Temporal Patterns of Electronic Health Record Use by Healthcare Teams: Associations with Patient Outcomes

While variations in electronic health record (EHR) use among healthcare professionals and across sociodemographic patient groups have been studied, the temporal EHR use by healthcare teams remains underexplored. This study aims to develop metrics to quantify temporal EHR use by teams, measure racial variations in these patterns, and assess their associations with patient outcomes using large-scale EHR audit logs. For each patient’s care episode, we used audit logs to construct a sequence of healthcare professionals who were involved in the patient’s care and performed actions in the patient’s EHR. Two professionals are considered neighbors in the sequence if they performed consecutive EHR actions or if their actions overlapped in time. We then identified temporal patterns as k-tuples—subsequences of healthcare professionals of length k extracted from the patient’s sequence. Term Frequency-Inverse Document Frequency (TF-IDF) was used to quantify the importance of each k-tuple within a patient’s sequence, treating each patient sequence as a document and k-tuples as words. Proportional-odds (PO) logistic regression models evaluated racial variations in k-tuples, adjusting for baseline factors including body mass index, type 2 diabetes mellitus, surgery type, age, sex, Charlson Comorbidity Index, hypertension, ischemic heart disease, depression, surgery duration, and surgery time. PO models also assessed associations between k-tuples and postoperative length of stay (PLOS), controlling for these baseline variables. A total of 1,691 patient sequences were analyzed, generating 487, 1,870, and 4,408 unique 3-, 4-, and 5-tuples, respectively. The odds of a longer PLOS increased by 0.7% to 5.5% for each unit increase in the TF-IDF of 12 k-tuples (3 ≤ k ≤ 5), particularly those involving consecutive EHR actions performed by multiple anesthesiologists (false discovery rate [FDR] p < 0.05). Conversely, nine k-tuples (3 ≤ k ≤ 5), particularly those involving consecutive EHR actions performed by resident physicians, anesthesiologists, and physicians, were associated with shorter PLOS, with odds decreasing by 1.3% to 6.1% per unit increase in their TF-IDF (FDR p < 0.05). Variations in the TF-IDF of four k-tuples (3 ≤ k ≤ 5) involving consecutive EHR actions performed by physicians and anesthesiologists, or by resident physicians and nurse anesthetists, were observed between White and Black patients (odds ratios ranging from 1.009 to 1.023, FDR p < 0.05); importantly, these variations were not associated with PLOS. Our findings suggest that specific temporal patterns of EHR use by healthcare teams are associated with patient outcomes. Further research is needed to investigate the reasons behind k-tuples that are positively or negatively associated with PLOS to inform guidelines aimed at improving patient outcomes.