Physician Note Composition Patterns and Time on the EHR Across Specialty Types: a National, Cross-sectional Study

J Gen Intern Med. 2023 Apr;38(5):1119-1126. doi: 10.1007/s11606-022-07834-5. Epub 2022 Nov 23.


Background: The burden of clinical documentation in electronic health records (EHRs) has been associated with physician burnout. Numerous tools (e.g., note templates and dictation services) exist to ease documentation burden, but little evidence exists regarding how physicians use these tools in combination and the degree to which these strategies correlate with reduced time spent on documentation.

Objective: To characterize EHR note composition strategies, how these strategies differ in time spent on notes and the EHR, and their distribution across specialty types.

Design: Secondary analysis of physician-level measures of note composition and EHR use derived from Epic Systems' Signal data warehouse. We used k-means clustering to identify documentation strategies, and ordinary least squares regression to analyze the relationship between documentation strategies and physician time spent in the EHR, on notes, and outside scheduled hours.

Participants: A total of 215,207 US-based ambulatory physicians using the Epic EHR between September 2020 and May 2021.

Main measures: Percent of note text derived from each of five documentation tools: SmartTools, copy/paste, manual text, NoteWriter, and voice recognition and transcription; average total and after-hours EHR time per visit; average time on notes per visit.

Key results: Six distinct note composition strategies emerged in cluster analyses. The most common strategy was predominant SmartTools use (n=89,718). In adjusted analyses, physicians using primarily transcription and dictation (n=15,928) spent less time on notes than physicians with predominant Smart Tool use. (b=-1.30, 95% CI=-1.62, -0.99, p<0.001; average 4.8 min per visit), while those using mostly copy/paste (n=23,426) spent more time on notes (b=2.38, 95% CI=1.92, 2.84, p<0.001; average 13.1 min per visit).

Conclusions: Physicians' note composition strategies have implications for both time in notes and after-hours EHR use, suggesting that how physicians use EHR-based documentation tools can be a key lever for institutions investing in EHR tools and training to reduce documentation time and alleviate EHR-associated burden.

MeSH terms

  • Cluster Analysis
  • Cross-Sectional Studies
  • Documentation
  • Electronic Health Records
  • Humans
  • Physicians*