Annals of Internal Medicine
September 6, 2016
Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties
By Christine Sinsky, MD; Lacey Colligan, MD; Ling Li, PhD; Mirela Prgomet, PhD; Sam Reynolds, MBA; Lindsey Goeders, MBA; Johanna Westbrook, PhD; Michael Tutty, PhD; and George Blike, MD
Background: Little is known about how physician time is allocated in ambulatory care.
Objective: To describe how physician time is spent in ambulatory practice.
Design: Quantitative direct observational time and motion study (during office hours) and self-reported diary (after hours).
Setting: U.S. ambulatory care in 4 specialties in 4 states (Illinois, New Hampshire, Virginia, and Washington).
Participants: 57 U.S. physicians in family medicine, internal medicine, cardiology, and orthopedics who were observed for 430 hours, 21 of whom also completed after-hours diaries.
Measurements: Proportions of time spent on 4 activities (direct clinical face time, electronic health record [EHR] and desk work, administrative tasks, and other tasks) and self-reported after-hours work.
Results: During the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on EHR and desk work. The 21 physicians who completed after-hours diaries reported 1 to 2 hours of after-hours work each night, devoted mostly to EHR tasks.
Limitations: Data were gathered in self-selected, high-performing practices and may not be generalizable to other settings. The descriptive study design did not support formal statistical comparisons by physician and practice characteristics.
Conclusion: For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.
Primary Funding Source: American Medical Association.
For more on this study:
Comment by Don McCanne
Although this study was somewhat selective and its generalizability may be limited, nevertheless, it does show that physicians spend a tremendous amount of time on work that does not involve direct clinical face time with patients. This study and other observations suggest that much of this work is related to record documentation.
What should be the purpose of the medical record? Its primary function should be to assist the health care professionals in caring for the patients. It reinforces memory of the clinical status to date, and it provides a source for newly consulted professionals to quickly assess the status of the patient.
What else does the record do? It provides documentation for those who determine what services should be billed for in fee-for-service models of payment (FFS). In capitation models, it provides evidence that contractual requirements were met. It provides data for various quality assessment programs, including P4P (pay for performance). It provides data for evaluation of payment models, including not only Medicare, Medicaid, CHIP, private insurance plans such as PPOs, EPOs, point of service, and health maintenance organizations, but also models such as patient centered medical homes, accountable care organizations, the Medicare shared savings program, merit-based incentive payment systems (MIPS), alternative payment models (APM), and endless others. The record serves as an information source for accreditation surveys. It also requires extra efforts to include information designed to provide defense in medical liability actions. Records also provide a rich research resource for the policy community as the wonks devise ever more ways of trying to convert the traditional patient service model of health care into a business model concerned more about flow of funds rather than optimal patient care. Those in the trenches can add innumerable other extraneous purposes of the medical record that burden them as they attempt to fulfill the requirements of the record, thereby reducing the face time needed for essential patient interactions.
Other studies have confirmed that much of this work is contributing to physician burnout, which has now reached epidemic proportions.
How about returning the record to the exclusive role of being a virtual clinical document that assists the health care team with care of the patient? That information alone would also be adequate to provide a basis for billing, whether FFS or capitation. So much of the other burdensome record keeping contributes to the extraordinary administrative excesses that characterize the U.S. health care system, wasting both money and time. Let's get back to what our health care system is all about - taking care of the patient.