a b s t r a c t

Objective: We evaluate physician productivity using electronic medical records in a community hospital emergency department.

Methods: Physician time usage per hour was observed and tabulated in the categories of direct patient contact, data and Order entry, interaction with colleagues, and review of test results and old records.

Results: The mean percentage of time spent on data entry was 43% (95% confidence interval, 39%-47%). The mean percentage of time spent in direct contact with patients was 28%. The pooled weighted average time allocations were 44% on data entry, 28% in direct patient care, 12% reviewing test results and records, 13% in discussion with colleagues, and 3% on other activities. Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selectED patient encounters. Total mouse clicks approach 4000 during a busy 10-hour shift.

Conclusion: Emergency department physicians spend significantly more time entering data into electronic medical records than on any other activity, including direct patient care. ImprovED efficiency in data entry would allow emergency physicians to devote more time to patient care, thus increasing hospital revenue.

(C) 2013

Introduction

Background

In 2009, the federal government passed into law the American Recovery and Reinvestment Act. This bill included the Health information technology (HIT) for Economic and Clinical Health Act, which provided for $19 billion in incentives to hospitals and physicians who demonstrate “meaningful use” of Electronic medical records [1].

The use of EMRs has created much controversy in the health care industry. Health Information Technology companies promise such systems will reduce costs by as much as $100 billion annually, but results are inconclusive. In the face of rising costs, escalating demand, and downward price pressures, Physician Efficiency is imperative, and with a $150 to $200 million price tag for the software alone, the stakes are high for hospitals implementing these systems [2].

Importance

Given the federal mandate and economic incentives to hospitals to implement EMRs, there has been a rush to comply. System deployment amid such haste has not always been optimal.

* Corresponding author. Tel.:/fax: +1 610 838 0275.

E-mail address: [email protected] (L.M. Sears).

The theoretical benefits to a well-functioning EMR system include improved communication and patient safety, seamless sharing of data via universal medical records, reduction of Medical errors in order entry, reduction of unnecessary diagnostic testing, increased patient satisfaction, and more efficient third-party billing [2].

Experience with implementation of EMR in emergency depart- ments (EDs) where, by definition, there can be large volumes of patients in need of expedient care has thus far met with mixed results [3-14]. Unfortunately, many hospitals deploy network-wide EMR systems that fail to accommodate ED operational processes. It behooves us to systematically analyze the EMR process and tailor it to better meet the unique requirements of EDs.

Goals of this investigation

We undertook a time study using an EMR system in our community hospital setting with an eye toward improving performance.

Materials and methods

An institutional review board waiver was obtained for this study. Attending physicians, emergency medicine residents, and mid- level providers in our ED were tracked for a total of 30 hours. Each of the 16 participants recorded minutes per hour spent in 4 categories: direct patient contact, data entry and order entry, consultation and discussion with colleagues and staff, and review of test results and prior records. We felt it best to enroll participants during busy times

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because it is during these times that efficiency is most critical. A control group (eg, paper charts) was not studied because the use of EMRs has become the new federally mandated standard.

The McKesson Horizon Emergency Care V.10.3 system (McKesson, San Francisco, CA) was in use for charting and order entry, along with McKesson systems for discharge instructions and prescription writing. McKesson Horizon Patient Folder 15.1.1136 was used for reviewing old records. Practitioners had the option of using Dragon voice recognition software (Nuance Communications, Inc., Burlington, MA) or free text typing of notes in addition to charting produced by McKesson software templates.

Mouse clicks per patient and per hour were counted for each practitioner and averaged over cases of varying complexity and extrapolated over a typical 10-hour shift in our ED. Specific data were garnered on the number of template mouse clicks per various operations such as ordering medications or tests, interpreting test results, documenting an examination, and discharging a patient.

The distribution of time across the 4 categories of activities was tabulated. Participants’ time was aggregated, and weighted averages were calculated based on total time allocated between tasks. Weighted averages were used because periods of observation varied from the assigned 60-minute blocks of time.

Actual third quarter 2012 physician productivity data were used from this ED, yielding baseline averages for patients seen per physician-hour, billed charges per patient, and relative value units (RVUs) per patient.

Results

Practitioners were observed completing selectED operations using the McKesson Horizon Emergency Care V.10.3 EMR system at a community teaching hospital ED based on a single observation. The number of mouse clicks used to accomplish these tasks is displayed in Table 1. Table 2 shows extrapolated quantities of mouse clicks over a 10-hour shift, given patient velocities of 2, 2.12, and 2.5 per hour.

Participants recorded time spent in 4 categories: direct patient care, case review, discussion, and data entry. Of the 16 respondents, 44% were residents or interns, 25% were attending physicians, and 31% were physician assistants or nurse practitioners. The mean percentage of time spent in data entry was 43% (95% confidence interval, 39.31%-46.69%). The range was 50.1; the lowest and highest percentages were 17.5% and 67.6%, respectively. The use of Dragon did not affect the results.

All time was pooled, and a weighted average allocation of time was calculated. The results are summarized in Fig.

Of primary concern was the amount of time spent in direct patient care relative to the time spent on order entry and charting (28% and 44%, respectively).

Limitations

The time study used a sample size of 30. The small sample size contributed to a standard error of 2.17 from the mean time spent on

Table 2

Calculation of mouse clicks per hour and per shift

Average at 2 patients per hour = 320 clicks per hour; 3200 clicks per 10-h shift Average at 2.12 patients per hour = 339 clicks per hour; 3390 clicks per 10-h shift Average at 2.5 patients per hour = 400 clicks per hour; 4000 clicks per 10-h shift

data entry (43%). Standard deviation was 11.9 from the mean of 43%, a likely indicator of substantial variation in practice styles and levels of training typical of a work environment.

This is a single-site study involving only 1 EMR system. Because 52% of US hospitals use McKesson products [15], we assume that McKesson’s Horizon Emergency Care is relevant to the topic at hand. This represents a call to EDs using different systems to perform our analysis so that other systems can be compared on an equal footing.

Discussion

The findings in this study are consistent with other studies, which estimate the time spent on documentation to be 30% to 40% of a workday, with electronic charting taking 30% longer than paper charts [16]. Factors such as operating system speed, server/ mainframe responsiveness, typing skills, user-friendliness of system, interruptions, extent of training, opportunity to delegate tasks, and various environmental attributes can influence data entry time. Efficient use of the EMR system will increase physician productivity and hospital revenue.

Table 3 demonstrates the impact on RVUs and charges billed given incremental increases in productivity and throughput. Given a baseline of $1215 in billed charges per physician-hour, at 14 600 physician-hours per year, a 10% increase in throughput would increase the annual gross revenue by $1.77 million. At a 12% accounts receivable collection rate, net revenue would increase by $212 826. In light of the Financial benefits arising from even this modest increase in through- put, efforts to improve physician productivity are well advised.

A key objective of HIT is the creation of universally available medical records, enabling expedient access to medical history and appropriate, prompt treatment while avoiding duplication of prior tests or services. Proponents expect considerable savings for third- party payers and patients, which could also result in less revenue for hospitals [17]. Therefore, the facilities that implement HIT systems must offset revenue shortfalls with corresponding savings in

Other 3%

Discussion 13%

Data Entry 44%

Patient Contact 28%

Review 12%

Table 1

Quantity of mouse clicks for selected EMR tasks

Order a 325-mg aspirin	6
Order a chest x-ray PA and lateral	8
View a test result in old records	11
View and interpret a chest x-ray post anterior and lateral	13
Write and print a single prescription	15
Create and print discharge instructions	20
Document physical examination of a hand-and-wrist injury	40
Document physical examination of back pain	47
Completed EMR right upper quadrant abdominal pain (discharged)	227
Completed EMR palpitations (discharged)	181
Completed EMR chest pain (admitted)	187
Average over selected cases and chief complaints	160

Fig. Emergency department practitioner time allocation.

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Table 3

Sensitivity analysis of productivity increase scenarios

extraordinary benefits. This facilitates research, formulation of quality standards, and the establishment of Performance metrics. There is

Patients per physician-hour

% of Time spent in patient care

RVU/h Charges billed

per hour

some concern that the traditional art of evidence-based medicine could evolve toward mechanistic delivery of health care: risk management and uniformity overshadowing principled professional judgment [19].

Electronic medical record use requires specialized computer skills, the absence of which can lead to errors that may broaden malpractice liability. Data entry errors, duplication of mistakes, inadequate training, and inconsistent use can damage the integrity of patient records. Although malpractice insurance premiums may drop upon adoption of information-rich EMR systems, the effect on legal

Baseline 2.12	28.19%	6.68	$1215
10% increase in 2.33	31.01%	7.35	$1336
productivity
20% increase in 2.54	33.83%	8.01	$1458
productivity 30% increase in 2.76 productivity	36.65%	8.68	$1579

productivity and throughput and/or enhanced revenue through more robust coding and billing.

Deployment of a new system is a massive project with far-reaching consequences. So far, EMR systems do not consistently meet expectations.

The major objective, cross-compatibility of systems allowing access to universal medical records, has not been achieved. There is no standard protocol for data among competing software vendors [17].

Studies at Harvard and Stanford Universities on more than 270 000 outpatient visits revealed no significant improvement in quality of care as a result of EMRs.

One recent study at The Medical University of S. Carolina, Charleston, SC, which looked at 105 ED patients on whom medical records were on file in a regional Health Information Exchange, reported an average of $2700 less in services performed per patient, mainly through reduced radiologic services or lower admission rates. It was noted that the Health Information Exchange records saved significant time–a mean savings of 120 minute per visit [9].

A study at Upper Chesapeake Health Systems reported that the use of EMRs resulted in higher RVUs per patient–4.737 as compared with

4.585 using paper charts. Patients seen per hour decreased slightly from 1.621 to 1.592. This 1.79% decrease in patient velocity coupled with a 3.3% increase in RVUs per patient suggests that the EMR’s may facilitate thorough coding and efficient billing, although the system may be more cumbersome than a paper chart. The decrease in patient velocity may also reflect a learning curve because this facility had only recently implemented the EMR system [8].

In one ED in Cincinnati, OH, that recently implemented an EMR system, the median length of stay decreased from 186 to 163 minutes within a few months. The study noted a long-term increase in laboratory testing and orders for medication, believed to be attributable to the ease in which such items can be ordered using the new system [10].

Automated prompts generated by some systems increase the ease and incidence of upcoding, facilitating delivery of additional services to bill higher codes [18].

An analysis of 364 hospital EDs in the National Hospital Ambulatory Medical Care Survey with fully functional EMR systems revealed a 22.4% shorter length of stay, shorter waiting time to see physicians, and 13.1% shorter treatment times [4].

Some analysts believe that data related to the use of EMR’s may be biased because of studies having been conducted at the most innovative institutions, using high-end customized systems [5]. Of all the factors affecting productivity, the type of system is the leading variable. However, all too often, Hospital systems purchase network-wide software packages that contain bundled ED soft- ware, which seems to be an afterthought rather than a product that has been collaboratively designed to meet the department’s needs. The costs and benefits of these cheaper “out-of-the box” vs customized systems must be evaluated. The long-term Opportunity costs of counterproductivity may outweigh the initial savings many times over.

electronic medical record systems rich in patient and practitioner data provide clinical and managerial tools with a wealth of

exposure is not yet clear. The abundance of data and ease of communication increase consumer expectations, raising standards of care to perhaps unrealistically high levels [20]. The availability of timestamps, records of responses to decision support prompts, and other such metadata give malpractice attorneys a world of digital footprints to peruse and call into question during the discovery process [21]. Computer-generated medical records bearing input from multiple providers may be rife with inconsistencies and contradictory statements. The disjointed syntax provided by software can thor- oughly obfuscate, rather than clarify and support the all important clinical decision process [22].

Deployment of new EMR systems necessitates taking a second look at job designs, training programs, occupational environments, and workflow. The increased use of computers raises concerns about repetitive stress injuries such as carpal tunnel syndrome. Other considerations are eyestrain and Muscle pain; these may be mitigated by proper ergonomics [23]. Mental fatigue engendered by prolonged repetitive tasks and performance of thousands of “point and shoot” mouse clicks aimed at small boxes on a computer screen should raise concerns about diminished concentration leading to Medical errors.

A thorough and integrated medical record is essential. Careful honing of EMR systems toward this end is of paramount importance. Further improvement of physician productivity and Data quality may be achieved by using scribes. Laptop in hand, a scribe shadows a practitioner, performing data entry, administra- tive, and ancillary tasks as directed by the physician. Some regulations limit the scope of their duties, and a physician must always review the work. An experienced scribe is adept at comprehensive procedure documentation that will facilitate optimal coding, fewer Data errors, and increased compliance, which should result in higher reimbursement rates [16,23]. Recent studies show that the use of scribes increases patient velocity by 15% to 40%, with some experiencing a 25% reduction in length of stay and a 15% increase in RVUs per hour [24,25].

Electronic medical records provide numerous benefits under the right conditions [14]. Functionality is expected to improve as this technology evolves to reach its full potential. Efficient integration of EMR systems into work routines will optimize physician time and improve data quality while increasing patient satisfaction and, ultimately, the bottom line.

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