Health Policy Journal Club, Health Policy, Technology, Telehealth, and Informatics, Administration & Operations

Health Policy Journal Club: The Limit (SHOULD) Not Exist!

Limiting the number of open charts in an EHR does not impact efficiency

Clinicians spend significant portions of their day staring at computer screens. Logging patient information into an Electronic Health Record (EHR) is a critically important, albeit time-intensive, aspect of patient care. While essential, EHR usage reduces time spent with patients and contributes to physician burnout. Additionally, EHRs play a role in patient safety by catching medication errors and facilitating hand-offs. To enhance patient care, we must understand the balance between mandating the use of EHR safeguards and maximizing provider efficiency by minimizing time spent in the EHR.

This study compared time spent actively in the EHR, between a restricted (limits providers to opening only one patient record at a time), and an unrestricted EHR configuration (allows providers to simultaneously open up to four patient records). The data was collected as a subset of a parent randomized control trial of 2,556 clinicians at an NYC medical center that found no significant difference in wrong-patient orders between the two configurations but noted higher physician self-reported satisfaction, efficiency, and usability in the unrestricted group.

The primary outcome was the total time from a clinician's first EHR login or interaction via mouse or keyboard to 30 seconds after their final interaction. Secondary outcomes included total mouse clicks, key presses, and daily screen changes.

There was no significant difference in the primary outcome, efficiency, between the unrestricted group (115.1 minutes) and the restricted group (113.3 minutes) (IRR, 0.9; 95% CI, 0.93-1.06). Similarly, there were no significant differences between groups for mouse clicks, key presses, or screen changes.

While the parent study found that physicians perceive unrestricted EHRs as more efficient, this sub-study showed no significant difference in primary or secondary measures of efficiency between configurations across all clinician types and practice areas.

Given the absence of safety or efficiency differences, it appears that an unrestricted configuration that lets providers open up to 4 patient records improves physician satisfaction, or that their satisfaction is based on a false pretense of inefficiency in the restricted configuration. Further studies are needed in different clinical settings, to test alternative measures of clinician efficiency, and to uncover ways to improve patient safety, provider efficiency, and patient satisfaction with alterations to the EHR. Local, state, and federal policymakers should also recognize that EHR alterations should be allowed if they prove non-inferior to more restrictive configurations that make it harder for clinicians to do their job.

Kneifati-Hayek JZ, Applebaum JR, Schechter CB, et al. Effect of restricting electronic health records on clinician efficiency: substudy of a randomized clinical trial. J Am Med Inform Assoc. 2023;30(5):953-957.

A prior randomized controlled trial (RCT) showed no significant difference in wrong-patient errors between clinicians assigned to a restricted electronic health record (EHR) configuration (limiting to 1 record open at a time) versus an unrestricted EHR configuration (allowing up to 4 records open concurrently). However, it is unknown whether an unrestricted EHR configuration is more efficient. This substudy of the RCT compared clinician efficiency between EHR configurations using objective measures. All clinicians who logged onto the EHR during the substudy period were included. The primary outcome measure of efficiency was total active minutes per day. Counts were extracted from audit log data, and mixed-effects negative binomial regression was performed to determine differences between randomized groups. Incidence rate ratios (IRRs) were calculated with 95% confidence intervals (CIs). Among a total of 2556 clinicians, there was no significant difference between unrestricted and restricted groups in total active minutes per day (115.1 vs 113.3 min, respectively; IRR, 0.99; 95% CI, 0.93–1.06), overall or by clinician type and practice area.

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care physicians, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.  

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