Consistency is key: documentation distribution and efficiency in primary care

Objectives: We analyzed the degree to which daily documentation patterns in primary care varied and whether specific patterns, consistency over time, and deviations from clinicians' usual patterns were associated with note-writing efficiency. Materials and Methods: We used electronic health record (EHR) active use data from the Oracle Cerner Advance platform capturing hourly active documentation time for 498 physicians and advance practice clinicians (eg, nurse practitioners) for 65 152 clinic days. We used k-means clustering to identify distinct daily patterns of active documentation time and analyzed the relationship between these patterns and active documentation time per note. We determined each primary care clinician's (PCC) modal documentation pattern and analyzed how consistency and deviations were related to documentation efficiency. Results: We identified 8 distinct daily documentation patterns; the 3 most common patterns accounted for 80.6% of PCC-days and differed primarily in average volume of documentation time (78.1 minutes per day; 35.4 minutes per day; 144.6 minutes per day); associations with note efficiency were mixed. PCCs with >80% of days attributable to a single pattern demonstrated significantly more efficient documentation than PCCs with lower consistency; for high-consistency PCCs, days that deviated from their usual patterns were associated with less efficient documentation. Discussion: We found substantial variation in efficiency across daily documentation patterns, suggesting that PCC-level factors like EHR facility and consistency may be more important than when documentation occurs. There were substantial efficiency returns to consistency, and deviations from consistent patterns were costly. Conclusion: Organizational leaders aiming to reduce documentation burden should pay specific attention to the ability for PCCs to execute consistent documentation patterns day-to-day.