Medical Documentation Burden Among US Office-Based Physicians in 2019

Abstract

This cross-sectional study uses data from the 2019 National Electronic Health Records Survey to assess the burden and time spent on medical documentation outside office hours among US physicians.

Many physicians perceive that medical documentation is onerous, detracts from face time with patients, and drives burnout.^1,2 We assessed the burden of medical documentation on US office-based physicians.

Methods

In this cross-sectional study, we analyzed office-based physician responses to the 2019 National Electronic Health Records Survey, which collects nationally representative data on the use and burdens of the electronic health record (EHR).³ The overall participation rate was 37.7%.³ The Cambridge Health Alliance Institutional Review Board deemed this analysis of publicly available, deidentified data exempt from review. Respondents provided informed consent at the time of data collection. Reporting followed the STROBE reporting guideline.

We evaluated the time physicians devoted to documentation outside office hours based on the question, “On average, how many hours per day do you spend outside of normal office hours documenting clinical care in your medical record system?” (none, <1, 1-2, >2-4, or >4 hours). We estimated mean daily hours devoted to documentation outside office hours by recoding categorical responses at the midpoint (for the highest category, the minimum) of response. We also explored 5 measures of satisfaction with the EHR and time spent documenting. For the complete question text and an explanation of how some response categories were combined for this analysis, see the eAppendix in the Supplement. We assessed the proportion of physicians with each outcome stratified by specialty and then the correlation among 3 physician and practice characteristics and mean documentation time outside office hours: (1) EHR use; (2) staff support for documentation (eg, scribes); and (3) participation in an Accountable Care Organization or pay-for-performance program (hereafter, value-based purchasing [VBP] participation).

Physician responses on satisfaction with documentation are summarized as weighted percentages and time spent on documentation as means with 95% CIs. Analyses were performed using Stata SE, version 16.1 (StataCorp LLC) survey procedures module. Two-sided P < .05 indicated statistical significance.

Results

The 1524 respondents (78.6% aged ≥50 years; 69.9% men) represented 301 603 physicians nationwide. Across primary care, surgical, and medical specialties, 64.1% of respondents reported satisfaction with the EHR; 64.5% found documentation to be easy (Table 1). However, 58.1% disagreed that the time spent documenting was appropriate and did not reduce time spent with patients, and 84.7% agreed that documentation solely for billing purposes increased total documentation time. Differences by physician specialty were not significant.

Table 1. Physician Experiences With Documentation According to Specialty, 2019^a.

Experience	Specialty, Weighted %				P value
	Primary care (n = 758)	Surgical (n = 341)	Medical (n = 425)	Total (N = 1524)
Satisfaction with EHRb
Satisfied (n = 849)	67.0	62.3	60.6	64.1	.32
Neutral (n = 127)	8.9	5.7	8.3	8.0
Dissatisfied (n = 388)	24.1	32.0	31.2	27.9
Time spent documenting outside office hours, hc
0 (n = 137)	5.3	11.4	13.0	9.0	.06
<1 (n = 265)	18.7	18.8	12.8	17.0
1-2 (n = 601)	41.1	41.2	42.2	41.4
>2-4 (n = 389)	26.6	23.1	20.6	24.0
>4 (n = 132)	8.3	5.5	11.4	8.6
Ease of documentationd
Easy (n = 940)	65.9	67.4	60.1	64.5	.36
Difficult (n = 538)	34.1	32.6	39.9	35.5
Time spent documenting is appropriatee
Agree (n = 610)	41.0	44.4	41.5	41.9	.82
Disagree (n = 880)	59.0	55.6	58.5	58.1
Time documenting does not reduce time with patientsf
Agree (n = 613)	42.9	40.2	41.4	41.9	.87
Disagree (n = 887)	57.1	59.8	58.6	58.1
Documentation solely for billing increases total documentation timeg
Agree (n = 1250)	85.2	85.5	83.3	84.7	.87
Disagree (n = 192)	14.8	14.5	16.7	15.3

Abbreviation: EHR, electronic health record.

^a For complete question text and an explanation of response categories used in this analysis, see the eAppendix in the Supplement. Percentages represent the weighted proportion of respondents providing each response.

^b Excluded responses (n = 160) included not applicable (n = 152), blank (n = 5), and a response of 6 (n = 3), which was not included as a response option in the code book. All responses of not applicable were among physicians who did not indicate EHR use.

^c No missing data.

^d Data missing from 46 respondents.

^e Data missing from 34 respondents.

^f Data missing from 24 respondents.

^g Data missing from 82 respondents.

Overall, physicians spent a mean of 1.77 (95% CI, 1.67-1.87) hours daily completing documentation outside office hours (Table 2). Differences by staff support for documentation (eg, scribes) were small and nonsignificant. Physicians who used EHRs spent a mean of 1.84 (95% CI, 1.74-1.94) h/d documenting outside office hours, significantly more than the 1.10 (95% CI, 0.83-1.37) h/d among those who did not use EHRs (P < .001). Physicians participating in VBP spent 2.02 (95% CI, 1.86-2.19) h/d on documentation outside office hours vs 1.58 (95% CI, 1.47-1.69) h/d among those who did not (P < .001). Assuming a 5-day work week and 47-week work year,⁴ we estimated US physicians spent 125 million hours documenting outside office hours in 2019.

Table 2. Mean Time Spent Documenting Outside Office Hours Among 1524 Physicians, 2019^a.

Variable	Time spent documenting, mean (95% CI), h/d	P valueb
Uses EHRc
Yes	1.84 (1.74-1.94)	<.001
No	1.10 (0.83-1.37)
Staff support for documentation or scribesd
Yes	1.77 (1.62-1.93)	.99
No	1.78 (1.65-1.90)
VBP participatione
Either	2.02 (1.86-2.19)	<.001
Neither	1.58 (1.47-1.69)
Total	1.77 (1.67-1.87)	NA

Abbreviations: EHR, electronic health record; NA, not applicable; VBP, value-based purchasing.

^a For complete question text and an explanation of response categories used in this analysis, see the eAppendix in the Supplement.

^b P value is from an univariable linear regression.

^c Data missing from 11 respondents.

^d Data missing from 3 respondents.

^e Whether the physicians or their reporting location participated in an Accountable Care Organization arrangement with public or private insurers or a pay-for-performance arrangement (either or both vs neither).

Discussion

This cross-sectional study reveals that documentation burdens US physicians. Most respondents indicated that documentation time is inappropriate and takes time from patients.

The large majority of US physicians reported that billing-related tasks exacerbate their documentation burden, which suggests that payment strategies specific to the US, vs to EHRs per se, account for some of the overload.⁵ Relative to EHR users in other nations, US physicians spend more time documenting in the EHR,⁵ with outpatient notes approximately 4 times longer.¹

Per our analysis, VBP participation is associated with a higher documentation burden, a finding consonant with the doubling in length of EHR ambulatory notes in the VBP era (among EHR users).¹ Surprisingly, we did not find that scribe use was associated with less overall documentation time; however, this does not address whether scribe users saw more patients.

A limitation of our study is that data were cross-sectional, precluding firm causal inference. Moreover, all data were self-reported by physicians, and the survey did not define documentation.³ Reassuringly, our estimate of time spent documenting outside office hours is comparable with some previous estimates based on other approaches.⁶ Reconsideration of the US approach to medical documentation may be warranted.

Supplement.

eAppendix. Questions and Response Options in the 2019 National Electronic Health Records Survey