• This technical brief identifies 11 measure categories for documentation burden: overall time spent in the electronic health record (EHR), activities related to clinical documentation, inbox management, time spent in clinical review, time spent in orders, work outside work/after hours, administrative tasks (billing and insurance related), fragmentation of workflow or multitasking, measures of efficiency, EHR activity rate, and usability.
• The most common source for measures was EHR usage logs. Direct tracking, such as through time-motion analysis, was fairly uncommon.
• Documentation burden measures have been developed and applied across a diverse range of settings, populations, and uses, with physicians and nurses in the United States (U.S.) being the most frequently represented groups.
• Published information on the validity of documentation burden measures is limited and incomplete, hindering interpretation and implementation.
• Published information on the appropriateness of measures in terms of scalability, feasibility, or equity across various contexts is limited.
• The physician perspective on documentation burden was the most robustly captured in the literature compared with perspectives from other stakeholders including other healthcare professionals, patients, and caregivers, and it focused on increased stress and burnout, satisfaction with EHR, EHR usability, EHR-associated workload, and impact on learners’ education.
• Future research on measuring documentation burden should address the perspectives of various healthcare professional and other stakeholders, explicitly report validity evidence of developed measures, and produce measures that are multidimensional incorporating facets other than measurement of time.

Background. The 2009 enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act and the wide adoption of electronic health record systems (EHR) have ushered an increasing documentation burden, frequently cited as a key factor affecting the work experience of healthcare professionals and a contributor to burnout.

Purpose. This Technical Brief aims to identify: (1) measures of documentation burden, including evaluation of validity evidence, strengths, and weaknesses; (2) different perspectives on the appropriateness of different measures of documentation burden; and (3) perceptions of documentation burden from people in different clinical roles including patients/caregivers. The targeted audiences of this Technical Brief are clinicians, researchers, healthcare system leaders, policymakers, and electronic health record (EHR) vendors.

Methods. We integrated discussions with Key Informants and synthesis of evidence from a comprehensive search of the literature, including Embase®, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, MEDLINE® Daily, MEDLINE®, Cochrane Central Registrar of Controlled Trials, Ovid® Cochrane Database of Systematic Reviews, Scopus®, and select gray literature from January 2010 to December 2023.

Findings. We identified 135 articles about measuring documentation burden. We identified 11 categories of measures for documentation burden: overall time spent in EHR, activities related to clinical documentation, inbox management, time spent in clinical review, time spent in orders, work outside work/after hours, administrative tasks (billing and insurance related), fragmentation of workflow, measures of efficiency, EHR activity rate, and usability. The most common source of data for most measures was EHR usage logs. Direct tracking such as through time–motion analysis was fairly uncommon. We found that measures have been developed and applied across a diverse range of settings, populations, and uses, with physicians and nurses in the United States being the most frequently represented groups. Evidence of validity of these measures was limited and incomplete. Published information on the appropriateness of measures in terms of scalability, feasibility, or equity across various contexts was limited. Physician perspective on documentation burden was the most robustly captured in the literature than other stakeholders and focused on increased stress and burnout due to documentation burden, satisfaction with EHR and its usability, EHR-associated workload, and impact on teaching.

Conclusion. The current literature on documentation burden measures offers a wide range of measures, yet with serious limitations that must be remedied to further inform practical solutions. Greater diversity of settings and perspectives is needed for future development of valid measures. Identifying measurement gaps of documentation burden should serve as the basis for developing interventions and solutions, and benchmarking progression of mitigating documentation burden.

Wang, Z West CP, Vaa Stelling, BE, Hasan B, Simha, S, Saadi, S, Firwana, M, Nayfeh, T, Viola, KE, Prokop, LJ, Murad, MH. Measuring Documentation Burden in Healthcare. Technical Brief No. 47. (Prepared by the Mayo Clinic Evidence-based Practice Center under Contract No. 75Q80120D00005/75Q80123F32005.) AHRQ Publication No. 24-EHC023. Rockville, MD: Agency for Healthcare Research and Quality. May 2024. DOI: https://doi.org/10.23970/AHRQEPCTB47. Posted final reports are located on the Effective Health Care Program search page.