Gender Differences in Primary Care Physicians’ Electronic Health Record Use over Time: an Observational Study

This retrospective cross-sectional study was approved by the University of Wisconsin’s institutional review board. We collected monthly EHR usage (Epic Systems; Verona, WI), scheduling, panel, and demographic data for all PCPs who practiced at UW Health—a large academic medical center serving over 290,000 medically homed patients—from April 2019 to March 2022. We calculated five measures of monthly EHR use for each physician and normalized each measure per 8 hours of scheduled clinic: total EHR time (EHR8), time in notes (Notes8), time in inbox (Inbox8), time in orders (Orders8), and time outside scheduled clinic hours or “Work Outside of Work” (WOW8). 5


INTRODUCTION
Female physicians spend more time interacting with electronic health records (EHRs) and experience higher rates of burnout than male physicians. [1][2][3] This study sought to assess whether the gender gap in EHR use has changed over time for primary care physicians (PCPs), who use EHRs more than physicians in other specialties. 4

METHODS
This retrospective cross-sectional study was approved by the University of Wisconsin's institutional review board. We collected monthly EHR usage (Epic Systems; Verona, WI), scheduling, panel, and demographic data for all PCPs who practiced at UW Health-a large academic medical center serving over 290,000 medically homed patients-from April 2019 to March 2022. We calculated five measures of monthly EHR use for each physician and normalized each measure per 8 hours of scheduled clinic: total EHR time (EHR 8 ), time in notes (Notes 8 ), time in inbox (Inbox 8 ), time in orders (Orders 8 ), and time outside scheduled clinic hours or "Work Outside of Work" (WOW 8 ). 5 We performed unadjusted comparisons of physician demographics, workload, and EHR use with χ 2 tests for count data and Mann-Whitney U tests for continuous variables. We used multivariable linear regression to perform adjusted comparisons of EHR use by gender. We modeled gender differences in EHR use during the last year of the study (April 2021-March 2022), controlling for physician specialty, duration of employment, panel size, monthly visit volume, normalized visit volume (Visit 8 ), and combined normalized volume of four laborintensive inbox message types: laboratory results management, medication management, telephone calls, and patient portal messages (Msg 8 ). We modeled longitudinal changes in the gender gap by revising the above models to include data from all three study years (April 2019-March 2022), adding a term for the interaction between physician gender and study year, and controlling for year and month to account for potential seasonality. Each model used random effects to account for longitudinal correlation in individual physician's EHR use. Data from March to May 2020 were excluded from analysis due to the transitory changes in EHR use early in the COVID-19 pandemic. 6 Vendor-provided EHR usage data were missing for February and April 2021, so these months were likewise excluded.

RESULTS
One-hundred-and-sixty PCPs were included in this study (

DISCUSSION
This cross-sectional study found female PCPs spend more time interacting with EHRs than male PCPs. The gaps observed in this study are larger than those reported in prior work, 1,2 which may be due to differences in health systems, time periods, or specialties observed. The gender gap in EHR use is growing, particularly for note writing, inbox management, and time outside scheduled clinical hours (WOW). The gap in WOW is particularly concerning given the association between outside-hours EHR use and physician burnout. 7 It is critical that health systems explore root causes behind these differences and develop solutions to address them considering the higher burnout among female physicians. 3 Possible solutions include additional documentation and inbox support, reduced panel size, and/or reduced patient contact time.
This study observed PCPs' ambulatory use of a single EHR at a single academic health center. As an observational study, it could not determine the cause of observed differences, whether they might be attributed to asynchronous work patterns, patient population, or other systemic factors. Future work might examine the gender gap in EHR use in other domains and the impact of targeted interventions to reduce EHR burden for female physicians.