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Research ArticleOriginal ResearchA

Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations

Brian G. Arndt, John W. Beasley, Michelle D. Watkinson, Jonathan L. Temte, Wen-Jan Tuan, Christine A. Sinsky and Valerie J. Gilchrist
The Annals of Family Medicine September 2017, 15 (5) 419-426; DOI: https://doi.org/10.1370/afm.2121
Brian G. Arndt
1School of Medicine and Public Health, Department of Family Medicine and Community Health, University of Wisconsin, Madison, Wisconsin
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  • For correspondence: brian.arndt@fammed.wisc.edu
John W. Beasley
1School of Medicine and Public Health, Department of Family Medicine and Community Health, University of Wisconsin, Madison, Wisconsin
2University of Wisconsin College of Engineering, Department of Industrial and Systems Engineering, Madison, Wisconsin
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Michelle D. Watkinson
1School of Medicine and Public Health, Department of Family Medicine and Community Health, University of Wisconsin, Madison, Wisconsin
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Jonathan L. Temte
1School of Medicine and Public Health, Department of Family Medicine and Community Health, University of Wisconsin, Madison, Wisconsin
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Wen-Jan Tuan
1School of Medicine and Public Health, Department of Family Medicine and Community Health, University of Wisconsin, Madison, Wisconsin
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Christine A. Sinsky
3American Medical Association, Chicago, Illinois
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Valerie J. Gilchrist
1School of Medicine and Public Health, Department of Family Medicine and Community Health, University of Wisconsin, Madison, Wisconsin
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  • Figure 1
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    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.

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    Figure 2

    Family physicians’ EHR use by time of day.

    EHR=electronic health record.

Tables

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    Table 1

    Classifying User-Event Log Data Into 15 EHR Task Categories

    EHR Task CategoryExamples
    Clerical
     AdministrativeAccessing patient demographics for telephone number before calling patient
     Billing and CodingAssigning CPT and ICD-10 codes to encounter diagnosis/diagnoses
     DocumentationTyping into a progress note within any encounter type
     Order EntryPlacing an order for a medication, laboratory test, consultation or referral, durable medical equipment, others
     System SecurityLogging in, logging out, secondary login to review psychiatric records
    Medical care
     Chart Review-ImagingReviewing findings of a chest radiograph
     Chart Review-LaboratoriesReviewing cholesterol test results
     Chart Review-MedicationsReviewing medication list
     Chart Review-NotesReviewing an encounter note from office visit, urgent care, emergency department
     EBM, Point of CareAccessing an evidence-based resource available through an EHR link, such as UpToDate
     Problem ListReviewing or editing the active problem list
    Inbox
     Refills and Results ManagementRefilling medications; interpreting new laboratory and imaging results
     Letter GenerationDeveloping a letter to patient
     MyChart PortalResponding to a patient’s question about a medication through asynchronous e-mail–type dialog
     Telephone CallAddressing 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.

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    Table 2

    Characteristics of Family Medicine Physicians

    CharacteristicPhysicians, No. (%) (N=142)
    Clinic type
     Community76 (53.5)
     Residency44 (31.0)
     Regional22 (15.5)
    Sex
     Female80 (56.3)
     Male62 (43.7)
    Years of practice
     ≤933 (23.2)
     10–1947 (33.2)
     20–2931 (21.8)
     ≥3031 (21.8)
    Clinical FTEs
     0.90–1.0040 (28.2)
     0.75–0.8922 (15.5)
     0.50–0.7433 (23.2)
     <0.5047 (33.1)
    • FTE=full-time equivalent.

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    Table 3

    Average Time Spent Per Day by EHR Task Category, Comparing Work Hours and After Hours

    EHR Task CategoryTime Spent per Day, minTotal Time Spent per Day, min (% of Daily Total)
    Work HoursAfter HoursRatio
    Clerical
     Documentation64203.284 (23.7)
     Order Entry3584.443 (12.1)
     Billing and Coding1042.514 (3.9)
     System Security824.010 (2.8)
     Administrative422.06 (1.7)
     Subtotal121363.4157 (44.2)
    Medical care
     Chart Review – Notes47133.660 (16.9)
     Chart Review – Medications2154.226 (7.3)
     Problem List842.012 (3.4)
     Chart Review – Laboratories632.09 (2.5)
     EBM, Point of Care22104 (1.1)
     Chart Review – Imaging212.03 (0.8)
     Subtotal86283.1114 (32.1)
    Inbox
     Refills and Results41142.955 (15.5)
     Management
     MyChart Portal1553.020 (5.6)
     Telephone Call522.57 (2.0)
     Letter Generation111.02 (0.6)
     Subtotal62222.884 (23.7)
    Total269863.1355 (100.0)
    • EBM=evidence-based medicine; EHR=electronic health record.

Additional Files

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  • 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

    1. 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.
    2. 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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    Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations
    Brian G. Arndt, John W. Beasley, Michelle D. Watkinson, Jonathan L. Temte, Wen-Jan Tuan, Christine A. Sinsky, Valerie J. Gilchrist
    The Annals of Family Medicine Sep 2017, 15 (5) 419-426; DOI: 10.1370/afm.2121

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    Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations
    Brian G. Arndt, John W. Beasley, Michelle D. Watkinson, Jonathan L. Temte, Wen-Jan Tuan, Christine A. Sinsky, Valerie J. Gilchrist
    The Annals of Family Medicine Sep 2017, 15 (5) 419-426; DOI: 10.1370/afm.2121
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