Although there is wide variation among specialties, all ambulatory care physicians spend a great deal of time working in their EHR—an average of 5.8 hours per eight hours of time scheduled for patient care—and a significant amount of that time is spent outside of scheduled clinical hours, according to a study using data from a sample of more than 200,000 physicians.
“Across all physician specialties in the outpatient setting, physicians spend nearly six hours on the electronic health record for every eight hours of patient scheduled time,” said Christine A. Sinsky, MD, the study’s lead author and vice president of professional satisfaction at the AMA.
“The study highlights how, with all of the important clinical work physicians do plus all the mandatory clerical work that's been added to their daily responsibility, EHR-based work competes with our ability to provide our undivided attention to our patients,” Dr. Sinsky added.
From AI implementation to EHR adoption and usability, the AMA is fighting to make technology work for physicians, ensuring that it is an asset to doctors—not a burden.
How specialties compare
The study, published in the Journal of General Internal Medicine, found that infectious disease specialists spent the most time working in the EHR. Anesthesiologists spent the least.
Specialties whose physicians had the highest amount of overall EHR time were:
- Infectious disease—8.4 hours per eight hours of scheduled patient time.
- Endocrinology—7.7.
- Nephrology—7.5.
- Primary care (family and internal medicine)—7.3.
- Hematology—7.2.
Specialties whose physicians spent the least time in the EHR are:
- Anesthesiology—2.5 hours per eight hours of scheduled patient time.
- Orthopaedics—3.3.
- Otorhinolaryngology—4.
- Surgery—4.
- Dermatology—4.3.
“Primary care and some of the medical subspecialties like infectious disease, endocrine, nephrology and hematology tend to be specialties that are associated with a high level of complexity with the patients that they care for,” Dr. Sinsky said. “These are specialties with complicated patients with multiple medical conditions for whom there's a lot of visit-note documentation, lots of orders and require a lot of communication between the patient and the physicians or the team between visits, so the inbox time is highest among those five specialties as well.”
On average, physicians across all specialties averaged 0.8 hours on inbox tasks per eight hours of scheduled patient time.
Physicians specializing in primary care, infectious disease and endocrinology averaged 1.2 hours of inbox work per eight hours of scheduled patient time. Hematologists averaged 1.1 hours, while anesthesiologists and orthopaedists averaged 0.2 and 0.4 hours, respectively.
“My hypothesis would be that many of the procedural specialties have hired staff who assist with some of the tasks of order entry, visit-note documentation and being the first responders to the inbox,” Dr. Sinsky said.
Data from more than 200,000 doctors
Dr. Sinsky and colleagues used deidentified data generated by 200,081 unique physicians at 396 organizations from November 2021 through April 2022 using Epic Systems’ Signal platform, which tracks any mouse activity or keystrokes in the EHR. The data was used to measure physician activity in four primary functions: Documentation, chart review, orders and inbox management.
Also counted was time spent in the EHR outside of scheduled hours and time on unscheduled days. This was characterized in the study as “work after work.”
On average, Dr. Sinsky and colleagues found that physicians across all specialties spent 3.4 hours per eight hours of scheduled patient time in the EHR during patient scheduled hours or 57.8% of total time in the EHR. They spent another 1.2 hours outside of patient scheduled hours on days with scheduled appointments (20.7% of total time), and 1.3 hours on unscheduled days (21.5% of total time).
“The other takeaway of the study is the amount of time that physicians are spending on EHR-based work during their personal time,” Dr. Sinsky said.
“So, for example, primary care physicians are spending 2.7 hours of their personal time on the electronic health record outside of time scheduled with patients,” she added. “In many ways, that's uncompensated labor. Much of this work outside of work derives from the time demands from the inbox, which has become a second job for physicians that begins after hours.”
Fighting for Physicians
Get updates on how the AMA is fighting for physicians on critical issues—delivered to your inbox.
The study establishes a post-COVID onset baseline for EHR time that, Dr. Sinsky and colleagues wrote, will be “critical to tracking changes over time as well as evaluating the impact of policy efforts to reduce EHR burden.”
The study was supported by the AMA’s Electronic Health Record Use Research Grant Program that supports studies identifying patterns in EHR use that may contribute to physician burnout and detract from patient care. Since the program’s inception in 2019, the AMA has awarded more than $2.25 million to researchers in 28 organizations to expand insight into EHR systems and measure the technology’s capacity to support or undermine the delivery of efficient and effective clinical work.
Solving the problem
To address the EHR burdens documented, Dr. Sinsky and her co-authors suggest that “reducing EHR burden should be a critical priority for health system leaders, policymakers, technology vendors and physicians.”
Dr. Sinsky suggested several actions that can be taken that would allow physicians to spend more time giving direct care to patients and less time in the EHR.
“One is to make sure that vendors and health systems have done everything they can to reduce the number of clicks and screen changes required to do a task,” she said. “In my own clinical practice, it had taken 32 clicks to order and record having given a flu shot. This is just too many clicks.”
It is important to give other care-team members opportunities to do EHR tasks currently done by physicians, including order entry, visit-note documentation and the initial response and management of inbox messages.
“We can just look at the fact that family physicians are spending 1.4 hours of every eight-hour session entering orders and, in large part, that's a task that could be delegated to team members, freeing up physicians to provide more attention and care to their patients.” Dr. Sinsky said.
It often takes a few seconds to communicate the next steps to take with a patient’s care to a team member verbally or via checklist, but translating that decision into a clinical order within the EHR can take minutes. Multiply that over hundreds of orders per day and the time quickly adds up.
“Medical decision-making—that's what physicians are trained to do,” Dr. Sinsky said.
“Data entry into the electronic health record for that order can take several minutes and we found that adds up to about an hour and a half of primary care physician time per eight hours of being with patients,” she added. “Most physicians would rather use that hour and a half to give their patients access to care, give them their undivided attention and spend more time with their own families rather than doing the rote tasks of order entry.”
Physicians and health care leaders also should explore the AMA STEPS Forward® “Taming the EHR Playbook,” which outlines how to implement effective system-level policies to reduce the physician burden of EHR work.
For further resources to help support EHR improvements, visit the AMA STEPS Forward EHR topic page.
