Compared with counterparts outside the United States, clinicians working in the U.S. spend much more time during the workday, and after hours, engaging with electronic health records (EHR), a new study suggests.

Researchers examined data on utilization of EHR software from Epic Systems by clinicians at 348 health systems in the U.S. and 23 health systems in Canada, the Middle East, Northern Europe, Oceania, and Western Europe from January through August 2019. Overall, mean daily time spent using ERH was much higher among U.S. clinicians (90.2 minutes) than among peers in other countries (59.1 minutes).

While the study wasn’t designed to determine the reason for this time discrepancy, it’s likely that a number of differences between health systems in the U.S. and other countries influence how EHR get used and how much time clinicians spend with EHR on a daily basis, said lead study author Jay Holmgren, a health policy researcher at Harvard Business School in Boston.

For example, U.S. clinicians do more electronic prescribing than their counterparts elsewhere, time that gets counted as EHR usage in the U.S. but is done on paper in other countries, Holmgren said by email.

“This, and a perception to guard against litigation or malpractice may contribute to defensive documentation that results in longer notes and more EHR time,” Holmgren said.

U.S. clinicians spent more time adding notes to EHRs (mean time 40.7 minutes) than clinicians in other countries (30.7 minutes), Holmgren and his colleagues report in JAMA Internal Medicine.

Clinicians in the U.S. also spent more time entering orders into EHR (mean time 19.5 minutes) than clinicians elsewhere (8.75 minutes).

And clinicians in the U.S. devoted more time responding to in-basket messages via EHR systems (mean time 12.5 minutes) than clinicians in other countries (4.8 minutes).

Clinical review also took more time in EHR in the U.S. (mean time 17.6 minutes) than outside the U.S. (14.8 minutes).

In the U.S., clinicians spent more time using EHR to record notes (77.5 percent of note text vs 60.8 percent elsewhere) and received more in-box messages per day (33.8 vs 12.8 outside the U.S.).

Finally, U.S. clinicians spent more time using EHR during non-working hours (26.5 minutes) than clinicians elsewhere (19.5 minutes).

One limitation of the study is that it only examined usage of a single EHR system. Of the 23 systems outside the U.S. included in the analysis, half (11) were in Western Europe.

Even so, the results suggest that U.S. health systems may need to identify opportunities for clinicians to spend less time with EHRs and more time engaging directly with patients, said Dr. Christine Sinsky, vice president for professional satisfaction at the American Medical Association in Chicago, who wrote a commentary accompanying the study.

“As physicians our primary responsibility is to care for patients,” Dr. Sinsky said by email. “Technology designers, implementers and regulators, along with health system leaders need to build care environments that allow physicians to quickly develop situational awareness about the patient before the encounter, focus solely on the patient during the encounter, and then work with a well-trained team to safely and efficiently translate the care decisions into action.”