At ONC, we are not advancing data liquidity as an abstract technology project. We are advancing it so that our health system works better for patients, families, and clinicians on the front lines. One challenge encountered by clinicians is administrative burden related to external information retrieval, prior authorization, and after-hours documentation, often referred to as “pajama time.” Many of these burdens arise when needed information is difficult to access, exchange, or use in clinical workflows. In our recently published study, we examined the prevalence and co-occurrence of these burdens among more than 8,400 family physicians. More than three-quarters experienced at least one substantial burden, and 15% experienced all three, or the “triple burden.” New data through 2026 provide some encouraging signs of progress, while also highlighting areas where substantial burden persists.
Administrative Burden is Declining in Some Areas
Between 2024 and 2026, substantial pajama time (defined as three or more hours per day) declined by 6.2 percentage points among family physicians, from 41% to 34%, and substantial burden tracking down external health information declined by five percentage points, from 43% to 38%. However, substantial prior authorization burden moved in the opposite direction, remaining persistently high and increasing from 54% in 2024 to 58% in 2026.
| Measure | 2024 | 2025 | 2026 | Δ (2024-2026) |
|---|---|---|---|---|
| Substantial Pajama Time (3+ hours per day) | 41% | 37%* | 34% |
↓ 6.2 pp |
| Substantial prior authorization burden | 54% | 57%* | 58% |
↑ 3.3 pp |
| Substantial external-information burden | 43% | 40%* | 38%* |
↓ 5.0 pp |
Figure 1: Trends in Administrative Burden Among Family Physicians, 2024–2026
For external health information, the decline in substantial burden from 43% to 38% is encouraging, but more than one-third of family physicians still report substantial burden tracking down information from outside organizations. Continued expansion of nationwide exchange through Trusted Exchange Framework and Common Agreement™ (TEFCA®) and Fast Healthcare Interoperability Resources® (FHIR®-based) exchange provides an opportunity to make needed information more readily available at the point of care.
Prior authorization remains a particularly persistent challenge. Substantial prior authorization burden increased from 54% in 2024 to 58% in 2026. HHS efforts, including ONC’s HTI-4 rule and corresponding CMS policies, are designed to support more streamlined, standards-based electronic prior authorization workflows and reduce the manual processes that contribute to clinician burden.
Pajama time showed the largest improvement of the three measures, declining from 41% to 34%. At the same time, one-third of family physicians still report spending three or more hours per day on after-hours documentation. Continued technology evolution, including emerging opportunities to use artificial intelligence to support documentation and clinical workflows, may offer additional avenues for reducing this burden.
Fewer Family Physicians are Experiencing the “Triple Burden”
The percentage of family physicians experiencing the triple burden declined from 15% in 2024 to 12% in 2025 and remained relatively stable at 12.2% in 2026. If we extrapolate nationally, this 2.8 percentage-point decline is equivalent to approximately 3,000 fewer family physicians experiencing all three substantial burdens in 2026 than in 2024. This could result in those physicians having more time to treat patients, rather than spending so much of their time on administrative work. Even with this improvement, the triple burden remains a challenge, and further progress will require a combination of technical, operational, and workflow improvements.
From Reducing Burden to “Ideal” Interoperability
Another study developed a measurement approach that examined family physicians’ real-world experience with interoperability to create a composite measure of “ideal interoperability”:
- Automatic data receipt occurs often: Clinical information from outside organizations flows into the EHR without manual search or retrieval.
- Data are often easy to find: External data are clearly labeled, logically placed, and intuitively accessible in the EHR interface.
- Data are often easy to use: The information is structured, reconcilable, and able to be incorporated into orders, medication lists, problem lists, and clinical decision-making.
Figure 3. Ideal Interoperability Experience for Medications
One of the more important components physicians identified for ideal interoperability is related to medication information. Unfortunately, despite it being critical for care, only 13% of family physicians experienced ideal interoperability, meaning all three components occurred often and simultaneously. If we broaden the definition to include when these components occur sometimes as well as often, ideal interoperability for medication data would increase more than three-fold, from 13% to 45%.
That broader lens captures partial progress and highlights the importance of moving from a system where interoperability sometimes or occasionally works, to one where it works seamlessly to support clinicians and their patients. Such progress is integral for reducing time spent on paperwork and increasing time caring for patients.
Single Fixes Don’t Move the Needle Much
The largest interoperability gap we identified was data availability, showing a continued need to improve the exchange of patient health information. But availability alone is not enough; successful interoperability depends on usability, standards, and data quality so that information can be easily found, integrated, and used. The study’s policy simulation found that targeting only one dimension of interoperability at a time produced minimal improvement, reinforcing that interoperability, paperwork, and process burdens are connected and must be tackled together.
These findings reinforce why efforts to improve connectivity, streamline administrative workflows, and make information easier for clinicians to use is important to advance in parallel. help us to identify where progress is occurring and where targeted initiatives may help reduce administrative burden and improve interoperability. As ONC and our federal partners continue working to build a more connected, person-centered health care system, understanding and acting upon clinicians’ real-world experiences will remain an important measure of progress.
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