.D., Matthew R. Fred, M.D., and Susan B. Bostwick, M.D., in the Journal of the American Medical Informatics Association 18, pp. 112-117, 2011.

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