The impact of electronic health record systems on clinical documentation times: A systematic review

Highlights

• Impact of electronic health record (EHR) use on documentation time was examined.

• EHR implementation associated with increased documentation time for hospital staff.

• A need for longer follow-up of EHR impact is highlighted.

• Multitasking and interruptions to staff work flow is a concern to patient safety.

• Adaptation to EHR over time could potentially solve inefficiencies in work flow.

Abstract

Background

Effective management of hospital staff time is crucial to quality patient care. Recent years have seen widespread implementation of electronic health record (EHR) systems but the effect of this on documentation time is unknown. This review compares time spent on documentation tasks by hospital staff (physicians, nurses and interns) before and after EHR implementation.

Methods

A systematic search identified 8153 potentially relevant citations. Studies examining proportion of total workload spent on documentation with ≥40 h of staff observation time were included. Meta-analysis was performed for physicians, nurses and interns comparing pre- and post-EHR results. Studies were weighted by person-hours observation time.

Results

Twenty-eight studies met selection criteria. Seventeen were pre-EHR, nine post-EHR and two examined both periods. With implementation of EHR, physicians’ documentation time increased from 16% (95% confidence interval (CI) 11–22%) to 28% (95% CI 19–37%), nurses from 9% (95% CI 6–12%) to 23% (95% CI 15–32%) and interns from 20% (95% CI 7–32%) to 26% (95% CI 10–42%).

Conclusions

There is a lack of long-term follow-up on the effects of EHR implementation. Initial adjustment to EHR appears to increase documentation time but there is some evidence that as staff become more familiar with the system, it may ultimately improve work flow.

Introduction

Hospital staff are a valuable healthcare resource and effective use of their skills is a major determinant of quality of care and achievement of national health goals [1]. Staff salaries often constitute the majority of hospital costs; Australian hospitals spent 62% and German hospitals spent 60% of their total expenditure on staff salaries in 2012/13 and 2013 respectively [2], [3]. Therefore it is vital that staff time can be allocated to ensure efficiency and for optimised quality of patient care.

The last two decades have seen an increase in the amount of time spent by hospital clinicians on documentation and clerical tasks, decreasing the time available to them to spend on direct patient care and communication with patients and relatives [4], [5]. The rising focus on quality of documentation, with more detail needing to be documented about the care process has led to increasing time pressure and staff dissatisfaction [5]. A consequence of this is burnout, with studies reporting up to 49% of hospital physicians meeting burnout criteria [6], [7]. Burnout is associated with decreased quality of care and an increase in subsequent health costs [7].

The widespread adoption of electronic health record (EHR) systems over recent years held the promise of more efficient information sharing between clinical staff. It was hoped that transitioning from paper to electronic health records would ultimately lead to decreased documentation time for staff and increased time for direct patient care. EHR documentation typically involves use of a bedside terminal, central computer or personal digital assistant (PDA). An advantage of EHR systems is that they can be augmented with computerised physician order entry (CPOE), electronic prescribing and decision support features.

In particular, computer-based decision support systems have been shown to improve patient safety by reducing the rate of prescribing and documentation errors and subsequent adverse events [8], [9]. They can provide staff with alerts for suggested corollary actions, potential drug interactions and adjustment of drug doses, a task poorly performed by human prescribers without aid [8]. In addition, EHR systems have the potential to improve information flow and access to knowledge, perform checks in real time and assist with monitoring [8].

Several factors have been found to be associated with staff satisfaction with EHR and associated decision support, and their acceptance within clinical care. Speed of the system is reported to be the most important, with subsecond “screen flips” recommended [10]. The availability of advanced features such as CPOE and automated reports have been reported as a positive [11]. The user-friendliness and reliability of the system is highly important, and features should be tested prior to implementation [10], [12]. For example, order-writing has been found to take longer using the computer than using paper when many screens or windows are involved [10]. The familiarity of users with computer systems affects ease of use, perhaps favouring younger users in developed countries [13].

When training staff in the use of an EHR system, it has been reported that educational efforts should ensure that staff understand why the system is being implemented as well as how to use all relevant features [12]. Problems with EHR integration have arisen when staff training was started too late in the implementation phase [12]. It is important to address infrastructure issues early, such as identifying appropriate spaces for computer instalment and use, and ensuring that sufficient backup and technical support exists in case of computer malfunctions [12].

Taking all steps necessary to ensure effective EHR integration is vital. In its absence, EHR implementation has the potential to disrupt documentation speed, add to time pressure and decrease the quality of care [14], [15]. The proportion of staff time spent on documentation tasks is often used as a measure of time efficiency [11]. It is of interest to study the overall impact of EHR on this outcome, comparing pre- and post-EHR systems for physicians and nurses.

Two previous systematic reviews have compared pre- and post-EHR time allocation by hospital staff for documentation tasks [11], [16]. However, neither of these reviews reported the proportion of total workload spent on documentation tasks, nor performed meta-analysis. Moreover, they included studies with self-reported outcomes and did not impose limits on the required period of observation, thus including studies with very short observation periods.

Observational studies such as time-motion and work-sampling studies have greater accuracy than self-reported studies for measuring staff time allocation in real time [17]. In order to understand the impact of EHR on documentation time as a measure of staff efficiency, there is a need for a comprehensive systematic review and meta-analysis of high-quality observational studies with sufficient observational time of whole of staff’s workloads. That is the primary objective of this systematic review.