Patel Arati, Mummaneni Praveen V, Zheng Jeff, Rosner Benjamin I, Thombley Robert, Sorour Omar, Theodosopoulos Philip V, Aghi Manish K, Berger Mitchel S, Chang Edward F, Chou Dean, Manley Geoffrey T, DiGiorgio Anthony M
Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
Center for Clinical Informatics and Improvement Research, University of California, San Francisco, San Francisco, California, USA.
Neurosurgery. 2023 Apr 1;92(4):870-875. doi: 10.1227/neu.0000000000002288. Epub 2022 Dec 12.
The electronic health record (EHR) is central to clinical workflow, yet few studies to date have explored EHR usage patterns among neurosurgery trainees.
To describe the amount of EHR time spent by postgraduate year (PGY)-2 and PGY-3 neurosurgery residents during on-call days and the distribution of EHR activities in which they engage.
This cohort study used the EHR audit logs, time-stamped records of user activities, to review EHR usage of PGY-2 and PGY-3 neurosurgery residents scheduled for 1 or more on-call days across 2 calendar years at the University of California San Francisco. We focused on the PGY-2 and PGY-3, which, in our training program, represent the primary participants in the in-house on-call pool.
Over 723 call days, 12 different residents took at least one on-call shift. The median (IQR) number of minutes that residents spent per on-call shift actively using the EHR was 536.8 (203.5), while interacting with an average (SD) of 68.1 (14.7) patient charts. There was no significant difference between Active EHR Time between residents as PGY-2 and PGY-3 on paired t -tests. Residents spent the most time on the following EHR activities: patient reports, notes, order management, patient list, and chart review.
Residents spent, on average, 9 hours of their on-call shift actively using the EHR, and there was no improved efficiency as residents gained experience. We noted several areas of administrative EHR burden, which could be reduced.
电子健康记录（EHR）是临床工作流程的核心，但迄今为止，很少有研究探讨神经外科住院医师的EHR使用模式。
描述二年级（PGY-2）和三年级（PGY-3）神经外科住院医师在值班日花费在EHR上的时间，以及他们参与的EHR活动的分布情况。
这项队列研究使用EHR审计日志（用户活动的时间戳记录），回顾了加利福尼亚大学旧金山分校在两个日历年度内安排了1个或更多值班日的PGY-2和PGY-3神经外科住院医师的EHR使用情况。我们关注PGY-2和PGY-3，在我们的培训项目中，他们是内部值班人员的主要参与者。
在723个值班日中，12名不同的住院医师至少值了一次班。住院医师在每个值班班次积极使用EHR的中位数（IQR）分钟数为536.8（203.5），同时平均（SD）与68.1（14.7）份患者病历进行交互。配对t检验显示，PGY-2和PGY-3住院医师之间的主动EHR时间没有显著差异。住院医师在以下EHR活动上花费的时间最多：患者报告、记录、医嘱管理、患者列表和病历审查。
住院医师平均在每个值班班次花费9小时积极使用EHR，并且随着住院医师经验的增加，效率并没有提高。我们注意到了几个行政EHR负担领域，可以减轻这些负担。
