Social Determinants of Health and After-Hours Electronic Health Record Documentation: A National Survey of US Physicians

Introduction

Capturing patient social determinants of health (SDoH)—social and environmental conditions that influence health and quality of life—is a necessary first step to improving individual and population health. ¹ Widespread adoption of electronic health record (EHR) systems enables health care systems to integrate patients' medical and SDoH information for better clinical decision-making. ² However, clinical practice time constraints combined with EHR documentation burden often require clinicians to work after hours, leading to professional dissatisfaction and burnout. ³ As a result, there are concerns that integrating SDoH into the EHR may increase documentation burden and clinical workload (eg, require additional patient follow-up). ^4,5 Research is needed to better understand how many physicians document SDoH information in the EHR and the incremental time burden from SDoH documentation and resulting follow-up. Such information could inform efforts to improve SDoH documentation rates while considering the overall EHR documentation burden and potential impacts on clinician burnout. ⁵ To address this gap, this study examines the association of SDoH documentation and time spent after hours on EHR documentation among a nationally representative sample of US office-based physicians.

Methods

This study was a pooled cross-sectional analysis of 2018–2019 National Electronic Health Records Survey (NEHRS) data. NEHRS data are a national representation of US office-based physicians with information on EHR utilization, health information exchange participation, medical record documentation, and self-reported physician burden associated with EHR use and documentation (38.6% overall response rate). ⁶ The 2018–2019 NEHRS included 1917 office-based physicians. Physicians who reported having no EHR system were excluded (n = 384) from the analysis. NEHRS measures EHR adoption and capabilities and the burden associated with EHR use. This study defined SDoH documentation as “yes” if physicians reported using an EHR to record patients' SDoH (including employment status, education level, other health-related social needs) at their primary practice location. The survey also asks how many hours per day the physician spends on after-hours EHR documentation (ranging from none to ˃4 hours). After-hours EHR work was defined as “yes” if physicians reported after-hours work on the medical record system to document patient care. More details about the survey sampling and methodology are available at https://www.cdc.gov/nchs/nehrs/about.htm. ⁶

A survey design-adjusted bivariate analysis compared physician and practice characteristics by SDoH documentation and after-hours EHR documentation. A modified Poisson model estimated prevalence ratios (PRs) while adjusting for physician age, sex, specialty, practice size, number of mid-level providers (eg, nurse practitioners, physician assistants), practice ownership, program participation (Accountable Care Organization [ACO], Patient-Centered Medical Home, EHR incentive programs, other pay-for-performance programs), and presence of staff support for EHR documentation (eg, scribe). A P value <0.05 and non-overlapping 95% confidence interval (CI) were considered statistically significant. All analyses were performed using SAS 9.4 (SAS Institute Inc., Cary, NC) in June 2021. This study uses publicly available data and was deemed exempt from review by the University of Florida Institutional Review Board.

Results

Of 1533 physicians practicing in the United States (31.5%, female; 72.5%, aged ≥50+ years; 48.8% primary care), 84.3% used a computerized system to record patients' SDoH information. Physicians documenting SDoH were younger (<50 years), worked in larger practices, and participated in ACO and EHR incentive programs (Table 1). After adjustment, the proportion of SDoH documentation was 10% lower for physicians aged 50+ old (adjusted PR [aPR], 0.90; 95% CI, 0.83–0.97). No significant difference was observed across other characteristics.

Prevalence estimates of after-hours EHR documentation were comparable between physicians who recorded patient SDoH and those who did not (33.7% vs. 33.0%), and this difference did not reach statistical significance in adjusted analysis (aPR, 0.94, 95% CI, 0.64–1.39) (Table 2). Physicians in practices participating in P4P arrangements had a 43% higher proportion of reporting after-hours work in EHR documentation (aPR, 1.43; 95% CI, 1.04–1.96), independent of SDoH documentation.

Discussion

Using a nationally representative US office-based physician survey, this study found that 84% of physicians reported that their practices recorded patients' SDoH information in 2018–2019. Recording patients' SDoH was commonplace and occurred across a wide variety of practices (eg, no differences based on size, ownership). There was no significant association between recording SDoH and after-hours EHR documentation, suggesting that there may be a systematic workload issue that requires 33% of physicians to spend time documenting patient care after hours. Thus, documentation of SDoH characteristics in an EHR may not contribute further to the documentation burden; however, implementing meaningful SDoH documentation would require practices changes, standardization, additional resources, and EHR capability. ^2,7 For example, prior studies have noted implementation barriers, such as inconsistent SDoH screening practices across physicians, including selection bias in patients chosen to be screened for social and economic risks. ⁷ These findings support the need for standardized processes (eg, guidelines) during clinical encounters and suggest that potential practice changes may be required to implement patient SDoH screening effectively. ^2,7 Improving practice capacity to address patient social needs or partnering with community-based programs also may be an effective strategy for reducing physician documentation burden. ^8,9 Recent studies suggested that primary care physicians in practices sufficiently resourced to address patient social needs (eg, having a social worker on the care team), including socioeconomic hardship, low literacy, and poor housing, have lower burnout rates (34% less likely) than physicians in practices without such resources. ^8,9

The current study only assessed whether physicians and their practices document patients' SDoH; thus, future research is required to evaluate resource needs and challenges for standardized implementation. Similarly, this study did not investigate the quality of SDoH documentation and interoperability between systems. The International Classification of Diseases, Tenth Revision (ICD-10) adoption for SDoH documentation (Z codes) may be an effective strategy to improve documentation and reduce EHR-associated burden, and facilitate interoperability for tailored patient care based on their SDoH information (eg, food prescription; housing assistance). ^10,11 However, a recent study of multiple health care systems found that the ICD-10 Z codes utilization is still suboptimal (<3% of patients recorded). ¹² Interestingly, the current study findings also showed that receiving staff support (eg, scribe) was not associated with reducing the EHR documentation burden. This finding raises questions regarding the impact of medical scribes on improving documentation and reducing burnout for physicians and other health care professionals (eg, nurses) who also report high levels of EHR-related burnout. ¹³

Conclusions

In summary, study findings show that documenting patients' SDoH is common among US office-based physicians and this activity is not associated with after-hours EHR documentation. However, further research is needed to understand the implementation of patients' SDoH documentation and the impact of SDoH documentation (and presumed follow-up) on patient and population-level outcomes.