Association between state-level malpractice environment and clinician electronic health record (EHR) time.

OBJECTIVE: Clinicians spend significant time working in the electronic health record (EHR). The US is an outlier in EHR time, suggesting that EHR-related work may be driven in part by the legal environment and threat of malpractice. To assess this, we evaluate the association between state-level malpractice climate and clinician time spent in the EHR. MATERIALS AND METHODS: We use EHR metadata from 351 ambulatory care health systems in the United States using Epic from January-August 2019 combined with state-level data on malpractice incidence and payouts. We used descriptive statistics to measure variation in clinician EHR time, including total EHR time, documentation time per day, and after-hours EHR time per day. Multi-variable regression evaluated the association between clinicians in high malpractice states and EHR use. RESULTS: We found no association between location in a state in the top-quartile of malpractice payouts and time spent in the EHR per day, time spent in the EHR outside of scheduled hours, or time spent documenting per day, except for a subgroup of the clinicians in the highest malpractice specialties, where there was a small increase in EHR time per day (B = 6.08 min, P < 0.001) and time spent documenting notes (B = 2.77 min, P < 0.001). DISCUSSION: State-level differences in malpractice incidence are unlikely to be a significant driver of EHR work for most clinicians. CONCLUSION: Policymakers seeking to address EHR documentation burden should examine burden driven by other socio-technical demands on clinician time, such as billing or quality measurement.

Electronic health record-based clinical decision support alert for severe sepsis: a randomised evaluation.

BACKGROUND: Sepsis remains the top cause of morbidity and mortality of hospitalised patients despite concerted efforts. Clinical decision support for sepsis has shown mixed results reflecting heterogeneous populations, methodologies and interventions. OBJECTIVES: To determine whether the addition of a real-time electronic health record (EHR)-based clinical decision support alert improves adherence to treatment guidelines and clinical outcomes in hospitalised patients with suspected severe sepsis. DESIGN: Patient-level randomisation, single blinded. SETTING: Medical and surgical inpatient units of an academic, tertiary care medical centre. PATIENTS: 1123 adults over the age of 18 admitted to inpatient wards (intensive care units (ICU) excluded) at an academic teaching hospital between November 2014 and March 2015. INTERVENTIONS: Patients were randomised to either usual care or the addition of an EHR-generated alert in response to a set of modified severe sepsis criteria that included vital signs, laboratory values and physician orders. MEASUREMENTS AND MAIN RESULTS: There was no significant difference between the intervention and control groups in primary outcome of the percentage of patients with new antibiotic orders at 3 hours after the alert (35% vs 37%, p=0.53). There was no difference in secondary outcomes of in-hospital mortality at 30 days, length of stay greater than 72 hours, rate of transfer to ICU within 48 hours of alert, or proportion of patients receiving at least 30 mL/kg of intravenous fluids. CONCLUSIONS: An EHR-based severe sepsis alert did not result in a statistically significant improvement in several sepsis treatment performance measures.