Electronic Order Volume as a Meaningful Component in Estimating Patient Complexity and Resident Physician Workload
Margaret Fang, MD, MPH, Associate Professor of Medicine, Division of Hospital Medicine, the University of California, San Francisco; Telephone: 415-502-7100; Fax: 415-514-2094; E-mail: Margaret.Fang@ucsf.edu
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.