Increasing Efficiency, Persistent Burden: Longitudinal Analysis of EHR Use and After-Hours Work in Emergency Medicine Residency

Objectives: Electronic Health Records (EHRs) impose a significant time burden on physicians, often requiring work to be completed outside of scheduled hours. While this burden is well-documented, how it evolves throughout emergency medicine (EM) residency remains poorly understood. This study aimed to quantify EHR usage patterns, analyze the composition of after-shift work, and characterize the development of EHR efficiency across EM training. Methods: We conducted a retrospective cohort study of EM residents (postgraduate year [PGY] 1-4) using 5.5 years of EHR audit log data (2020-2025) at a single academic institution. We analyzed EHR time per new patient encounter, stratified by postgraduate year, and categorized activities into domains such as documentation, chart review, and orders. EHR work was measured both during and after scheduled shifts. Results: The analysis included 144 unique residents and 167,010 new patient encounters across 15,386 shifts. Encounter-attributed EHR time per encounter decreased by 52% from PGY-1 to PGY-4 (median 19.9 to 9.6 minutes, p<0.001), despite an 86% increase in patient volume per shift (median 7 to 13 encounters). This efficiency gain was driven primarily by a 69% reduction in documentation time (9.3 to 2.9 minutes), accompanied by shorter notes. After-shift work (EHR activity after the 9-hour clinical shift) was present in 89.9-94.4% of encounters. At the shift level, combined after-shift EHR time (encounter-attributed plus tracking board) was a median of 64.2 minutes per shift for PGY-1 and 104.2 minutes for PGY-4. Shift-level tracking board activity dominated the after-shift burden and increased with training (median 40.2 to 79.0 minutes per shift from PGY-1 to PGY-4). Conclusions: EM residents achieve substantial gains in on-shift EHR efficiency, with the largest reductions observed in documentation time, accompanied by shorter notes and faster input speed. However, a persistent after-hours workload, dominated by administrative and patient flow tasks, suggests that (at least at this single institution) system-level factors--not just individual skill--may contribute to this pattern. Monitoring these objective EHR metrics may help programs identify struggling learners and evaluate the impact of interventions aimed at improving resident well-being and workflow efficiency.