Since 2019, the AMA has invested more than $2 million in research grants through the Electronic Health Record (EHR) Use Research Grant program.
Rigorous research continues to advance the science on the use of EHR audit log data, transactional data, or other EHR user data to identify patterns in EHR use that may detract from patient care or EHR efficiency; contribute to burnout, stress or attitudinal shifts related to work and career; or may inform decisions about workflows, teamwork, and resource allocation at the practice level. This research allows the AMA to partner with other institutions to meaningfully grow the body of knowledge on EHR use metrics.
Since the inception of this program in 2019, the AMA has funded studies across a variety of institutions and EHR-related topics. The field of study is in nascent stages and continues to grow as the science develops, more robust data becomes available, and researchers refine their methods for collecting and interpreting the data.
The AMA, in its efforts to ensure the EHR is an asset to medical practice and not a burden, is committed to building the evidence base to inform improvements to one of the largest sources of dissatisfaction and contributors to burnout for practicing physicians.
The research funded in the first years of the program set out to explore and test what, at the time, were relatively new metrics for measuring physician activity in the EHR. The metrics were identified and explained in the publication “Novel Metrics for Improving Professional Fulfillment” and further discussed in the article “Metrics for assessing physician activity using electronic health record log data,” led by Christine Sinsky, MD, vice president of professional satisfaction at the AMA. These metrics served as the foundation for most of the research studies funded by the AMA and have become standard across stakeholders in the pursuit of effective and comparable measurement of EHR use.
Our grants from the AMA have allowed us to undertake critically important work that examines how technology, and policies that shape technology, are impacting frontline physicians. Simply put, there is dearth of funders to support this work. However, with ongoing support from AMA, our research center has been able to build up capabilities and expertise in this area. We are studying how to improve varied dimensions of technology use – from less documentation for billing to team-based strategies for handling the dramatic increase in inbox messages. Ultimately, this work allows technology to be a helper, and not a hindrance, to physicians and their patients.
–Julia Adler-Milstein, PhD; Director, Center for Clinical Informatics and Improvement Research, University of California San Francisco
In 2021, the AMA funded research that would continue exploring the established metrics to quantify elements of practice efficiency and teamwork, and to evaluate the relationship between the metrics and burnout, professional satisfaction and well-being.
In 2022, grantees focused on the EHR inbox and the impacts of EHR use on the physician workforce.
In 2023, the funded studies aim to provide insights into the relationships between EHR use and physician cognitive load and relationships between EHR use and team structures and care team processes, as well as the time spent on EHR work during vacation or other time away from work.
The AMA’s EHR use measurement practice transformation initiatives have enabled multiple new lines of inquiry to understand and improve the practice environment. As an investigator, I am grateful for the opportunity to join the vibrant and growing community of researchers in this space to have an immediate impact on clinical practice.
–Ted Melnick, MD, MHS; Interim Research Section Chief & Associate Professor of Emergency Medicine, Yale School of Medicine; Associate Professor of Biostatistics (Health Informatics), Yale School of Public Health; Program Director, Yale-VA Clinical Informatics Fellowship Program
- Brigham and Women’s Hospital
- Stanford University School of Medicine
- University of California – San Francisco
- University of Colorado School of Medicine
- University of Wisconsin – Madison
- Wake Forest University School of Medicine
- Yale University School of Medicine
Research funded through the AMA’s grant program has contributed valuable and influential insights to the field, and several of the key findings have been published in peer-reviewed journals and presented at relevant conferences throughout the U.S.
The support provided by the AMA enabled us to conduct rigorous research into how specific initiatives impact physicians’ experiences and time on the electronic health record. The results provided crucial insight into how future programs should be structured to enhance physician wellbeing.
-Lisa Rotenstein, MD, MBA; Assistant Professor of Medicine, Harvard Medical School; Medical Director of Population Health, Brigham and Women’s Hospital
Highlights of published findings include:
- Precise, reliable, valid metrics that are cost-effective and require reasonable implementation time and effort are needed to drive EHR improvements and decrease EHR burden. This research group identified actionable solutions to address core categories of EHR metric implementation challenges (Levy, 2023 [PDF]).
- This longitudinal cohort study of ambulatory physicians at UCSF Health, a large academic medical center, finds a strong, linear relationship between telemedicine use and EHR time during and outside of patient scheduled hours – but not more messages received from patients (Holmgren, 2023).
- Primary care visits often start with a myriad of standardized intake screening questions that are tied to performance metrics and incorporated into EHRs. But prioritizing repetition of intake screening questionnaires at primary care visits may have unintended consequences such as administrative burden, provision of low-value care, and reduced clinical capacity to deliver other, high-value services (Simon, 2023).
- Perceived EHR stress and prescription reauthorization messages are significantly associated with burnout, as are non-EHR factors such as not feeling valued or aligned in values with clinic leaders. Younger physicians need more support. A multipronged approach targeting actionable levers and supporting young physicians is needed to implement sustainable improvements in physician well-being (Tai-Seale, 2023).
- Accurately quantifying clinician time spent on EHR activities outside the time scheduled with patients, formally known as work outside of work (WOW) is critical for understanding occupational stress associated with ambulatory clinic environments. Attributing all EHR work outside time scheduled with patients to WOW, regardless of when it occurs, will produce an objective and standardized measure better suited for use in efforts to reduce burnout, set policy, and facilitate research (Arndt, 2023).
- Physicians in outpatient ambulatory care receive more messages from patients through the EHR system than prior to the start of the COVID-19 pandemic. For physicians, the burden of managing an increasingly crowded inbox might be mitigated by having other members of the care team answer non-medical advice messages or reevaluating how that type of work is reimbursed (Nath, 2021).
For every 8 hours of scheduled patient time, ambulatory physicians spend more than 5 hours in the EHR (Melnick, 2021).
- Analysis of patient messages, using Natural Language Processing, can facilitate identification of negative messages, including those with expletives and violent language, and inform subsequent interventions, such as automated inbox filters, root cause analysis of patient frustrations, and efforts to improve patient experience (Baxter, 2022).
- Vendor-derived audit-log data are useful; however, their limitations do not allow for derivation of all core EHR metrics and comparison of metrics across vendor products, demonstrating the value of measurement using other types of EHR use data (Melnick, 2021).
- Physicians using virtual scribe services experience improvements in their EHR documentation time and quality (Ong, 2021).
- Excess screenings, such as those for tobacco use, can result in unnecessary repetition and task-load, possibly contributing to unintended negative consequences in applying quality measures (Simon, 2021).
- Female physicians spend more time on the EHR overall, after-hours, and on EHR-based documentation than male physicians, suggesting that women physicians may benefit from policy changes, workflow improvements, and technologies that reduce documentation burden (Rotenstein, 2022).
- Volume of EHR use can be tracked and used to predict physician departure from practice (Melnick, 2021).
- There are strong associations between EHR usability and workload, meaning that improving EHR usability while decreasing task load may allow practicing physicians more working memory for medical decision making and patient communication (Melnick, 2022).
The AMA will continue to support this important field of study, while exploring and maximizing its contributions to improving practice science. As EHR vendors adopt new and better data collection, and as health systems learn to maximize the potential of the available data, the measurement and utility of EHR use data will only get better. The AMA recognizes the high value of this research and is proud to be an integral part of this movement.