Abstract
Objectives
Outpatient rehabilitation (rehab) physical, occupational, and speech therapists use electronic health records (EHR), yet their documentation experiences, including any documentation burden, are not well researched. Therapists are a growing portion of the U.S. healthcare workforce, whose need is critical to the health of an aging population. We aimed to describe outpatient rehab therapists’ documentation experiences and identify strategies for mitigating any documentation burden.
Materials and Methods
We used qualitative descriptive methodology to conduct 4 focus groups with outpatient rehab therapists at Hospital for Special Surgery, a multi-site orthopedic institution. Transcripts were inductively coded to identify themes and actionable strategies for improving the therapists’ documentation experiences. Therapists provided feedback and prioritization of proposed strategies.
Results
A total of 13 therapists were interviewed. Five themes and 10 subthemes characterize the therapists’ documentation experience by a feeling that documentation inhibits clinical care and work/life balance, a perceived lack of support and efficiencies, the desire to document to communicate clinical care, and a design vision for improving the EHR. Top prioritized strategies for improvement included use of timesaving templates, expanding dictation, decluttering the EHR interface, and support for free texting over discrete data capture.
Discussion
Outpatient rehab therapists experience documentation burden similar to that documented of physicians and nurses. Manual data entry imposes burden on therapists’ time and clinical care.
Conclusion
A multi-faceted approach is needed for improving therapists’ experiences including EHR redesign, technology supporting dictation and narrative to discrete data capture, and support from leadership and regulators.
Keywords: documentation, electronic health record, rehabilitation, physical therapy specialty, quality improvement
Introduction
Electronic documentation burden has been a topic of increasing priority in the healthcare and informatics communities. Evidence suggests that documentation burden is correlated with burnout,1,2 medical errors,3 and reduced quality of clinical notes.4 However, most research focuses on burden among physicians and nurses. Ancillary clinical providers, such as rehabilitation (rehab) therapists, and their documentation experiences are not as well understood. Rehab therapists are a growing portion of the U.S. healthcare workforce, which is expected to grow faster than the prescribing provider workforce over the next 10 years.5,6 The need for outpatient rehab therapists, in particular, is critical as the U.S. population ages and non-opioid pain management approaches are encouraged.6 Their experiences with electronic documentation, including any documentation burden, must be understood to optimize their care delivery.
Outpatient adult rehab therapists see patients 1-3 times a week for an average of 37 to 268 weeks, depending on the patient’s condition and goals for therapy. Pediatric rehab therapists often see patients for years to manage chronic conditions such as cerebral palsy.9 Data from 2017 estimate physical therapists see a median of 44 patients per week,10 and each patient visit is accompanied by documentation. Documentation requirements stem from regulations, payor policy, hospital policy, and best practice guidelines.11–14 Outpatient rehab therapists’ documentation workflows resemble both outpatient physicians, as they write notes and use time-based billing, and inpatient nurses, as they document care plan goals along with measures and interventions over time. Therefore, it is reasonable to hypothesize that they experience similar documentation burdens as outpatient physicians and inpatient nurses, potentially compounded by the fact that their workflows resemble both. However, their experiences may also be quite unique, as they practice in gymnasium settings, often spending the entire visit guiding patients through therapeutic exercises.
At Hospital for Special Surgery (HSS), a specialty orthopedic hospital serving the New York tri-state area and West Palm Beach, FL, approximately 30% of outpatient clinicians are physical therapists (PTs), occupational therapists (OTs), or speech language pathologists (SLPs) working in the Rehabilitation and Performance department. Therapists are a critical clinical team to HSS’s mission of providing the highest quality care to orthopedic patients. HSS has 12 rehabilitation sites with an aggregate of over 320 000 outpatient visits per year, treating over 40 000 unique patients. Outpatient rehab therapists treat a variety of conditions encompassing both post-operative diagnoses such as total knee replacement and non-operative diagnoses such as low back pain. Outpatient rehab therapists document extensive assessments in their initial encounter with a patient, termed the “evaluation.” In subsequent visits, termed “treatments,” therapists document the therapeutic exercises they administer, objective measures of the patient’s affected body part, and updates to the patient assessment as needed, all of which are displayed in a note. They document a “progress report” at intervals set by policy and insurance, then a “discharge note” at the end of the patient’s episode of care. Additionally, patients are sent a patient-reported outcome measure (PROM) and a clinical intake form to complete before or during their evaluation encounter. When they continue therapy, they are asked to complete the PROM every 2-3 weeks to measure their progress. Figures 1 and 2 display an example evaluation note and the typical documentation workflows at HSS, respectively. Both represent documentation requirements and norms set by regulations, policy, and payors.11–14 HSS has used Epic (Epic Systems Corporation, Verona, WI) since 2016, facilitating interdisciplinary communication between therapists and the medical and nursing teams. Thus, HSS is an excellent setting to examine the documentation experience of outpatient rehab therapists.
Figure 1.
Example of therapist evaluation note at hospital for special surgery prior to study.
Figure 2.
Outpatient rehabilitation therapist documentation requirements and workflow at Hospital for Special Surgery. Depicts typical episode of care with visits scheduled 1-3 times per week. Evaluation visits are 45 minutes; all other visits are 30 minutes. Documentation requirements are presented in the trained EHR workflow order. aDiscrete data entry which generates text in note. bBody part metrics and assessments such as range of motion, strength, edema. cTreatment exercises with sets and repetitions such as, “Squat 3 × 10.” PROM = patient reported outcome measure.
Objectives
The study objective was to characterize the documentation experiences of outpatient rehab therapists at HSS and to identify practical strategies for reducing any documentation burden. This study was part of a quality improvement initiative.
Methods
Study design
We conducted a qualitative descriptive study to understand our outpatient rehab therapists’ documentation experiences. Data were collected via focus groups in May through August 2023 and analyzed using inductive content analysis.15 Focus groups were divided into 2 subgroups: adult therapists and pediatric therapists. We understood there to be enough unique about the patients and workflows in pediatric therapy to warrant a separate focus group. Each focus group was conducted by 2-3 Clinical Informaticists working in the Rehab department, led by the principal investigator.
In line with the qualitative paradigm, we used purposive sampling to maximize the breadth of information uncovered.16 We recruited to create heterogeneous groups with respect to tenure at HSS, Rehab site, average documentation time (as measured by time to sign encounters and percentage of encounters signed same day), documentation style (assessed by proportion of encounters utilizing discrete data entry fields vs free text data entry fields), experience as an “Epic Expert” (therapists who serve as super users in their department), and specialty (PT, OT, or SLP). Documentation time and style data were acquired through Epic reports. Inpatient rehab therapists were not included at this time due to the different nature of their workflows.
Recruitment was conducted via an individual email sent by the principal investigator asking therapists identified based on the criteria outlined above if they were interested in participating in a focus group about their documentation experience. In the adult therapist focus group, 15 therapists were contacted and 7 participated. In the pediatric therapist focus group, 6 therapists were contacted and all participated.
Following the initial focus group, a follow-up focus group was conducted involving our informatics team presenting proposed interventions for improving their documentation experiences back to the group to get their feedback and prioritization of the proposed strategies. Each therapist consented to participate and be recorded and were advised they could opt out at any time and that anything they said would remain confidential.
Data collection and analysis
Focus groups were guided by a semi-structured interview guide (Supplementary Material). Questions ranged from broad to specific and ended with the moderators displaying the EHR, talking through an evaluation workflow to solicit discussion from the participants. The initial adult focus group was 90 minutes and the follow-up was 60 minutes. The initial pediatric focus group was 60 minutes and the follow-up was 45 minutes.
Interviews were conducted via Microsoft Teams, which was also used for recording and transcription. Transcripts were cleaned by the principal investigator and coded for themes characterizing the documentation experience of outpatient rehab therapists at HSS. Initial coding was conducted by 2 team members (J.S.D. and T.N.). Following, codes were discussed as a research team (J.S.D., T.N., J.V., D.J., and M.M.W.) until a consensus on final themes and subthemes was reached. The research team brought varying and complementary perspectives to the analysis with backgrounds in rehabilitation, informatics, Epic implementation, qualitative research, nursing, and leadership.
We employed multiple strategies outlined by Guba16 to enhance the trustworthiness of our findings. We used peer debriefing, member checking between focus groups, and assessed our final themes for structural corroboration to facilitate credibility. To facilitate transferability, we describe our site and details about the EHR and therapy practice that characterize our sample of therapists’ work environment. We created a codebook and an audit trail to facilitate dependability. The research team also practiced reflexivity, discussing our potential biases and documenting our professional orientations, to reduce a biased interpretation of the data. Finally, our purposive sampling strategy to achieve a heterogeneous sample facilitated the breadth of information we were able to attain.
Results
Our adult therapist focus group consisted of 7 therapists (6 PTs and 1 OT). Our pediatric therapist focus group consisted of 6 therapists (4 PTs, 1 OT, and 1 SLP). As intended, the focus group participants demonstrated a range of documentation styles in the EHR as measured by percentage of encounters with discretely documented objective measures, percentage of encounters closed the same day, and average time to sign encounters (Table 1). Adult focus group participants came from 6 of our 12 outpatient rehab sites. All pediatric focus group participants came from our pediatric rehab site. At least one therapist in each group served as an “Epic Expert.”
Table 1.
Focus group participant descriptives.
| Adult therapists |
Pediatric therapists |
|||
|---|---|---|---|---|
| Characteristic | Range | Average | Range | Average |
| Evaluation encountersa with objective measures documented discretelyb | 0-71% | 49% | 0-62% | 23% |
| Encounters closed on day of visitc | 6-100% | 74% | 0-48% | 9% |
| Average time to sign evaluation encounters percentile of all adult or pediatric therapistsd | 9-98 | 52 | 12-76 | 36 |
First visit in episode of care.
Of all evaluations in 2022.
Of 1-month sample.
Percentile rank among 182 adult therapists and 25 pediatric therapists ranked longest to shortest average time to sign evaluation encounters in 2022.
Five themes and 10 subthemes emerged from the analysis (Table 2). Following, we describe each theme and subtheme with illustrative quotes.
Table 2.
Documentation experience themes and subthemes.
| Theme | Subtheme |
|---|---|
| Documentation as a Detriment | Opportunity Cost |
| Note Bloat and Poor Readability | |
| Patient Documentation Burden Leads to Inaccurate Information | |
| We’re Working for the EHR, but the EHR Isn’t Working for Us | Time vs Benefit |
| Efficiencies Needed | |
| EHR Makes Everything Possible but Nothing Functional | |
| Pediatric Therapists Cannot Document in Real-Time | |
| Want to Communicate Clinical Care | |
| Disconnect Between Operational Leadership and Clinicians | |
| Design Vision | Simplify |
| One Screen | |
| Reduce Clicks |
Documentation as a detriment
Therapists described feeling that the current standard of documentation is a detriment to clinical care, their work satisfaction, and work/life balance.
Opportunity cost
The subtheme, Opportunity Cost, emerged from therapists discussing the tradeoffs they make between getting their documentation done, getting home on time, and having a good interaction with their patient.
“I think if you're [getting your documentation done on time every time], … you're probably not spending a lot of time with your patient.”—Adult therapist
“But then your own quality of life is gonna suffer if you're not doing anything [documentation] during the day, and then you're taking it home with you.”—Adult therapist
“I could leave at 3:00 every single day if I choose to. However, I feel, I would say, disconnected, is the word that best describes the feeling every single time I do that…almost like I’m watching myself treat patients.”—Adult therapist
Note bloat and poor readability
The therapists expressed that their notes are bloated, that it is difficult to easily find pertinent clinical information, and that the EHR tools for capturing documentation discretely make notes difficult to read. For example, the exam form that therapists are expected to use to document their objective measures of the patient’s affected body part, because it saves data discretely for reporting, uses functionality to present the data in the note. Therapists expressed that the way it is presented is very difficult to read. Because of this, and because the large library of objective measures makes the tool slow to load and navigate, many therapists forego using the tool in favor of free texting the measures in their note, leaving the objective data uncaptured and unable to be reported or trended.
“I have a huge issue with the way that it pulls through… I can't figure out if I'm looking at the left or the right because it's not bolded [nodding]. It's not like organized right? It's just word vomited into the note.”—Adult therapist
Patient documentation burden leads to inaccurate information
Finally, therapists expressed that the documentation load expected from patients has its own negative consequences. Therapists reported that (1) when patients do not fill out their PROM electronically, therapists are expected to give them the paper PROM and then transcribe responses which they report is inefficient and unrealistic to do within the allotted visit time, and (2) they perceive some patients answer the questions with the intent of getting more visits approved from insurance.
“I understand what Rehab’s goal is, I totally get it, but this [entering PROMs scores] is just wasting time in the eval. From my standpoint…we didn’t become physical therapists to input LEFS [Lower Extremity Functional Scale]17 scores like this.”—Adult therapist
“How many times is the person doing so much more, right? Their pain is so much less, objectively, they’re so much better, and their outcome measure is worse because they wanna get more insurance visits. [nodding]”—Adult therapist
We’re working for the EHR, but the EHR isn’t working for us
The therapists expressed frustration at what they are expected to document given the lack of efficiencies they perceive receiving from EHR functionality, with one therapist describing it as working for the EHR rather than the EHR working for them.
Time vs benefit
Therapists wanted to know that leadership considers the time documentation takes before adding any more requirements. “If we could figure out the bare minimum that is necessary and then anything that’s added, I think it would be helpful to say, ‘How long does this take? How long is that going to take per year?…Is it worth it?’”—Adult therapist
Therapists valued documenting less so that clinically important data points remain salient. One Adult therapist said, “I don’t need to, you know, show every 2 degree increase in the hip external rotation. But I do need that one clue, which was great about the paper notes…I write the one clue that ‘OK, today I had a big breakthrough with this one single exercise, this one mobilization.’”
They also reported that the frequency with which patients were prompted to complete their PROMs was too often, “I don’t see the benefit to doing it every 2 weeks…it’s too short of a time to really appreciate a clinical difference in patients so I think that we’re overburdening people without giving any clinical relevance to it.”—Adult therapist
Efficiencies needed
Therapists outlined many efficiencies they perceive the EHR should be able to deliver but currently does not. One common request was for the EHR to prompt the therapist to write a progress report. Without assistance from the EHR, therapists and administrators spend time counting visits and messaging reminders. Some therapists also wanted more standard templates for common patient populations so they could easily document guidelines-based exercises, objective measures, and goals for those patients. Many adult therapists expressed that they wanted to be able to document efficiently in real-time, as opposed to getting allotted documentation time, which was previously a policy in the department.
“Maybe there’s something in [the EHR] that could help us be a little bit more efficient about tracking like prescriptions, progress notes, how many visits they’ve had, aside from us kind of doing it on our own for each patient.”—Pediatric therapist
Pediatric therapists’ described difficulty sharing information between disciplines in the EHR. Some pediatric patients see a PT and an OT or SLP in sequential appointments. However, the therapists report that they have to duplicate documentation because some of what was captured in the first appointment does not populate in the second.
“I know when [occupational therapist] goes in and does her note that has very similar information…I almost just wish that information could automatically be like carried over…it doesn’t just live in one place and then because she’s a different discipline, it doesn’t then get automatically directed to [my] note.”—Pediatric therapist
EHR makes everything possible but nothing functional
Finally, one adult therapist described the EHR as “it looks like it's like someone over engineered [it], but someone who did it wasn't a clinician…someone made everything possible and nothing really functional.”
Therapists also commented that the library of objective measures to document on the discrete objective exam form was too many, “no one is doing 37 different quantitative sensory tests, right? They’re gonna do light touch or deep pressure and that’s it.”—Adult therapist
Pediatric therapists cannot document in real-time
One subtheme that emerged uniquely from the pediatric focus group was the challenge of documenting while treating a pediatric patient. “I see [adult] therapists treating and it’s just so much easier when you have an adult that you can tell them what exactly they’re doing…and at the same time…are able to type, whereas opposed to we are kind of chasing kids around making sure they’re not hurt or we have little babies that we really…give our patients a little more attention.”—Pediatric therapist
Want to communicate clinical care
Our interviews revealed that therapists’ primary goal from their documentation was to communicate clinical care. This meant communicating to themselves (reminders of what worked well for the patient), to the referring provider, and to their colleagues. They want the most pertinent clinical information to be clear to others reading their documentation. Many reported that they felt free texting tells a better patient story, choosing to type out the subjective section of their note as opposed to clicking the discrete flowsheet rows in the clinical intake section of the EHR (which therapists have previously been encouraged to use as a replacement for the subjective section). One adult therapist said, “I feel like I paint a better picture just free texting into the subjective, so if they haven’t filled it out [the clinical intake form], I’m not doing that. I will just write down what they tell me.”
Disconnect between operational leadership and clinicians
Therapists expressed a sense that their leadership did not understand their documentation burden and that the informatics team was not always working for them. One therapist said, “When everyone is like, ‘oh, could you do a 30-minute eval [typically a 45-minute visit]?’ You’re really asking you to do a 30-minute eval and 20 minutes of documentation after. So, it’s really not an ask that I think the administration understands what they’re asking.”—Adult therapist
Therapists felt they were not always considered when documentation decisions were made and that when requesting enhancements to the EHR, sometimes they were dismissed.
“I think we asked…a long time ago, like years ago, if [objective measures] could show up in a chart like range of motions, you could see left versus right, and at the time the answer was no, and that was the end of it.”—Adult therapist
Some therapists also wanted more time allotted to help them increase their efficiency—with someone helping them to create personalizations and show them efficiency tips, beyond the training they get in onboarding.
Design vision
Finally, the therapists many times described what they wished the EHR looked like or could do for them. This distilled into 3 subthemes: (1) Simplify, (2) One Screen, and (3) Reduce Clicks. Therapists described wanting the EHR screen to be simpler and less cluttered so that they may easily see what they need to review about the patient and what they need to document. They also primarily want to work on one single screen, as opposed to toggling between different sections of the EHR or splitting their screen between multiple sections. As mentioned previously, they want to see their objective measures organized logically so that they can easily visually compare the patient’s affected side to their non-affected side and trend progress over visits. Finally, they want less clicking. Some therapists had tried using a dictation microphone and were positive about its benefits. In many circumstances, therapists preferred dictating and free texting over clicking.
Prioritization of improvement strategies
Our informatics team came up with many potential interventions to reduce documentation burden based on the data from the first focus group. Some interventions were already in development and the most salient ideas were brought back to the follow-up focus groups for prioritization. We asked therapists to prioritize based on any criteria that were important to them, to which they mentioned impact and time to implement (Table 3).
Table 3.
Improvement strategies.
| Solution | Priority | Status |
|---|---|---|
| Creating guidelines-based macrosa for exercise and objective measure documentation | Adult 1, Pediatric 1 | Live |
| Reduce clutter in the visit navigator | Adult 2 | In-progress |
| Expanding use of dictation software | Pediatric 2 | Live |
| Pilot documenting objective measures in data-backed tables | Adult 3 | Not possible |
| Pilot documenting objective measures in flowsheets | Pediatric 3 | In-progress |
| Automatically notifying the therapist when a progress report is due | (N/A; was already in progress at time of focus group) | Live |
| Implementing tablets for patient electronic form completion at check-in | (N/A; was already in progress at time of focus group) | In-progress |
| Reducing the frequency with which patients receive PROMs (from Q2 to Q3 weeks) | N/A | Live |
| De-cluttering note templates (ie, cutting down on note bloat) | N/A | Live |
| Offering additional efficiency training | N/A | On-going |
| Implementing a documentation checklist | N/A | In-progress |
| Supporting data flow between appointments of different disciplines | N/A | In-progress |
A template of expected data points that can be documented with one click.
Furthermore, our informatics and leadership teams have committed to reducing documentation burden by building a culture focused on removing and not adding data points that are not required by regulations, imperative for our strategic initiatives, or meaningful to clinical care, and investigating technology that supports efficiency.
Discussion
The results from the focus groups conducted with outpatient adult and pediatric rehabilitation therapists illuminate the documentation experiences of a clinical population currently unrepresented in documentation burden literature. As hypothesized, therapists described documentation burdens similar to those experienced by physicians and nurses; poor interface design,18–20 a lack of optimizations,18 emphasis on adding and not removing features,18 lack of efficiency,18,19 and cognitive interruptions.18–20 They also reported documentation burden leads to note bloat,21,22 takes time away from the patient,19,20,23 infringes on time after hours,19,24,25 and contributes to burnout,1,25 with one therapist explicitly describing feeling depersonalization, a subscale of the Maslach Burnout Inventory.26 Evidence shows that inpatient nurses also characterize documentation burden by a disconnect between leadership and clinicians23 and described a misalignment between EHR functionality and their goal of communicating clinical care.20,23 Therapists also felt dictation would decrease burden, as has been reported by primary care physicians who dictate or use scribes.27,28
The themes that emerged from our focus groups with adult and pediatric outpatient therapists primarily paint a picture of clinicians looking to simplify their documentation experience so that they can return time to their patients and improve their clinical care. They want thoughtful consideration of their time and evidence supporting their documentation requirements. They want an EHR that efficiently supports the regulatory requirements imposed upon them while allowing their clinical care to be clearly communicated to all stakeholders. Finally, they want to know that their leadership understands their documentation burden. These findings come at a time when therapists report burnout from their administrative tasks,29 increased pressure to see more patients which is associated with intent-to-leave30 and reduced clinician health,31 and an increase in practices that are short-staffed.32 Interestingly, it is also the first, to our knowledge, to report that patient documentation burden may lead to clinician burden and poor data quality which should be further investigated.
Therapists described sources of burden that fall into each of the 6 domains enumerated by the American Nursing Informatics Association: reimbursement, regulatory, quality, usability, interoperability/standards, and self-imposed.33 As such, reducing their burden and improving their experience will take a multi-faceted approach. We believe our findings have many generalizable operational implications. First, our list of EHR optimization strategies may serve as a starting point for other institutions, and we plan to report on their impact in future research. Second, our findings indicate that discrete data points entered by therapists must be strategically prioritized rather than sought universally, as we heard that discrete data entry can be burdensome. Evidence that discretizing data entry where it does not cognitively fit can lead to poor data quality bolsters this argument.3 While discrete data entry is important for informatics initiatives toward reporting, trending, and modeling data, strategically prioritizing that data which is most important will reduce burden while potentially facilitating compliance. We look to models set by Nursing at UCHealth in our efforts to reducing discrete data entry.34 Third, investment in dictation or ambient AI, coupled with scalable natural language processing (NLP) solutions to discretize data is likely to reduce documentation burden without foregoing reporting and analysis goals, as others have called for among nurses and physicians.35–37 This is especially salient for pediatric therapists who often must be hands-on with their patients and unable to type during visits. Fourth, we hypothesize that supporting therapists with scribes or physical therapy assistants to document patient history, PROMs scores, and other administrative data may decrease therapist documentation burden.37 Finally, operational leadership acknowledgement and open commitment to reducing documentation burden may improve therapists’ documentation experience and our leadership has done so based on these results.
Furthermore, our findings and proposed solutions align with those of a large, multidisciplinary task force dedicated to reducing documentation burden (25 × 5), including the need to involve clinicians in documentation decisions, interdisciplinary documentation, and the need to balance brevity with completeness.38 25 × 5 released a call to action urging agencies to invest in research and technology that supports billing without engaging clinician time.38 Additionally, experts recommend a complete reimagining of EHRs with administrative work entirely removed from clinical encounters.39 Outpatient therapists would greatly benefit from regulatory overhauls and innovative technology that derives administrative data without engaging clinician time, as most of the efficiencies therapists asked for surrounds administrative or regulatory tasks, which are associated with burnout.29
Limitations
As this was a quality improvement initiative, we had limited time with therapists to conduct focus groups and our sample may not represent the experiences of all outpatient therapists at HSS or rehabilitation practices, generally. However, we feel confident that the themes that emerged are broadly representative as they were endorsed by an intentional sample, across multiple focus groups. Because these data come from one specialty orthopedic hospital, our findings may not transfer to therapists’ experiences in other settings or to those using other EHR vendors. Particularly, therapists using therapy-specific EHRs may have different experiences. Finally, social desirability bias may have inhibited therapists’ responses, as the interviewers work with therapists in other capacities as informaticists.
Conclusion
Our qualitative descriptive study of outpatient rehab therapists at an orthopedic institution found that therapists’ documentation experiences were largely characterized by impeding work/life balance and time with patients, and a lack technology to support efficiency. Our informatics team is studying the impact of our implemented improvement strategies, and our leadership is committed to reducing documentation burden. We join the calls for large regulatory changes and technological developments needed to reduce documentation burden.38
Supplementary Material
Acknowledgments
The authors are very grateful to the therapists who participated in our focus groups for their generous time and insights as well as HSS Rehabilitation and Performance leadership for supporting this initiative.
Contributor Information
Jessica Schwartz-Dillard, Hospital for Special Surgery, Rehabilitation and Performance, New York, NY 10021, United States.
Travis Ng, Hospital for Special Surgery, Rehabilitation and Performance, New York, NY 10021, United States.
Joann Villegas, Hospital for Special Surgery, Rehabilitation and Performance, New York, NY 10021, United States.
Derrick Johnson, Hospital for Special Surgery, Rehabilitation and Performance, New York, NY 10021, United States.
Mary Murray-Weir, Hospital for Special Surgery, Rehabilitation and Performance, New York, NY 10021, United States.
Author contributions
Jessica Schwartz-Dillard, Derrick Johnson, and Mary Murray-Weir conceived of the idea. Jessica Schwartz-Dillard, Travis Ng, and Joann Villegas collected the data. Jessica Schwartz-Dillard, Travis Ng, Joann Villegas, Derrick Johnson, and Mary Murray-Weir analyzed the data. Jessica Schwartz-Dillard wrote the manuscript with support from Travis Ng, Joann Villegas, Derrick Johnson, and Mary Murray-Weir.
Supplementary material
Supplementary material is available at Journal of the American Medical Informatics Association online.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest
The authors have no conflicts of interest to declare.
Data availability
The data underlying this article cannot be shared publicly for the privacy of the individuals that participated in the study.
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Data Availability Statement
The data underlying this article cannot be shared publicly for the privacy of the individuals that participated in the study.