Article Figures & Data
Figures
- Figure 1
Screenshot of WorkStudy+ application for the iPad.
Note: For direct observation, we developed 15 electronic health record (EHR) task categories plus several non-EHR task categories (eg, staff interactions, e-mail, paperwork and other administrative work, and personal time). Some of the categories shown have further subcategories that appear once the category is selected.
- Figure 2
Family physicians’ EHR use by time of day.
EHR=electronic health record.
Tables
EHR Task Category Examples Clerical Administrative Accessing patient demographics for telephone number before calling patient Billing and Coding Assigning CPT and ICD-10 codes to encounter diagnosis/diagnoses Documentation Typing into a progress note within any encounter type Order Entry Placing an order for a medication, laboratory test, consultation or referral, durable medical equipment, others System Security Logging in, logging out, secondary login to review psychiatric records Medical care Chart Review-Imaging Reviewing findings of a chest radiograph Chart Review-Laboratories Reviewing cholesterol test results Chart Review-Medications Reviewing medication list Chart Review-Notes Reviewing an encounter note from office visit, urgent care, emergency department EBM, Point of Care Accessing an evidence-based resource available through an EHR link, such as UpToDate Problem List Reviewing or editing the active problem list Inbox Refills and Results Management Refilling medications; interpreting new laboratory and imaging results Letter Generation Developing a letter to patient MyChart Portal Responding to a patient’s question about a medication through asynchronous e-mail–type dialog Telephone Call Addressing an incoming telephone call or generating an outgoing telephone call encounter CPT= Current Procedural Terminology; EBM = evidence-based medicine; EHR = electronic health record; ICD-10 = International Classification of Diseases, 10th Revision.
Characteristic Physicians, No. (%) (N=142) Clinic type Community 76 (53.5) Residency 44 (31.0) Regional 22 (15.5) Sex Female 80 (56.3) Male 62 (43.7) Years of practice ≤9 33 (23.2) 10–19 47 (33.2) 20–29 31 (21.8) ≥30 31 (21.8) Clinical FTEs 0.90–1.00 40 (28.2) 0.75–0.89 22 (15.5) 0.50–0.74 33 (23.2) <0.50 47 (33.1) FTE=full-time equivalent.
- Table 3
Average Time Spent Per Day by EHR Task Category, Comparing Work Hours and After Hours
EHR Task Category Time Spent per Day, min Total Time Spent per Day, min (% of Daily Total) Work Hours After Hours Ratio Clerical Documentation 64 20 3.2 84 (23.7) Order Entry 35 8 4.4 43 (12.1) Billing and Coding 10 4 2.5 14 (3.9) System Security 8 2 4.0 10 (2.8) Administrative 4 2 2.0 6 (1.7) Subtotal 121 36 3.4 157 (44.2) Medical care Chart Review – Notes 47 13 3.6 60 (16.9) Chart Review – Medications 21 5 4.2 26 (7.3) Problem List 8 4 2.0 12 (3.4) Chart Review – Laboratories 6 3 2.0 9 (2.5) EBM, Point of Care 2 2 10 4 (1.1) Chart Review – Imaging 2 1 2.0 3 (0.8) Subtotal 86 28 3.1 114 (32.1) Inbox Refills and Results 41 14 2.9 55 (15.5) Management MyChart Portal 15 5 3.0 20 (5.6) Telephone Call 5 2 2.5 7 (2.0) Letter Generation 1 1 1.0 2 (0.6) Subtotal 62 22 2.8 84 (23.7) Total 269 86 3.1 355 (100.0) EBM=evidence-based medicine; EHR=electronic health record.
The Article in Brief
Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations
Brian G. Arndt , and colleagues
Background US physicians spend numerous hours each day interacting with electronic health record (EHR) systems, which in turn contributes to work life imbalance, dissatisfaction, high rates of attrition, and burnout. This study assessed primary care physician time and usage patterns interacting with the EHR.
What This Study Found Primary care physicians spent more than one-half of their workday interacting with the electronic health record during and after clinic hours. Research based on data from EHR event logs (an automated tracking feature) and confirmed by direct observation data found that physicians spent 355 minutes (5.9 hours) of an 11.4 hour workday in the EHR, including 269 minutes (4.5 hours) during clinic hours and 86 minutes (1.4 hours) after hours. Almost half of their total EHR time per day (44 percent) was devoted to clerical tasks and an additional 84 minutes per day (24 percent) was spent managing the inbox. Time spent on EHR activities differed by time of day on weekdays and weekends, with weekend EHR work peaking around 10:00 am and 10:00 pm. A number of factors contribute to physician burnout and increased workload related to the EHR, the authors explain. This includes the amount of time required for documentation (84 minutes) and order entry (43 minutes), as well as the inefficiency and distraction of communicating with team members through the EHR instead of verbally.
Implications
- The authors contend that solutions for common problems in primary care, such as proactive planned care, team-based care, and sharing of clerical tasks, require thoughtful EHR system applications.
Annals Journal Club
Sep/Oct 2017: Tethered to the EHR: A Physician Workload Assessment
The Annals of Family Medicine encourages readers to develop a learning community to improve health care and health through enhanced primary care. Participate by conducting a RADICAL journal club. RADICAL stands for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. We encourage diverse participants to thinking critically about important issues affecting primary care and act on those discussions.1
HOW IT WORKS
In each issue, the Annals selects an article and provides discussion tips and questions. Take a RADICAL approach to these materials and post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Discussion/ Submit a comment.") Discussion questions and information are online at: http://www.AnnFamMed.org/site/AJC/.
The Annals Twitter Journal Club (#AJC), featuring a discussion of this article, will be held on Wednesday October 4 at 12:00 pm EDT / 16:00 pm GMT.
CURRENT SELECTION
Article for Discussion
Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med 2017;15(5):419-426.
Discussion Tips
With advancements in medicine have come an increased demand for non-face-to-face patient care and administrative tasks for primary care physicians. This study retrospectively assessed how many hours primary care physicians dedicate to their work, with a focus on increased time spent on electronic health records (EHR). The article provides an opportunity to discuss expectations of physicians and the direct effects on physician burnout, professional satisfaction, and direct patient care.
Discussion Questions
- What question is asked by this study and why does it matter?
- How does this study advance beyond previous research on this topic?
- How strong is the study design for answering the question?
- What are the main study findings?
- To what degree can the findings be accounted for by:
- How physicians were selected for the study?
- The type of practice of the physicians in the study?
- How the main variables were measured?
- How the findings were interpreted?
- How comparable is the study sample to physicians in your practice? What is your judgment about the transportability of the findings?
- What contextual factors are important for interpreting the findings?
- How might this study change your practice? Policy? Education? Research? System level intervention?
- Who are the constituencies for the findings, and how might they be engaged in interpreting or using the findings?
- What are the implications for:
- Design of the EHR
- Staffing of family medicine offices (see the article by Gidwani et al in this issue, on the use of scribes)2
- Scheduling patients
- The future of family medicine?
- What researchable questions remain?
References
- Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197 http://annfammed.org/content/4/3/196.full.
- Gidwani R, Nguyen C, Kofoed A, et al. Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial. Ann Fam Med. 2017;15(5):427-433.
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