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Christopher Jason


Scientifically tracking EHR use measures could improve clinician well-being and ultimately mitigate clinician burden.


To effectively boost EHR optimization and reduce clinician burnout, healthcare stakeholders must develop EHR use measures that are actionable, usable, transparent, and trustworthy, according to a JAMA Network op-ed from American Medical Association and Yale School of Medicine leaders.

Scientific-based methods could effectively track EHR use and performance, op-ed authors Christine Sinsky from the AMA, and Harlan Krumholz and Edward Melnick, both from Yale, wrote.

Extended EHR use, documentation, excessive EHR inbox messages and notifications, and other EHR usability issues can result in clinician burnout. According to a recent study published in the Journal of the American Medical Informatics Association (JAMIA), ambulatory physicians spend more than five hours on the EHR for every eight hours of scheduled patient time.

This EHR use study, plus many more, revealed EHR performance measures and variations that led health IT professionals and developers to increase focus on patient care and clinician burnout.

“Without the capacity to identify targets and evaluate interventions, quality was mired in an era of implicit review without systemic approaches to improvement,” wrote the op-ed authors. “Measures are not sufficient for improvement, but good measures, in the proper context, have a central role in supporting and incentivizing better performance.”

EHR use metrics are vital to measuring EHR design, implementation, and regulation, along with gauging improvement in clinical workflow and teamwork, according to Melnick, Sinski, and Krumholz.

“For a measure to be scientifically sound, its results must be precise, reliable, valid, and adequately risk adjusted,” the authors explained. “Such measures can be used to compare vendors and instances of the same product, identify variation and best practices among clinicians, support training of students and residents, and spark efforts to improve.”

For example, researchers, health systems, and health IT developers could leverage EHR use measures to determine:

  • Total EHR time
  • Work outside of work
  • EHR documentation time
  • Prescription orders
  • Inbox usage time
  • Teamwork for orders
  • Undivided attention

EHR audit logs are a common and current way to gauge EHR use measurements. Audit logs automatically capture observational data, such as number of workflows, keystrokes, and mouse clicks.

“EHR audit logs are an appealing data source for measurement,” explained Melnick, Sinski, and Krumholz. “Yet the validity and reliability of their data remain in question due to their unwieldy and subsequent inaccessible nature and lack of standard data definitions. Standard definitions of time-out lengths and work performed outside of scheduled clinical hours across vendor products and better integration of clinician schedules with EHR audit logs could begin to address many of these issues.”

Although audit logs do not always tell the complete story, they can offer critical data and implications. For example, the previously noted JAMIA study authors leveraged audit logs to reveal female physicians spend more time on the EHR than their male counterparts.

Researchers and health systems can utilize this information to conduct further studies or optimize their respective EHR systems. Furthermore, this data could emphasize EHR user experience to add visibility and transparency to the specific problem at hand.

To prove the importance of EHR use data, the authors suggested the Office of the National Coordinator of Health IT (ONC) to require regular vendor EHR use measure reporting to maintain certification. Thus, ONC would place the measurement burden on the developers and not the clinicians.

Reporting EHR use data could also result in accurate, meaningful, and current EHR use measurements, which could trigger policy, regulatory, or workflow changes, Melnick, Sinski, and Krumholz wrote.

EHR use measures should have evidence that links it to a particular outcome, must target a poor performance area, and must produce actionable and usable results that are relevant to healthcare stakeholders, the trio recommended.

“The EHR has the potential for benefit, harm, and burden,” concluded Melnick, Sinski, and Krumholz. “To optimize EHR design, implementation, and regulation, EHR use measures must be developed that are trustworthy, clinically important, scientifically sound, transparent, and feasible for implementation. These measures are needed now.”