Higher electronic order volume may be associated with increased patient complexity

The analysis also found that 91.2% of patients had a discharge summary completed within 24 hours, but that patients were less likely to receive a timely summary if the treating team had a higher volume of orders the day before discharge.


Electronic order volume may be significantly associated with patient complexity and could therefore represent a potential marker of resident physician workload, a recent study suggested.

Researchers retrospectively assessed admissions to the internal medicine teaching service of an academic medical center during a 13-month period. They tested the association between electronic order volume and patient level of care and severity of illness category. They also used multivariable logistic regression to determine the association between daily team orders and two discharge-related quality metrics (receipt of a high-quality patient after-visit summary and timely discharge summary), adjusting for team census, patient severity of illness, and patient demographics. Results were published online on Aug. 29 by the Journal of Hospital Medicine.

Overall, clinicians entered 929,153 orders for 5,032 inpatient admissions, and the median daily number of orders per team was 343. Mean daily order volume correlated with patient severity of illness, with those in the lowest quartile of Medicare Severity–Diagnosis Related Group weight receiving an average of 98 orders in the first three days of hospitalization, compared to 105 orders in the second quartile, 132 orders in the third quartile, and 149 orders in the fourth and highest quartile (P<0.001 for all comparisons). In addition, mean daily order volume was higher for patients in the ICU than for those in step-down units and general medical wards (40 vs. 24 vs. 19, respectively; P<0.001).

Of 5,032 discharged patients, 3,657 (73%) received a high-quality after-visit summary. After adjustment, there was no significant association between total orders on the day of discharge and the odds of receiving a high-quality after-visit summary.

Among 3,835 patients with data on timing of discharge summary, 3,455 (91.2%) had a discharge summary completed within 24 hours. After adjustment, there was no significant association between total team orders on the day of discharge and odds of receiving a timely discharge summary. However, patients were 12% less likely to receive a timely discharge summary for every 100 additional team orders placed on the day before discharge (odds ratio, 0.88 [95% CI, 0.82 to 0.95]; P=0.002).

The study authors noted limitations, such as the many factors that influence resident workload and the fact that they focused on team orders as opposed to individual work, which may be more directly linked to discharge-related quality metrics.

“Further investigation to determine whether the statistically significant differences identified in this study are clinically significant, how the technique used in this work may be applied to different EHRs, an examination of other EHR-derived metrics that may represent workload, and an exploration of additional patient-centered outcomes may be warranted,” they wrote.