Use of electronic clinical documentation: time spent
and team interactions
George Hripcsak,1,2David K Vawdrey,1,2Matthew R Fred,2Susan B Bostwick3
Objective To measure the time spent authoring and
viewing documentation and to study patterns of usage in
Design Audit logs for an electronic health record were
used to calculate rates, and social network analysis was
applied to ascertain usage patterns. Subjects comprised
all care providers at an urban academic medical center
who authored or viewed electronic documentation.
Measurement Rate and time of authoring and viewing
clinical documentation, and associations among users
Results Users spent 20e103 min per day authoring
notes and 7e56 min per day viewing notes, with
physicians spending less than 90 min per day total.
About 16% of attendings’ notes, 8% of residents’ notes,
and 38% of nurses’ notes went unread by other users,
and, overall, 16% of notes were never read by anyone.
Viewing of notes dropped quickly with the age of the
note, but notes were read at a low but measurable rate,
even after 2 years. Most healthcare teams (77%)
included a nurse, an attending, and a resident, and those
three users’ groups were the first to write notes during
Limitations The limitations were restriction to a single
academic medical center and use of log files without
Conclusions Care providers spend a significant amount
of time viewing and authoring notes. Many notes are
never read, and rates of usage vary significantly by
author and viewer. While the rate of viewing a note
drops quickly with its age, even after 2 years inpatient
notes are still viewed.
The nation is increasingly focused on the adoption
of electronic health records. Clinical documenta-
tiondwhich defines the patientdis the core of the
electronic health record, forming the foundation on
which sit most other functions, including informa-
tion access, interprovider communication, auto-
mated decision support, and registry functions.1
Physicians in hospital settings spend much of
their daily working time on documentation.2 3In
a broad study of the perceptions of medical resi-
dents about the time they spend on documenta-
tion,4two-thirds reported spending over 4 h, which
was more than they reported spending on direct
patient care. Most studies assessing time efficiency
have noted a substantial increase in time spent
documenting when using an electronic health
record compared to paper.5
Compared to paper, electronic provider docu-
mentation allows faster and more complete access
to the patient record, and may improve communi-
cation among members of the healthcare team.6 7
Some evidence exists that electronic documenta-
tion may be associated with improved patient
outcomes and decreased costs.8In contrast to these
benefits, evaluators have also identified unintended
documentation, including changes to workflow,
increased time spent writing notes, and an adverse
effect on documentation quality.5 9 10Furthermore,
residents perceive that they get feedback on their
documentation less than 30% of the time.4
Many electronic health records have detailed
audit logs that permit the monitoring of user
behavior, including authoring and viewing clinical
notes. These logs are often used to infer suspicious
activity with respect to patient privacy,11but they
may also be used to learn about healthcare. For
example, they have been used to infer clinicians’
We believe that audit logs of the authoring and
viewing of documentation can advance the infor-
matics field in three ways. First, by better under-
standing the use of documentation facilities, it may
be possible to improve the electronic health record.
For example, its user interface can be tailored to
make access to frequently used features or data more
efficient. Second, the audit logs can reveal informa-
tion about individual clinician’s behavior. For
example, while there is a body of literature on
creating documentation,13e15few have focused in
detail on the viewing of documentation. Third, the
audit logs can also reveal information about inter-
actions among team members, potentially diag-
nosing and offering solutions to communications
gaps. In this study, we use clinical documentation
audit logs to characterize the generation and use of
clinical documentation, as well as the formation of
clinical teams and the communication within them.
The study was carried out for the inpatient area of
an academic medical center. All clinical notes at the
center are authored and viewed in the Eclipsys XA
(Eclipsys Corporation, Atlanta, Georgia) electronic
health record product. We used detailed usage logs
for the Eclipsys product (Corman Technologies,
Santa Rosa, California), which show user identity,
note type, and time spent viewing the note. Insti-
tutional review board approval was obtained for
We tallied the rates and timing of authoring and
viewing clinical notes among user groups. We
employed social network analysis16to characterize
the relationships among users. Social network anal-
ysis has been used in a wide variety of contexts,
1Department of Biomedical
Informatics, Columbia University
Medical Center, New York, USA
2Department of Information
Services, New YorkePresbyterian
Hospital, New York, USA
3Department of Pediatrics, Weill
Cornell Medical College, New
Dr George Hripcsak, Department
of Biomedical Informatics,
Columbia University Medical
Center, 622 West 168th Street,
VC5, New York, NY 10032,
Received 13 September 2010
Accepted 18 December 2010
Published Online First
2 February 2011
112 J Am Med Inform Assoc 2011;18:112e117. doi:10.1136/jamia.2010.008441
Research and applications
The study has several limitations. The study did not capture
in-person or telephone conversations. Therefore, some of the
uncovered lapses in communication may be met orally. For
example, critical results may be more likely to be communicated
orally and immediately. While this study limitation is important,
the results remain useful, as they represent trends, and the rates
may be compared to each other. Another limitation is that we are
inferring actions and intentions from artifacts like notes and logs
of keystrokes; for example, system idle time while a user carries
out other tasks may be counted as authoring or viewing time. A
full timeemotion study with concrete observation of user
activity coupled with a think-aloud protocol to elicit intentions
would complement this one. Such a study would reveal deep
information about a small number of clinical interactions, while
our present study permits a broad view of activity across many
user types. As noted above, the documentation analysis excluded
nursing flowsheets because of the way they are incorporated into
the application, and this will cause an underestimate of nursing
documentation time and can affect the analysis of communica-
tions. The study was conducted at a single academic medical
center, reflecting the workflow of a single institution; a multi-
center study would improve generalizability.
A detailed log of authoring and viewing clinical notes in an
electronic health record revealed documentation workload, team
structure, and levels of communication among team members.
Communication appeared strong in some cases (eg, supervision
of medical students) but weaker in others (eg, nurse to physician
information transfer), which may point to opportunities for
Funding This project was partially supported by grants from the Agency for
Healthcare Research and Quality (R03 HS018250) and from the National Library of
Medicine (R01 LM006910).
Competing interests None.
Ethics approval Ethics approval was provided by the IRBs of Columbia University
Medical Center and Weill Cornell Medical College.
Provenance and peer review Not commissioned; externally peer reviewed.
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Research and applications