The Impacts of Electronic Health Record Note Usage by Physicians on Efficiency and Quality of Care: An Analysis Using EHR Audit Logs

Abstract

Electronic health record (EHR) clinical notes constitute a core documentation subsystem through which physicians externalize clinical assessments and care plans in narrative form. Yet clinical documentation is time intensive and is frequently viewed as an administrative burden, leaving limited evidence on whether and how physician note usage improves inpatient operational efficiency and downstream quality outcomes. This study examines the impact of lead physician note activity on discharge efficiency and post discharge outcomes using granular EHR audit logs from a major U.S. teaching hospital. Leveraging more than 6.8 million audit log access events across 30 services, we model discharge as a time to event outcome at an hourly resolution and address endogeneity in documentation intensity using an instrumental variable strategy. We find that increased lead physician note activity predicts faster discharge. Specifically, a 1% increase in lead physician note activity measured 12 h earlier is associated with approximately a 0.075% decrease in expected remaining time to discharge, and the result is directionally consistent under alternative lag specifications. We further test an operational mechanism grounded in knowledge transfer and care team coordination. Higher lead physician note activity is followed by greater near-term nurse information access, operationalized as nurse non-note chart activity within a short response window after physician documentation, and this timely information access is associated with shorter time to discharge in the mediated survival specification. In an additional analysis, we model time to readmission within 30 days using a time to event framework and find that greater lead physician documentation during the index stay is associated with a longer expected time to readmission, providing complementary evidence that documentation practices are linked to downstream outcomes. Collectively, the results advance healthcare operations and information systems research by identifying physician note activity as an operationally consequential form of clinical work and by clarifying a coordination mechanism through timely care team information access in the EHR. This study contributes to healthcare operations management literature and practical implications include optimizing EHR note utilization, implementing tailored training programs, and investing in user-friendly EHR infrastructure to balance efficiency and quality of care improvements and time constraints.