{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T18:11:58Z","timestamp":1783447918577,"version":"3.55.0"},"reference-count":38,"publisher":"Georg Thieme Verlag KG","issue":"02","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Appl Clin Inform"],"published-print":{"date-parts":[[2024,3]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:p>\n          Background\u2003Electronic health record (EHR) user interface event logs are fast providing another perspective on the value and efficiency EHR technology brings to health care. Analysis of these detailed usage data has demonstrated their potential to identify EHR and clinical process design factors related to user efficiency, satisfaction, and burnout.<\/jats:p><jats:p>\n          Objective\u2003This study aimed to analyze the event log data across 26 different health systems to determine the variability of use of a single vendor's EHR based on four event log metrics, at the individual, practice group, and health system levels.<\/jats:p><jats:p>\n          Methods\u2003We obtained de-identified event log data recorded from June 1, 2018, to May 31, 2019, from 26 health systems' primary care physicians. We estimated the variability in total Active EHR Time, Documentation Time, Chart Review Time, and Ordering Time across health systems, practice groups, and individual physicians.<\/jats:p><jats:p>\n          Results\u2003In total, 5,444 physicians (Family Medicine: 3,042 and Internal Medicine: 2,422) provided care in a total of 2,285 different practices nested in 26 health systems. Health systems explain 1.29, 3.55, 3.45, and 3.30% of the total variability in Active Time, Documentation Time, Chart Review Time, and Ordering Time, respectively. Practice-level variability was estimated to be 7.96, 13.52, 8.39, and 5.57%, respectively, and individual physicians explained the largest proportion of the variability for those same outcomes 17.09, 27.49, 17.51, and 19.75%, respectively.<\/jats:p><jats:p>\n          Conclusion\u2003The most variable physician EHR usage patterns occurs at the individual physician level and decreases as you move up to the practice and health system levels. This suggests that interventions to improve individual users' EHR usage efficiency may have the most potential impact compared with those directed at health system or practice levels.<\/jats:p>","DOI":"10.1055\/s-0044-1782228","type":"journal-article","created":{"date-parts":[[2024,3,21]],"date-time":"2024-03-21T00:45:36Z","timestamp":1710981936000},"page":"212-219","source":"Crossref","is-referenced-by-count":10,"title":["Explaining Variability in Electronic Health Record Effort in Primary Care Ambulatory Encounters"],"prefix":"10.1055","volume":"15","author":[{"given":"J. Marc","family":"Overhage","sequence":"additional","affiliation":[{"name":"The Overhage Group, Zionsville, Indiana, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fares","family":"Qeadan","sequence":"additional","affiliation":[{"name":"Department of Public Health Sciences, Loyola University Chicago, Chicago, Illinois, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eun Ho Eunice","family":"Choi","sequence":"additional","affiliation":[{"name":"University of New Mexico School of Medicine, Albuquerque, New Mexico, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Duncan","family":"Vos","sequence":"additional","affiliation":[{"name":"Division of Epidemiology and Biostatistics, Department of Biomedical Sciences, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3748-5884","authenticated-orcid":false,"given":"Philip J.","family":"Kroth","sequence":"additional","affiliation":[{"name":"Department of Biomedical Informatics, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"194","published-online":{"date-parts":[[2024,3,20]]},"reference":[{"key":"ref1","doi-asserted-by":"crossref","first-page":"103343","DOI":"10.1016\/j.jbi.2019.103343","article-title":"EHR audit logs: a new goldmine for healths services research?","volume":"101","author":"J Adler-Milstein","year":"2020","journal-title":"J Biomed Inform"},{"issue":"08","key":"ref2","doi-asserted-by":"crossref","first-page":"1676","DOI":"10.1093\/jamia\/ocab042","article-title":"Measuring time clinicians spend using EHRs in the inpatient setting: a national, mixed-methods study","volume":"28","author":"G R Cohen","year":"2021","journal-title":"J Am Med Inform Assoc"},{"issue":"01","key":"ref3","doi-asserted-by":"crossref","first-page":"144","DOI":"10.1093\/jamia\/ocac177","article-title":"Using event logs to observe interactions with electronic health records: an updated scoping review shows increasing use of vendor-derived measures","volume":"30","author":"A Rule","year":"2022","journal-title":"J Am Med Inform Assoc"},{"issue":"05","key":"ref4","doi-asserted-by":"crossref","first-page":"955","DOI":"10.1093\/jamia\/ocaa266","article-title":"Measures of electronic health record use in outpatient settings across vendors","volume":"28","author":"S L Baxter","year":"2021","journal-title":"J Am Med Inform Assoc"},{"issue":"04","key":"ref5","doi-asserted-by":"crossref","first-page":"639","DOI":"10.1093\/jamia\/ocz223","article-title":"Metrics for assessing physician activity using electronic health record log data","volume":"27","author":"C A Sinsky","year":"2020","journal-title":"J Am Med Inform Assoc"},{"issue":"01","key":"ref6","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1108\/14637151011017930","article-title":"The performance impact of business process standardization","volume":"16","author":"B Munstermann","year":"2010","journal-title":"Bus Process Manag"},{"issue":"06","key":"ref7","doi-asserted-by":"crossref","first-page":"621","DOI":"10.1007\/s12599-021-00693-0","article-title":"A typology of business proceess standardization strategies","volume":"63","author":"K Goel","year":"2021","journal-title":"Bus Inf Syst Eng"},{"key":"ref8","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1007\/s40746-015-0026-4","article-title":"Standardizing care processes and improving quality using pathways and continuous quality improvement","volume":"1","author":"J Lavelle","year":"2015","journal-title":"Curr Treat Options Pediatr"},{"issue":"04","key":"ref9","doi-asserted-by":"crossref","first-page":"893","DOI":"10.1016\/j.pcl.2009.05.005","article-title":"Standardize to excellence: improving the quality and safety of care with clinical pathways","volume":"56","author":"P Kurtin","year":"2009","journal-title":"Pediatr Clin North Am"},{"issue":"02","key":"ref10","doi-asserted-by":"crossref","first-page":"434","DOI":"10.3390\/cancers12020434","article-title":"Clinical pathways for oncological gastrectomy: Are they a suitable instrument for process standardization to improve process and outcome quality for patients undergoing gastrectomy? A retrospective cohort study","volume":"12","author":"P T\u00e9oule","year":"2020","journal-title":"Cancers (Basel)"},{"issue":"05","key":"ref11","doi-asserted-by":"crossref","first-page":"1082","DOI":"10.1055\/s-0041-1739519","article-title":"Evaluating electronic health record limitations and time expenditure in a German medical center","volume":"12","author":"T de Hoop","year":"2021","journal-title":"Appl Clin Inform"},{"issue":"05","key":"ref12","doi-asserted-by":"crossref","first-page":"1002","DOI":"10.1055\/s-0041-1736625","article-title":"Characterizing multitasking and workflow fragmentation in electronic health records among emergency department clinicians: Using time-motion data to understand documentation burden","volume":"12","author":"A J Moy","year":"2021","journal-title":"Appl Clin Inform"},{"issue":"05","key":"ref13","doi-asserted-by":"crossref","first-page":"1871","DOI":"10.1111\/j.1475-6773.2006.00689.x","article-title":"Time allocation in primary care office visits","volume":"42","author":"M Tai-Seale","year":"2007","journal-title":"Health Serv Res"},{"issue":"12","key":"ref14","doi-asserted-by":"crossref","first-page":"1903","DOI":"10.1111\/j.1532-5415.2007.01467.x","article-title":"Two-minute mental health care for elderly patients: inside primary care visits","volume":"55","author":"M Tai-Seale","year":"2007","journal-title":"J Am Geriatr Soc"},{"issue":"05","key":"ref15","doi-asserted-by":"crossref","first-page":"704","DOI":"10.1136\/amiajnl-2011-000083","article-title":"Using the time and motion method to study clinical work processes and workflow: methodological inconsistencies and a call for standardized research","volume":"18","author":"K Zheng","year":"2011","journal-title":"J Am Med Inform Assoc"},{"issue":"10","key":"ref16","doi-asserted-by":"crossref","first-page":"E743","DOI":"10.25270\/jic\/22.00065","article-title":"Process standardization in high-risk coronary interventions is associated with quality of care measures","volume":"34","author":"Y Heinen","year":"2022","journal-title":"J Invasive Cardiol"},{"issue":"06","key":"ref17","doi-asserted-by":"crossref","first-page":"962","DOI":"10.1016\/j.bja.2021.07.002","article-title":"Standardised handover process with checklist improves quality and safety of care in the postanaesthesia care unit: the Postanaesthesia Team Handover trial","volume":"127","author":"F Jaulin","year":"2021","journal-title":"Br J Anaesth"},{"issue":"02","key":"ref18","doi-asserted-by":"crossref","first-page":"e20192711","DOI":"10.1542\/peds.2019-2711","article-title":"Implementation of a standardized approach to improve the pediatric discharge medication process","volume":"147","author":"K Philips","year":"2021","journal-title":"Pediatrics"},{"issue":"06","key":"ref19","doi-asserted-by":"crossref","first-page":"469","DOI":"10.1038\/jp.2015.219","article-title":"Prevention of unplanned extubations in neonates through process standardization","volume":"36","author":"T D Font\u00e1nez-Nieves","year":"2016","journal-title":"J Perinatol"},{"issue":"01","key":"ref20","first-page":"5","article-title":"Standardization as a mechanism to improve safety in health care","volume":"30","author":"J D Rozich","year":"2004","journal-title":"Jt Comm J Qual Saf"},{"issue":"05","key":"ref21","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1370\/afm.2121","article-title":"Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time-motion observations","volume":"15","author":"B G Arndt","year":"2017","journal-title":"Ann Fam Med"},{"issue":"03","key":"ref22","doi-asserted-by":"crossref","first-page":"169","DOI":"10.7326\/M18-3684","article-title":"Physician time spent using the electronic health record during outpatient encounters: a descriptive study","volume":"172","author":"J M Overhage","year":"2020","journal-title":"Ann Intern Med"},{"issue":"06","key":"ref23","doi-asserted-by":"crossref","first-page":"e20194017","DOI":"10.1542\/peds.2019-4017","article-title":"Pediatrician electronic health record time use for outpatient encounters","volume":"146","author":"J M Overhage","year":"2020","journal-title":"Pediatrics"},{"issue":"07","key":"ref24","doi-asserted-by":"crossref","first-page":"1383","DOI":"10.1093\/jamia\/ocab011","article-title":"Characterizing physician EHR use with vendor derived data: a feasibility study and cross-sectional analysis","volume":"28","author":"E R Melnick","year":"2021","journal-title":"J Am Med Inform Assoc"},{"issue":"07","key":"ref25","doi-asserted-by":"crossref","first-page":"e2116375","DOI":"10.1001\/jamanetworkopen.2021.16375","article-title":"Differences in clinician electronic health record use across adult and pediatric primary care specialties","volume":"4","author":"L S Rotenstein","year":"2021","journal-title":"JAMA Netw Open"},{"issue":"04","key":"ref26","doi-asserted-by":"crossref","first-page":"655","DOI":"10.1377\/hlthaff.2016.0811","article-title":"Electronic health record logs indicate that physicians split time evenly between seeing patients and desktop medicine","volume":"36","author":"M Tai-Seale","year":"2017","journal-title":"Health Aff (Millwood)"},{"issue":"04","key":"ref27","doi-asserted-by":"crossref","first-page":"644","DOI":"10.1093\/jamia\/ocz222","article-title":"Have you got the time? Challenges using vendor electronic health record metrics of provider efficiency","volume":"27","author":"J D Hron","year":"2020","journal-title":"J Am Med Inform Assoc"},{"issue":"06","key":"ref28","doi-asserted-by":"crossref","first-page":"573","DOI":"10.1370\/afm.1713","article-title":"From triple to quadruple aim: care of the patient requires care of the provider","volume":"12","author":"T Bodenheimer","year":"2014","journal-title":"Ann Fam Med"},{"issue":"04","key":"ref29","first-page":"61","article-title":"National academy of medicine's action collaborative on clinician well-being and resilience: a solution-focused strategy is designed to curtail the burnout epidemic","volume":"14","author":"B Melnyk","year":"2019","journal-title":"Am Nurse Today"},{"issue":"07","key":"ref30","doi-asserted-by":"crossref","first-page":"1073","DOI":"10.1377\/hlthaff.2018.05509","article-title":"Physicians' well-being linked to in-basket messages generated by algorithms in electronic health records","volume":"38","author":"M Tai-Seale","year":"2019","journal-title":"Health Aff (Millwood)"},{"issue":"07","key":"ref31","doi-asserted-by":"crossref","first-page":"673","DOI":"10.1093\/jamia\/ocz021","article-title":"The complex case of EHRs: examining the factors impacting the EHR user experience","volume":"26","author":"M A Tutty","year":"2019","journal-title":"J Am Med Inform Assoc"},{"issue":"02","key":"ref32","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1055\/s-0039-1688753","article-title":"Local investment in training drives electronic health record user satisfaction","volume":"10","author":"C A Longhurst","year":"2019","journal-title":"Appl Clin Inform"},{"issue":"01","key":"ref33","doi-asserted-by":"crossref","first-page":"e14203","DOI":"10.1111\/1475-6773.14203","article-title":"The role of organizations in shaping physician use of electronic health records","volume":"59","author":"D A Cross","year":"2024","journal-title":"Health Serv Res"},{"issue":"01","key":"ref34","first-page":"17","article-title":"Automation of balanced nested design; NeDPy","volume":"10","author":"M Obinna","year":"2020","journal-title":"Int J Stat Appl"},{"issue":"11","key":"ref35","doi-asserted-by":"crossref","first-page":"2355","DOI":"10.1007\/s11606-019-05025-3","article-title":"Variation in physicians' electronic health record documentation and potential patient harm from that variation","volume":"34","author":"G R Cohen","year":"2019","journal-title":"J Gen Intern Med"},{"issue":"01","key":"ref36","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1055\/a-1976-2052","article-title":"Reflections on the documentation burden reduction amia plenary session through the lens of 25\u2009\u00d7\u20095","volume":"14","author":"D R Levy","year":"2023","journal-title":"Appl Clin Inform"},{"issue":"02","key":"ref37","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1055\/s-0042-1746169","article-title":"25\u2009\u00d7\u20095 symposium to reduce documentation burden: report-out and call for action","volume":"13","author":"M Hobensack","year":"2022","journal-title":"Appl Clin Inform"},{"key":"ref38","doi-asserted-by":"crossref","first-page":"384","DOI":"10.1186\/s12913-015-1025-7","article-title":"A comparison of a multistate inpatient EHR database to the HCUP Nationwide Inpatient Sample","volume":"15","author":"J P DeShazo","year":"2015","journal-title":"BMC Health Serv Res"}],"container-title":["Applied Clinical Informatics"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/www.thieme-connect.de\/products\/ejournals\/pdf\/10.1055\/s-0044-1782228.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,11,5]],"date-time":"2024-11-05T10:25:22Z","timestamp":1730802322000},"score":1,"resource":{"primary":{"URL":"http:\/\/www.thieme-connect.de\/DOI\/DOI?10.1055\/s-0044-1782228"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,3]]},"references-count":38,"journal-issue":{"issue":"02","published-online":{"date-parts":[[2024,3,13]]},"published-print":{"date-parts":[[2024,3]]}},"URL":"https:\/\/doi.org\/10.1055\/s-0044-1782228","archive":["Portico","CLOCKSS"],"relation":{},"ISSN":["1869-0327"],"issn-type":[{"value":"1869-0327","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,3]]}}}