New study shows high levels of EHR documentation burden “crowd out” use of HIE

While electronic health record (EHR) documentation plays a vital role in modern healthcare, it is known to reduce clinician well-being and cause stress and burnout. Yet a new study from UCSF shows it may have worse unintended consequences.

Electronic Health Record Documentation Burden Crowds Out Health Information Exchange Use By Primary Care Physicians,” was published on November 4, 2024, in Health Affairs by A Jay Holmgren, PhD, MHI, assistant professor and associate chief for research in the UCSF Division of Clinical Informatics and Digital Transformation (DoC-IT) and director of the Center for Clinical Informatics and Improvement Research (CLIIR); Julia Adler-Milstein, PhD, chief and professor of UCSF DoC-IT; and Nate Apathy, PhD, from the University of Maryland.

The study found that high levels of EHR activity, including billing and meeting regulatory requirements, limited non-mandatory but high-value EHR-based activity, including detailed chart review, using clinical decision support tools, and use of the health information exchange (HIE). It is the first to assess evidence of the “crowd-out” impact of high levels of documentation.

"This study highlights that the true cost of time dedicated to EHR documentation work is even greater than previously thought. Documentation burden is a real barrier to other EHR-based tasks that improve care and reduce costs, including health information exchange."

A Jay Holmgren, PhD, MHI

Associate Chief for Research and Assistant Professor, UCSF Division of Clinical Informatics and Digital Transformation (DoC-IT)

Director, UCSF Center for Clinical Informatics and Improvement Research (CLIIR)

By examining the effect of increased documentation time, the researchers found that each additional hour spent on documentation led to a 7.1% decrease in the likelihood of primary care physicians accessing outside patient records. These findings underscore the urgent need for policymakers to address and reduce documentation burdens to improve both clinician efficiency and patient care.

"While we have been discussing documentation burden for many years, this paper fundamentally changes the conversation. We now know not just that documentation burden is bad but that it is impeding high-value uses of EHRs. I don’t think any patient would prefer that their doctor spend more time documenting as compared to reviewing their past medical history to be more informed about their care."

Julia Adler-Milstein, PhD

Chief and Professor, UCSF Division of Clinical Informatics and Digital Transformation (DoC-IT)

Read the publication here.

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About the Authors

A Jay Headshot

A Jay Holmgren, PhD, MHI
Associate Chief for Research and Assistant Professor, UCSF Division of Clinical Informatics and Digital Transformation (DoC-IT)
Director, UCSF Center for Clinical Informatics and Improvement Research (CLIIR)

Dr. Holmgren, recently appointed director of CLIIR, is an expert on the use of information technology in health care delivery. His research focuses on the impact of information technology on patients, clinicians, and healthcare organizations and seeks to identify strategies to improve the quality and experience of care using digital tools.

Julia Adler-Milstein Headshot

Julia Adler-Milstein, PhD
Chief and Professor, UCSF DoC-IT

Dr. Adler-Milstein is a leading researcher in health IT policy, with a specific focus on electronic health records and interoperability. She has examined policies and organizational strategies that enable effective use of electronic health records and promote interoperability. She is also an expert in EHR audit log data and its application to studying clinician behavior. Her research – used by researchers, health systems, and policymakers – identifies obstacles to progress and ways to overcome them.

Nate Apathy Headshot

Nate Apathy, PhD
Assistant Professor of Health Policy & Management, University of Maryland School of Public Health

Dr. Apathy’s research sits at the intersection of health policy, health services research, and health informatics. I study the role of health information technology in support of delivery and payment reform efforts, the impact of regulations on health IT innovation, adoption, and use, and specialize in the use of system-generated log data to increase our understanding of health IT's impact on care quality.


About the UCSF Division of Clinical Informatics and Digital Transformation (DoC-IT)
DoC-IT serves as the academic home for applied clinical informatics researchers within the UCSF Department of Medicine. We also serve as a coordinating entity with key internal and external digital stakeholders across all UCSF mission areas, schools, departments, and divisions. Clinical informatics is approached as a multidisciplinary field that involves the use of technology by a broad spectrum of health professionals, patients, and other stakeholders.

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