Department of Health Policy and Management, University of Maryland School of Public Health, College Park.
Division of Clinical Informatics and Digital Transformation, University of California, San Francisco.
JAMA Intern Med. 2024 Oct 1;184(10):1212-1221. doi: 10.1001/jamainternmed.2024.4123.
Physicians spend the plurality of active electronic health record (EHR) time on documentation. Excessive documentation limits time spent with patients and is associated with burnout. Organizations need effective strategies to reduce physician documentation burden; however, evidence on team-based documentation (eg, medical scribes) has been limited to small, single-institution studies lacking rigorous estimates of how documentation support changes EHR time and visit volume.
To analyze how EHR documentation time and visit volume change following the adoption of team-based documentation approaches.
DESIGN, SETTING, AND PARTICIPANTS: This national longitudinal cohort study analyzed physician-week EHR metadata from September 2020 through April 2021. A 2-way fixed-effects difference-in-differences regression approach was used to analyze changes in the main outcomes after team-based documentation support adoption. Event study regression models were used to examine variation in changes over time and stratified models to analyze the moderating role of support intensity. The sample included US ambulatory physicians using the EHR. Data were analyzed between October 2022 and September 2023.
Team-based documentation support, defined as new onset and consistent use of coauthored documentation with another clinical team member.
The main outcomes included weekly visit volume, EHR documentation time, total EHR time, and EHR time outside clinic hours.
Of 18 265 physicians, 1024 physicians adopted team-based documentation support, with 17 241 comparison physicians who did not adopt such support. The sample included 57.2% primary care physicians, 31.6% medical specialists, and 11.2% surgical specialists; 40.0% practiced in academic settings and 18.4% in outpatient safety-net settings. For adopter physicians, visit volume increased by 6.0% (2.5 visits/wk [95% CI, 1.9-3.0]; P < .001), and documentation time decreased by 9.1% (23.3 min/wk [95% CI, -30.3 to -16.2]; P < .001). Following a 20-week postadoption learning period, visits per week increased by 10.8% and documentation time decreased by 16.2%. Only high-intensity adopters (>40% of note text authored by others) realized reductions in documentation time, both for the full postadoption period (-53.9 min/wk [95% CI, -65.3 to -42.4]; 21.0% decrease; P < .001) and following the learning period (-72.2 min/wk; 28.1% decrease). Low adopters saw no meaningful change in EHR time but realized a similar increase in visit volume.
In this national longitudinal cohort study, physicians who adopted team-based documentation experienced increased visit volume and reduced documentation and EHR time, especially after a learning period.
医生在电子病历（EHR）中花费了大量的时间进行文档记录。过多的文档记录会限制医生与患者的交流时间，从而导致医生倦怠。各组织需要有效的策略来减轻医生的文档记录负担；然而，关于基于团队的文档记录（例如，医疗记录员）的证据仅限于小范围的单一机构研究，缺乏关于文档记录支持如何改变 EHR 时间和就诊量的严格估计。
分析采用基于团队的文档记录方法后，EHR 文档记录时间和就诊量的变化情况。
设计、地点和参与者：这是一项全国性的纵向队列研究，分析了 2020 年 9 月至 2021 年 4 月期间的每周一次的医师 EHR 元数据。采用双向固定效应差分差异回归方法分析主要结果在采用基于团队的文档支持后的变化。事件研究回归模型用于分析随时间变化的变化情况，分层模型用于分析支持强度的调节作用。该样本包括使用 EHR 的美国门诊医生。数据于 2022 年 10 月至 2023 年 9 月之间进行分析。
基于团队的文档支持，定义为与另一位临床团队成员共同撰写文档的新出现和持续使用。
主要结果包括每周就诊量、EHR 文档记录时间、总 EHR 时间和 EHR 非工作时间记录时间。
在 18265 名医生中，有 1024 名医生采用了基于团队的文档支持，而 17241 名比较医生没有采用这种支持。该样本包括 57.2%的初级保健医生、31.6%的医学专家和 11.2%的外科专家；40.0%的医生在学术环境中工作，18.4%的医生在门诊安全网环境中工作。对于采用者医生，就诊量增加了 6.0%（每周就诊 2.5 次[95%CI，1.9-3.0]；P<0.001），文档记录时间减少了 9.1%（每周减少 23.3 分钟[95%CI，-30.3 至-16.2]；P<0.001）。在采用后的 20 周学习期后，每周就诊次数增加了 10.8%，文档记录时间减少了 16.2%。只有高强度的采用者（超过 40%的记录文本由他人撰写）实现了文档记录时间的减少，无论是在整个采用后期间（-53.9 分钟/周[95%CI，-65.3 至-42.4]；减少 21.0%；P<0.001）还是在学习期后（-72.2 分钟/周；减少 28.1%）。低采用者的 EHR 时间没有明显变化，但就诊量却有类似的增加。
在这项全国性的纵向队列研究中，采用基于团队的文档记录的医生就诊量增加，文档记录和 EHR 时间减少，尤其是在学习期之后。
