Clinician and visit characteristics
A heterogeneous sample of 26 pediatricians and one pediatric nurse practitioner participated in this study (). Their gender and age distribution was comparable to that of clinicians in the broader network, and 25 of the 27 clinicians worked at study practices prior to the implementation of the EMR (data not shown). Most participants were full-time clinicians working outside of resident teaching practices. Their mean length of use of the EMR was 40 months (range 19–67). Eight of the 27 clinicians reported low self-assessed computer skill.
The average overall visit length, including documentation inside and outside the exam room, lasted 11 min 30 s (range 2:18 to 36:30). Visits with computer time after the visit had a mean length that was 1:12 (11%) longer than those without. Nearly half of visits were for ear, nose, throat, dental, and mouth diseases (47%), a category that includes upper respiratory infections ().
Patient visit characteristics
Patterns of computer use
Of the 9:06 spent in the exam room during an average visit, clinicians spent 2:30 (27%) using the EMR (family with computer time+solo computer time during the patient visit) (). The EMR was used throughout the visit and use occurred at all DOC stages of the visit except the physical exam. Overall, clinicians used the computer in the exam room in 81% of visits. This use spanned 29% of the time spent interacting, chatting, and building rapport, 53% of the time spent history taking, and 36% of the time spent formulating and communicating the diagnosis and treatment plan. Clinicians used the computer in the exam room during interacting, chatting and building rapport, history taking, and while formulating and communicating the diagnosis and treatment plan in 27%, 62%, and 63% of visits, respectively. Of note, the EMR was not used during any single DOC stage at more than 63% of visits.
Computer use in exam room during acute pediatric visits* (N=529)
When clinicians used the EMR, 70% of this time, on average 1:45 out of 2:30, involved simultaneous interaction with the family (family with computer time) (). This pattern was consistent across clinicians and visits. Twenty-five of the 27 clinicians studied used the computer while interacting with families, and 22 of these 25 did so at more than 80% of observed visits. Of the patient visit length, face time, time spent interacting with the family either with or without EMR use, comprised 92% of the total.
Clinicians also frequently used the EMR outside of the exam room (computer time after the visit). Twelve clinicians documented outside the exam room at ≥90% of visits, 12 between 50 and 89% of visits, and only three at fewer than 10% of visits. Further, 77% of observed visits included this style of documentation. Among all study visits, the mean computer time after the visit was 2:24 (range 0 to 21:30) representing, on average, 21% of the overall visit length.
The impact of practice, clinician, and visit characteristics on visit time
Computer time after the visit was the only modifiable visit-level factor significantly associated with the overall visit length. Specifically, adjusting for covariates, out of exam room documentation (computer time after the visit) was associated with visits that were 1:51 longer (95% CI 0:46 to 2:56, p=0.001) than those with documentation limited to the exam room (). Otherwise, the factors significantly associated with the overall visit length were the primary diagnosis and number of diagnoses (all p≤0.003). For example, visits with a primary diagnosis in the ear, nose, throat, dental, and mouth group were at least 2:12 shorter than those in other groups.
Impact of clinician, patient, and visit, characteristics on overall visit length, face time, and family with computer time*
Clinician characteristics were not significantly associated with overall visit length or face time with families. In particular, low self-assessed computer skill was not significantly associated with either overall visit length or face time (p>0.67) and affected the overall visit length and face time by <20 s among the experienced users studied (). Similarly, clinicians who reported that they would like to receive tips to improve efficiency were no different from others in terms of the overall visit length, face time, or family with computer time (all p≥0.64, data not shown). Among other factors studied, there was no impact of age or full- or part time status on the overall visit length.
In contrast to the overall visit length and face time, clinician characteristics were associated with family with computer time, the time spent interacting with families while using the computer. In adjusted models, females spent 1:06 longer interacting with families while using the computer than males (95% CI 0:22 to 1:50, p=0.003) (). In addition, clinicians between 40 and 49 years of age used the computer while interacting more commonly than others. Use of the EMR while conversing with families was also more common at visits with children at least 5 years of age, who could actively participate in discussions. The above associations were all confirmed using Poisson models that accounted for the overall visit length.
Clinician impact on variability in visit length
We found that 20% of the variability in overall visit length and face time was related to physician practice style as defined in the Methods section. In contrast, 40% of the variability in family with computer time was related to physician practice style.