Original Research
6 September 2016

Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties

Publication: Annals of Internal Medicine
Volume 165, Number 11

Abstract

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.

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Supplemental Material

Supplement. Supplemental Information

References

1.
Jamoom EPatel VKing JFurukawa MF. Physician experience with electronic health record systems that meet meaningful use criteria: NAMCS Physician Workflow Survey, 2011. NCHS Data Brief. 2013:1-8. [PMID: 24152607]
2.
Casalino LPGans DWeber RCea MTuchovsky ABishop TFet al. US physician practices spend more than $15.4 billion annually to report quality measures. Health Aff (Millwood). 2016;35:401-6. [PMID: 26953292]  doi: 10.1377/hlthaff.2015.1258
3.
Ratanawongsa NBarton JLLyles CRWu MYelin EHMartinez Det al. Association between clinician computer use and communication with patients in safety-net clinics. JAMA Intern Med. 2016;176:125-8. [PMID: 26619393]  doi: 10.1001/jamainternmed.2015.6186
4.
Friedberg MChen PGVan Busum KRAunon FPham CCaloyeras Jet al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems and Health Policy. Santa Monica, CA: RAND; 2013.
5.
Shanafelt TDHasan ODyrbye LNSinsky CSatele DSloan Jet al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600-13. [PMID: 26653297]  doi: 10.1016/j.mayocp.2015.08.023
6.
Shanafelt TDBoone STan LDyrbye LNSotile WSatele Det al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377-85. [PMID: 22911330]
7.
Babbott SManwell LBBrown RMontague EWilliams ESchwartz Met al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014;21:e100-6. [PMID: 24005796]  doi: 10.1136/amiajnl-2013-001875
8.
Shanafelt TDDyrbye LNSinsky CHasan OSatele DSloan Jet al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836-48. [PMID: 27313121]  doi: 10.1016/j.mayocp.2016.05.007
9.
Gottschalk AFlocke SA. Time spent in face-to-face patient care and work outside the examination room. Ann Fam Med. 2005;3:488-93. [PMID: 16338911]
10.
Gilchrist VMcCord GSchrop SLKing BDMcCormick KFOprandi AMet al. Physician activities during time out of the examination room. Ann Fam Med. 2005;3:494-9. [PMID: 16338912]
11.
Farber JSiu ABloom P. How much time do physicians spend providing care outside of office visits? Ann Intern Med. 2007;147:693-8. [PMID: 18025445].  doi: 10.7326/0003-4819-147-10-200711200-00005
12.
Baron RJ. What's keeping us so busy in primary care? A snapshot from one practice. N Engl J Med. 2010;362:1632-6. [PMID: 20427812]  doi: 10.1056/NEJMon0910793
13.
Doerr EGalpin KJones-Taylor CAnander SDemosthenes CPlatt Set al. Between-visit workload in primary care. J Gen Intern Med. 2010;25:1289-92. [PMID: 20700665]  doi: 10.1007/s11606-010-1470-2
14.
Chen MAHollenberg JPMichelen WPeterson JCCasalino LP. Patient care outside of office visits: a primary care physician time study. J Gen Intern Med. 2011;26:58-63. [PMID: 20811956]  doi: 10.1007/s11606-010-1494-7
15.
Westbrook JIAmpt A. Design, application and testing of the Work Observation Method by Activity Timing (WOMBAT) to measure clinicians' patterns of work and communication. Int J Med Inform. 2009;78 Suppl 1:S25-33. [PMID: 18951838]  doi: 10.1016/j.ijmedinf.2008.09.003
16.
Li LHains IHordern TMilliss DRaper RWestbrook J. What do ICU doctors do? A multisite time and motion study of the clinical work patterns of registrars. Crit Care Resusc. 2015;17:159-66. [PMID: 26282253]
17.
Ballermann MAShaw NTMayes DCGibney RTWestbrook JI. Validation of the Work Observation Method By Activity Timing (WOMBAT) method of conducting time-motion observations in critical care settings: an observational study. BMC Med Inform Decis Mak. 2011;11:32. [PMID: 21586166]  doi: 10.1186/1472-6947-11-32
18.
Walter SRLi LDunsmuir WTWestbrook JI. Managing competing demands through task-switching and multitasking: a multi-setting observational study of 200 clinicians over 1000 hours. BMJ Qual Saf. 2014;23:231-41. [PMID: 24135815]  doi: 10.1136/bmjqs-2013-002097
19.
Arabadzhiyska PNBaysari MTWalter SDay ROWestbrook JI. Shedding light on junior doctors' work practices after hours. Intern Med J. 2013;43:1321-6. [PMID: 23800071]  doi: 10.1111/imj.12223
20.
Westbrook JI. Work Observation Method by Activity Timing (WOMBAT): A Guide to the Installation and Use of WOMBAT V2.0. Sydney, Australia: Macquarie University; 2014.
21.
Westbrook JIAmpt AKearney LRob MI. All in a day's work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Med J Aust. 2008;188:506-9. [PMID: 18459920]
22.
Westbrook JIDuffield CLi LCreswick NJ. How much time do nurses have for patients? A longitudinal study quantifying hospital nurses' patterns of task time distribution and interactions with health professionals. BMC Health Serv Res. 2011;11:319. [PMID: 22111656]  doi: 10.1186/1472-6963-11-319
23.
Westbrook JICoiera EDunsmuir WTBrown BMKelk NPaoloni Ret al. The impact of interruptions on clinical task completion. Qual Saf Health Care. 2010;19:284-9. [PMID: 20463369]  doi: 10.1136/qshc.2009.039255
24.
Westbrook JILi LGeorgiou APaoloni RCullen J. Impact of an electronic medication management system on hospital doctors' and nurses' work: a controlled pre-post, time and motion study. J Am Med Inform Assoc. 2013;20:1150-8. [PMID: 23715803]  doi: 10.1136/amiajnl-2012-001414
25.
Landis JRKoch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159-74. [PMID: 843571]
26.
McGinn TWyer PCNewman TBKeitz SLeipzig RFor GGEvidence-Based Medicine Teaching Tips Working Group. Tips for learners of evidence-based medicine: 3. Measures of observer variability (kappa statistic). CMAJ. 2004;171:1369-73. [PMID: 15557592]
27.
Black ADCar JPagliari CAnandan CCresswell KBokun Tet al. The impact of eHealth on the quality and safety of health care: a systematic overview. PLoS Med. 2011;8:e1000387. [PMID: 21267058]  doi: 10.1371/journal.pmed.1000387
28.
Romano MJStafford RS. Electronic health records and clinical decision support systems: impact on national ambulatory care quality. Arch Intern Med. 2011;171:897-903. [PMID: 21263077]  doi: 10.1001/archinternmed.2010.527
29.
Himmelstein DUWright AWoolhandler S. Hospital computing and the costs and quality of care: a national study. Am J Med. 2010;123:40-6. [PMID: 19939343]  doi: 10.1016/j.amjmed.2009.09.004
30.
McDonald CJCallaghan FMWeissman AGoodwin RMMundkur MKuhn T. Use of internist's free time by ambulatory care electronic medical record systems. JAMA Intern Med. 2014;174:1860-3. [PMID: 25200944]  doi: 10.1001/jamainternmed.2014.4506
31.
Arndt B, Beasley J, Temte J, Tuan W, Gilchrist V. Work after work: evidence from PCP utilization of an EHR system [Abstract]. Presented at North American Primary Care Research Group Annual Meeting 2015, Cancun, Mexico, 24–28 October 2015.
32.
Fiks AGAlessandrini EAForrest CBKhan SLocalio ARGerber A. Electronic medical record use in pediatric primary care. J Am Med Inform Assoc. 2011;18:38-44. [PMID: 21134975]  doi: 10.1136/jamia.2010.004135
33.
Montague EAsan O. Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor-patient communication and attention. Int J Med Inform. 2014;83:225-34. [PMID: 24380671]  doi: 10.1016/j.ijmedinf.2013.11.003
34.
Devine EBHollingworth WHansen RNLawless NMWilson-Norton JLMartin DPet al. Electronic prescribing at the point of care: a time-motion study in the primary care setting. Health Serv Res. 2010;45:152-71. [PMID: 19929963]  doi: 10.1111/j.1475-6773.2009.01063.x
35.
Howard KA, Hele K, Salabi N, Wilcox S, Cohen M. Adapting the EHR scribe model in community health clinic: the experience of Shasta Community Health Center's pilot. BTW Informing Change; Blue Shield California Foundation. 2012.
36.
Murphy DRReis BSittig DFSingh H. Notifications received by primary care practitioners in electronic health records: a taxonomy and time analysis. Am J Med. 2012;125:209. [PMID: 22269625]  doi: 10.1016/j.amjmed.2011.07.029
37.
Reuben DBKnudsen JSenelick WGlazier EKoretz BK. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174:1190-3. [PMID: 24819399]  doi: 10.1001/jamainternmed.2014.1315
38.
Bank AJObetz CKonrardy AKhan APillai KMMcKinley BJet al. Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: a prospective study. Clinicoecon Outcomes Res. 2013;5:399-406. [PMID: 23966799]  doi: 10.2147/CEOR.S49010
39.
Arya RSalovich DMOhman-Strickland PMerlin MA. Impact of scribes on performance indicators in the emergency department. Acad Emerg Med. 2010;17:490-4. [PMID: 20536801]  doi: 10.1111/j.1553-2712.2010.00718.x
40.
Misra-Hebert ADRabovsky AYan CHu BRothberg MB. A team-based model of primary care delivery and physician-patient interaction. Am J Med. 2015;128:1025-8. [PMID: 25912207]  doi: 10.1016/j.amjmed.2015.03.035
41.
Koshy SFeustel PJHong MKogan BA. Scribes in an ambulatory urology practice: patient and physician satisfaction. J Urol. 2010;184:258-62. [PMID: 20483153]  doi: 10.1016/j.juro.2010.03.040
42.
Ghorob ABodenheimer T. Share the Care™: building teams in primary care practices. J Am Board Fam Med. 2012;25:143-5. [PMID: 22403193]  doi: 10.3122/jabfm.2012.02.120007
43.
Grumbach KBodenheimer T. Can health care teams improve primary care practice? JAMA. 2004;291:1246-51. [PMID: 15010447]
44.
Willard-Grace RHessler DRogers EDubé KBodenheimer TGrumbach K. Team structure and culture are associated with lower burnout in primary care. J Am Board Fam Med. 2014;27:229-38. [PMID: 24610185]  doi: 10.3122/jabfm.2014.02.130215
45.
Sinsky CASinsky TAAlthaus DTranel JThiltgen M. Practice profile. ‘Core teams': nurse-physician partnerships provide patient-centered care at an Iowa practice. Health Aff (Millwood). 2010;29:966-8. [PMID: 20439890]  doi: 10.1377/hlthaff.2010.0356
46.
Sinsky CAWillard-Grace RSchutzbank AMSinsky TAMargolius DBodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11:272-8. [PMID: 23690328]  doi: 10.1370/afm.1531
47.
Hopkins KSinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21:23-9. [PMID: 25403048]
48.
Colligan LPotts HWFinn CTSinkin RA. Cognitive workload changes for nurses transitioning from a legacy system with paper documentation to a commercial electronic health record. Int J Med Inform. 2015;84:469-76. [PMID: 25868807]  doi: 10.1016/j.ijmedinf.2015.03.003
49.
Ratwani RMFairbanks RJHettinger AZBenda NC. Electronic health record usability: analysis of the user-centered design processes of eleven electronic health record vendors. J Am Med Inform Assoc. 2015;22:1179-82. [PMID: 26049532]  doi: 10.1093/jamia/ocv050
50.
Holman GTBeasley JWKarsh BTStone JASmith PDWetterneck TB. The myth of standardized workflow in primary care. J Am Med Inform Assoc. 2016;23:29-37. [PMID: 26335987]  doi: 10.1093/jamia/ocv107
51.
Zheng KCiemins ELanham HLindberg C. Examining the Relationship between Health IT and Ambulatory Care Workflow Redesign. AHRQ publication no. 15-0058-EF. (Prepared by Billings Clinic under contract no. 290-2010-0019I-1.). Rockville, MD: Agency for Healthcare Research and Quality; 2015.
52.
McDonald CJMcDonald MH. Electronic medical records and preserving primary care physicians' time: comment on “Electronic health record-based messages to primary care providers.”. Arch Intern Med. 2012;172:285-7. [PMID: 22332168]  doi: 10.1001/archinternmed.2011.1678

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 165Number 116 December 2016
Pages: 753 - 760

History

Published online: 6 September 2016
Published in issue: 6 December 2016

Keywords

Authors

Affiliations

Christine Sinsky, MD
From the American Medical Association, Chicago, Illinois; Sharp End Advisory, Hanover, New Hampshire; Australian Institute of Health Innovation, Macquarie University, Sydney, Australia; and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Lacey Colligan, MD
From the American Medical Association, Chicago, Illinois; Sharp End Advisory, Hanover, New Hampshire; Australian Institute of Health Innovation, Macquarie University, Sydney, Australia; and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Ling Li, PhD
From the American Medical Association, Chicago, Illinois; Sharp End Advisory, Hanover, New Hampshire; Australian Institute of Health Innovation, Macquarie University, Sydney, Australia; and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Mirela Prgomet, PhD
From the American Medical Association, Chicago, Illinois; Sharp End Advisory, Hanover, New Hampshire; Australian Institute of Health Innovation, Macquarie University, Sydney, Australia; and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Sam Reynolds, MBA
From the American Medical Association, Chicago, Illinois; Sharp End Advisory, Hanover, New Hampshire; Australian Institute of Health Innovation, Macquarie University, Sydney, Australia; and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Lindsey Goeders, MBA
From the American Medical Association, Chicago, Illinois; Sharp End Advisory, Hanover, New Hampshire; Australian Institute of Health Innovation, Macquarie University, Sydney, Australia; and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Johanna Westbrook, PhD
From the American Medical Association, Chicago, Illinois; Sharp End Advisory, Hanover, New Hampshire; Australian Institute of Health Innovation, Macquarie University, Sydney, Australia; and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Michael Tutty, PhD
From the American Medical Association, Chicago, Illinois; Sharp End Advisory, Hanover, New Hampshire; Australian Institute of Health Innovation, Macquarie University, Sydney, Australia; and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
George Blike, MD
From the American Medical Association, Chicago, Illinois; Sharp End Advisory, Hanover, New Hampshire; Australian Institute of Health Innovation, Macquarie University, Sydney, Australia; and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Acknowledgment: The authors thank each of the medical students who assisted in this work: Komal Dhir, Eyitemi Fregene, Michelle Kim, Timothy Nobbee, Timothy O'Dowd, Nirali Patel, Max Schmidt-Bowman, Fernando Vasquez, Kathryn Whittington, and Sylven Yaccas. They also thank Louis Shelzi (Dartmouth-Hitchcock), who supported training and fieldwork, and Sheree Crick (Australian Institute of Health Innovation, Macquarie University), who provided essential support for all WOMBAT work.
Financial Support: By the American Medical Association.
Disclosures: Dr. Sinsky serves on the advisory committee for healthfinch, a start-up that works on practice automation. Dr. Li reports grants from Mary Hitchcock Hospital and Dartmouth-Hitchcock Clinic during the conduct of the study. Ms. Goeders reports that the study was paid for by her employer, the American Medical Association. Dr. Westbrook reports funding from Dartmouth-Hitchcock Clinic during the conduct of the study. Dr. Tutty reports that the study was paid for by his employer, the American Medical Association. Dr. Blike reports a grant from the American Medical Association during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-0961.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement: Study protocol: Not available. Statistical code: Available to approved persons through written agreement with the authors from Dr. Li (e-mail, [email protected]). Data set: See Tables 1, 2, 3 and 4.
Corresponding Author: Christine A. Sinsky, MD, American Medical Association, 330 North Wabash Avenue, Suite 39300, Chicago, IL 60611.
Current Author Addresses: Drs. Sinsky and Tutty and Ms. Goeders: American Medical Association, 330 North Wabash Avenue, Suite 39300, Chicago, IL 60611.
Dr. Colligan: Sharp End Advisory, LLC, PO Box 222, Hanover, NH 03755.
Drs. Li, Prgomet, and Westbrook: Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW 2109, Australia.
Mr. Reynolds: American Medical Association, 4622 North Damen Avenue, Chicago, IL 60625.
Dr. Blike: Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Building 50, Lebanon, NH 03756.
Author Contributions: Conception and design: C. Sinsky, L. Colligan, L. Li, M. Prgomet, S. Reynolds, J. Westbrook, M. Tutty, G. Blike.
Analysis and interpretation of the data: C. Sinsky, L. Colligan, L. Li, M. Prgomet, S. Reynolds, J. Westbrook, G. Blike.
Drafting of the article: C. Sinsky, L. Colligan, M. Prgomet, S. Reynolds, L. Goeders, M. Tutty, G. Blike.
Critical revision of the article for important intellectual content: C. Sinsky, L. Colligan, L. Li, M. Prgomet, S. Reynolds, L. Goeders, J. Westbrook, M. Tutty, G. Blike.
Final approval of the article: C. Sinsky, L. Colligan, L. Li, M. Prgomet, S. Reynolds, L. Goeders, J. Westbrook, M. Tutty, G. Blike.
Provision of study materials or patients: L. Colligan, S. Reynolds.
Statistical expertise: L. Li.
Obtaining of funding: C. Sinsky, L. Colligan, M. Tutty, G. Blike.
Administrative, technical, or logistic support: L. Colligan, S. Reynolds, L. Goeders, M. Tutty, G. Blike.
Collection and assembly of data: L. Colligan, M. Prgomet, S. Reynolds, L. Goeders.
This article was published at www.annals.org on 6 September 2016.

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Christine Sinsky, Lacey Colligan, Ling Li, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med.2016;165:753-760. [Epub 6 September 2016]. doi:10.7326/M16-0961

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