Electronic Order Volume as a Meaningful Component in Estimating Patient Complexity and Resident Physician Workload
BACKGROUND: Though patient census has been used to describe resident physician workload, this fails to account for variations in patient complexity. Changes in clinical orders captured through electronic health records may provide a complementary window into workload. We aimed to determine whether electronic order volume correlated with measures of patient complexity and whether higher order volume was associated with quality metrics. METHODS: In this retrospective study of admissions to the internal medicine teaching service of an academic medical center in a 13-month period, we tested the relationship between electronic order volume and patient level of care and severity of illness category. We used multivariable logistic regression to examine the association between daily team orders and two discharge-related quality metrics (receipt of a high-quality patient after-visit summary (AVS) and timely discharge summary), adjusted for team census, patient severity of illness, and patient demographics.
RESULTS: Our study included 5,032 inpatient admissions for whom 929,153 orders were entered. Mean daily order volume was significantly higher for patients in the intensive care unit than in step-down units and general medical wards (40 vs. 24 vs. 19, P < .001). Order volume was also significantly correlated with severity of illness (P < .001). Patients were 12% less likely to receive a timely discharge summary for every 100 additional team orders placed on the day prior to discharge (OR 0.88; 95% CI 0.82-0.95).
CONCLUSIONS: Electronic order volume is significantly associated with patient complexity and may provide valuable additional information in measuring resident physician workload.
Resident physician workload has traditionally been measured by patient census.1,2 However, census and other volume-based metrics such as daily admissions may not accurately reflect workload due to variation in patient complexity. Relative value units (RVUs) are another commonly used marker of workload, but the validity of this metric relies on accurate coding, usually done by the attending physician, and is less directly related to resident physician workload. Because much of hospital-based medicine is mediated through the electronic health record (EHR), which can capture differences in patient complexity,3 electronic records could be harnessed to more comprehensively describe residents’ work. Current government estimates indicate that several hundred companies offer certified EHRs, thanks in large part to the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, which aimed to promote adoption and meaningful use of health information technology.4, 5 These systems can collect important data about the usage and operating patterns of physicians, which may provide an insight into workload.6-8
Accurately measuring workload is important because of the direct link that has been drawn between physician workload and quality metrics. In a study of attending hospitalists, higher workload, as measured by patient census and RVUs, was associated with longer lengths of stay and higher costs of hospitalization.9 Another study among medical residents found that as daily admissions increased, length of stay, cost, and inpatient mortality appeared to rise.10 Although these studies used only volume-based workload metrics, the implication that high workload may negatively impact patient care hints at a possible trade-off between the two that should inform discussions of physician productivity.
In the current study, we examine whether data obtained from the EHR, particularly electronic order volume, could provide valuable information, in addition to patient volume, about resident physician workload. We first tested the feasibility and validity of using electronic order volume as an important component of clinical workload by examining the relationship between electronic order volume and well-established factors that are likely to increase the workload of residents, including patient level of care and severity of illness. Then, using order volume as a marker for workload, we sought to describe whether higher order volumes were associated with two discharge-related quality metrics, completion of a high-quality after-visit summary and timely discharge summary, postulating that quality metrics may suffer when residents are busier.
METHODS
Study Design and Setting
We performed a single-center retrospective cohort study of patients admitted to the internal medicine service at the University of California, San Francisco (UCSF) Medical Center between May 1, 2015 and July 31, 2016. UCSF is a 600-bed academic medical center, and the inpatient internal medicine teaching service manages an average daily census of 80-90 patients. Medicine teams care for patients on the general acute-care wards, the step-down units (for patients with higher acuity of care), and also patients in the intensive care unit (ICU). ICU patients are comanaged by general medicine teams and intensive care teams; internal medicine teams enter all electronic orders for ICU patients, except for orders for respiratory care or sedating medications. The inpatient internal medicine teaching service comprises eight teams each supervised by an attending physician, a senior resident (in the second or third year of residency training), two interns, and a third- and/or fourth-year medical student. Residents place all clinical orders and complete all clinical documentation through the EHR (Epic Systems, Verona, Wisconsin).11 Typically, the bulk of the orders and documentation, including discharge documentation, is performed by interns; however, the degree of senior resident involvement in these tasks is variable and team-dependent. In addition to the eight resident teams, there are also four attending hospitalist-only internal medicine teams, who manage a service of ~30-40 patients.
