Digital supervision in the clinical learning environment: Characterizing teamwork in the electronic health record.

Background: Attending physicians in academic hospitals work in supervisory team structures with medical residents to provide patient care. How attendings utilize the electronic health record (EHR) to support learning through supervision is not well understood.

Objective: To compare EHR behavior on teaching versus direct care, including evidence of supervisory calibration to learners.

Physician EHR Time and Visit Volume Following Adoption of Team-Based Documentation Support.

Importance: Physicians spend the plurality of active electronic health record (EHR) time on documentation. Excessive documentation limits time spent with patients and is associated with burnout. Organizations need effective strategies to reduce physician documentation burden; however, evidence on team-based documentation (eg, medical scribes) has been limited to small, single-institution studies lacking rigorous estimates of how documentation support changes EHR time and visit volume.

Access to preferred skilled nursing facilities: Transitional care pathways for patients with Alzheimer's disease and related dementias.

Objective: The study aimed to assess whether individuals with Alzheimer's disease and related dementias (ADRD) experience restricted access to hospitals' high-volume preferred skilled nursing facility (SNF) partners.

Data Sources: The data source includes acute care hospital to SNF transitions identified using 100% Medicare Provider Analysis and Review files, 2017-2019.

Study Design: We model and compare the estimated effect of facility "preferredness" on SNF choice for patients with and without ADRD.

The role of organizations in shaping physician use of electronic health records.

Objective: The aim of the study was to (1) characterize organizational differences in primary care physicians' electronic health record (EHR) behavior; (2) assess within-organization consistency in EHR behaviors; and (3) identify whether organizational consistency is associated with physician-level efficiency.

Data Sources: EHR metadata capturing averaged weekly measures of EHR time and documentation composition from 75,124 US primary care physicians across 299 organizations between September 2020 and May 2021 were taken. EHR time measures include active time in orders, chart review, notes, messaging, time spent outside of scheduled hours, and total EHR time.

Association of Primary Care Visit Length With Potentially Inappropriate Prescribing.

Importance: Time is a valuable resource in primary care, and physicians and patients consistently raise concerns about inadequate time during visits. However, there is little evidence on whether shorter visits translate into lower-quality care.

Objective: To investigate variations in primary care visit length and quantify the association between visit length and potentially inappropriate prescribing decisions by primary care physicians.

Perceptions of information continuity key to understanding quality of post-acute care transitions.

Background: Skilled nursing facilities' (SNFs) ability to provide optimal post-acute care depends on effective receipt of information from hospitals ("information continuity"). Little is known about how SNFs perceive information continuity and how it may relate to upstream information sharing processes, organizational context, and downstream outcomes.

Purpose: First, this study aims to identify how SNF perceptions of information continuity may be shaped by hospital information sharing practices, including measures of completeness, timeliness, and usability, as well as characteristics of the transitional care environment (i.

Information sharing to support care transitions for patients with complex mental health and social needs.

Background: Patients with complex behavioral and mental health conditions require significant transitional care coordination. It is unclear how skilled nursing facilities (SNFs) that serve these patients engage in care transfer with hospitals, specifically whether they experience discrepancies in the type of information shared by hospital partners and/or use different approaches to secure needed information.

Methods: Cross-sectional analysis of a national 2019-2020 SNF survey that collected information on transitional care practices with referring hospitals; respondents were directors of nursing services.

Management Opportunities and Challenges After Achieving Widespread Health System Digitization.

The adoption of electronic health records (EHRs) and digitization of health data over the past decade is ushering in the next generation of digital health tools that leverage artificial intelligence (AI) to improve varied aspects of health system performance. The decade ahead is therefore shaping up to be one in which digital health becomes even more at the forefront of health care delivery - demanding the time, attention, and resources of health care leaders and frontline staff, and becoming inextricably linked with all dimensions of health care delivery. In this chapter, we look back and look ahead.

I had not time to make it shorter: an exploratory analysis of how physicians reduce note length and time in notes.

Objective: We analyze observed reductions in physician note length and documentation time, 2 contributors to electronic health record (EHR) burden and burnout.

Materials And Methods: We used EHR metadata from January to May, 2021 for 130 079 ambulatory physician Epic users. We identified cohorts of physicians who decreased note length and/or documentation time and analyzed changes in their note composition.

Progress Toward Digital Transformation in an Evolving Post-Acute Landscape.

Digitization has been a central pillar of structural investments to promote organizational capacity for transformation, and yet skilled nursing facilities (SNFs) and other post-acute providers have been excluded and/or delayed in benefitting from the past decade of substantial public and private-sector investment in information technology (IT). These settings have limited internal capacity and resources to invest in digital capabilities on their own, propagating a limited infrastructure that may only further sideline SNFs and their role in an ever-evolving health care landscape that needs to be focused on age-friendly, high-value care. Meaningful progress will require continuous refinement of supportive policy, financial investment, and scalable organizational best practices specific to the SNF context.

Early Changes in Billing and Notes After Evaluation and Management Guideline Change.

Background: The American Medical Association updated guidance in 2021 for frequently used billing codes for outpatient evaluation and management (E/M) visits. The intent was to account for provider time outside of face-to-face encounters and to reduce onerous documentation requirements.

Objective: To analyze E/M visit use, documentation length, and time spent in the electronic health record (EHR) before and after the guideline change.

The Health Information Technology special issue: continuing the progress toward digital transformation.

A letter from the guest editor highlights the significant work that remains for provider organizations to integrate digital advancement as a key strategy in addressing some of the most pressing challenges that are transforming the health care landscape.

Survey of Information Exchange and Advanced Use of Other Health Information Technology in Primary Care Settings: Capabilities In and Outside of the Safety Net.

Background: Advanced use of health information technology (IT) functionalities can support more comprehensive, coordinated, and patient-centered primary care services. Safety net practices may benefit disproportionately from these investments, but it is unclear whether IT use in these settings has kept pace and what organizational factors are associated with varying use of these features.

Objective: The aim was to estimate advanced use of health IT use in safety net versus nonsafety net primary care practices.

Electronic Health Records as Biased Tools or Tools Against Bias: A Conceptual Model.

Unlabelled: Policy Points Electronic health records (EHRs) are subject to the implicit bias of their designers, which risks perpetuating and amplifying that bias over time and across users. If left unchecked, the bias in the design of EHRs and the subsequent bias in EHR information will lead to disparities in clinical, organizational, and policy outcomes. Electronic health records can instead be designed to challenge the implicit bias of their users, but that is unlikely to happen unless incentivized through innovative policy.

Patient Portal Use, Perceptions of Electronic Health Record Value, and Self-Rated Primary Care Quality Among Older Adults: Cross-sectional Survey.

Background: Older adults are increasingly accessing information and communicating using patient-facing portals available through their providers' electronic health record (EHR). Most theories of technology acceptance and use suggest that patients' overall satisfaction with care should be independent of their chosen level of portal engagement. However, achieving expected benefits of portal use depends on demonstrated support from providers to meet these expectations.

Information Sharing Practices Between US Hospitals and Skilled Nursing Facilities to Support Care Transitions.

Importance: Patient transitions from hospitals to skilled nursing facilities (SNFs) require robust information sharing. After a decade of investment in health information technology infrastructure and new incentives to promote hospital-SNF coordination in the US, the current state of information sharing at this critical transition is unknown.

Objective: To measure the completeness, timeliness, and usability of information shared by hospitals when discharging patients to SNFs, and to identify relational and structural characteristics associated with better hospital-SNF information sharing.

Measuring Primary Care Exam Length Using Electronic Health Record Data.

Background: Physicians' time with patients is a critical input to care, but is typically measured retrospectively through survey instruments. Data collected through the use of electronic health records (EHRs) offer an alternative way to measure visit length.

Objective: To measure how much time primary care physicians spend with their patients, during each visit.

Measures of electronic health record use in outpatient settings across vendors.

Electronic health record (EHR) log data capture clinical workflows and are a rich source of information to understand variation in practice patterns. Variation in how EHRs are used to document and support care delivery is associated with clinical and operational outcomes, including measures of provider well-being and burnout. Standardized measures that describe EHR use would facilitate generalizability and cross-institution, cross-vendor research.

Health information exchange between hospital and skilled nursing facilities not associated with lower readmissions.

Objective: To assess whether an electronic health record (EHR) portal to enable health information exchange (HIE) between a hospital and three skilled nursing facilities (SNFs) reduced likelihood of patient readmission.

Setting/data: Secondary data; all discharges from a large academic medical center to SNFs between July 2013 and March 2017, combined with portal usage records from SNFs with HIE access.

Design: We use difference-in-differences to determine whether portal implementation reduced likelihood of readmission over time for patients discharged to HIE-enabled SNFs, relative to those discharged to nonenabled facilities.

Drivers of health information exchange use during postacute care transitions.

Objectives: To characterize the drivers of the use of electronic health information exchange (HIE) by skilled nursing facilities (SNFs) to access patient hospital data during care transitions.

Study Design: Explanatory, sequential mixed-methods study. Quantitative data from an audit log captured HIE use by 3 SNFs to retrieve hospitalization information for the 5487 patients discharged to their care between June 2014 and March 2017, along with patient demographic data.

Mind the gap: the potential of alternative health information exchange.

Objectives: To determine the proportion of patient transitions that could be connected through 3 proprietary alternatives to open, community-based health information exchange (HIE): HIE between physicians who are part of the same integrated system, use the same electronic health record (EHR), or use an EHR that participates in an EHR vendor alliance.

Study Design: Cross-sectional analysis of Medicare patient transitions and physician EHR adoption and organizational affiliation from SK&A.

Methods: We characterized the percentage of transitions that could be covered by each HIE approach and the degree of redundancy.