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

An objective study that confirms what many of us have been saying for quite some time. And even these shocking results are probably an underestimation of the amount of time physicians spend "treating" the EHR instead of the actual patient. Physician efficiency, productivity and income decrease while frustration, helplessness and burnout increase. And yet our leaders in organized medicine and policy makers in government decry the shortage of primary care physicians and the growing popularity of the direct primary care model of medical practice.

To the editors, the study by Dr Sinsky et al, accurately reflects the distribution of time in my practice as well as those of my colleagues. While EHRs and new ways of communicating with patients may offer significant benefits, especially with respect to managing populations and improving communication, they also increase the workload and documentation requirements for clinicians. Before EHRs became widespread, I recall learning that the average appointment for an adult (primary care) patient, required 25 minutes to address 3 problems and complete documentation. Given the difficulty in retaining/attracting primary care physicians, addressing this issue is important.

To the Editor:
In their recent study, Sinsky et al address the growing concern that the electronic health record (EHR) is having on the physician-patient relationship, showing that only a fraction of a physician’s workday is spent in with patients (1). While it is often lamented that we must do more to bring physicians back to the bedside, they were likely never there to begin with. Time-motion studies over time have consistently shown that physicians have always been burdened with indirect patient care (2). Rather than helping, EHRs appear to have only added to an existing problem. Nevertheless it is worth wondering why the problem of physician burnout is blamed on EHR, if it is not substantially changing the time we spend with patients.
Perhaps it is the nature of indirect patient care that has changed. As Dr. Wachter illustrates in his recent book, “time used to be spent going to radiology and discussing cases and images in collaboration with other physicians, whereas now radiology images can be viewed virtually anywhere, saving a trip to the radiology department” (4). This can lead to today’s physicians feeling challenged by information overload, responsible for sifting through data with increasing orders of magnitude. Information is not necessarily organized or optimized for physicians, because, unlike the paper chart of old, the industry leading EMRs are built for documentation and billing and not primarily for ease of use by physicians for patient care (3).
Given the many automated time-saving features, EHRs have the potential to solve much inefficiency in healthcare, allowing for more time with patients. However, even the current generation of trainees who were raised on keyboards and screens will face significant challenges unless they are able to interact with EHRs that are intuitive, user-friendly and serve patients and the clinical team caring for them. If we can partner with EHR software developers to envision an ideal workflow, one that is time saving that optimizes use of clinical decision support to help providers do the right thing faster - we can then move towards a future where the EHR can synergize with our work rather than add to it. This study by Sinsky et al should serve as our reference point that we measure future success against. Any new system or work flow should look to see how much additional time at the bedside the “solution” provides.


1) Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L, Westbrook J, Tutty M, Blike G. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med. 2016 Sep 6. doi: 10.7326/M16-0961.

2) Czernik Z, Lin CT. A PIECE OF MY MIND. Time at the Bedside (Computing). JAMA. 2016 Jun 14;315(22):2399-400.

3) Zulman DM, Shah NH, Verghese A. Evolutionary Pressures on the Electronic Health Record: Caring for Complexity. JAMA. 2016 Sep 6;316(9):923-4. doi: 10.1001/jama.2016.9538.

4) Wachter, R (2016) The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. New York City, NY McGraw-Hill Education

To the editors:

This study by Dr. Sinsky and colleagues draws some unfortunate, but not surprising, conclusions. Their study gives weight to the concerns we and our colleagues have had about the practice of medicine for some time (1).

Looking beyond this study, if you could add up all of the additional time (i.e. costs) layered onto the practice of medicine, you would find an extraordinary tax on the provision of medical care. “Physician burnout,” “workload compression,” and other issues related to this taxation on physician time are the subjects of much study and scholarship currently. However, we are concerned that not enough is being done to eliminate or reduce the actual taxation as opposed to just studying it. Physicians choose medicine to care for the sick, not to tend to endless documents and forms. We are trapped in something economists call “Harberger’s Triangle (2).”

Harberger’s Triangle is a method of describing the “deadweight” created by taxation. A certain amount of physician time is available each day, and the time (and therefore cost) to complete each task must come from somewhere. As the costs of complying with tasks that don’t improve patient outcomes accelerated, we now find ourselves in a situation where the utility of each physician is severely diminished. This destructive tariff creates a gap between the clinical care we could provide and what we are able to provide.

”Rent-seeking” is another term for this accelerating tendency to create ever more complex regulations on physician time and resources.” Rent-seekers create rules, fees, and regulations where none are needed in order to redistribute wealth to themselves without creating new value in the process (3). Physicians and patients need to recognize this valueless taxation on our time, mental energy, and finances.

If we want something better, we encourage everyone to begin by calling these behaviors what they are: taxation--and on a massive scale. This taxation and “rent-seeking” steals time between doctor and patient, depletes the wealth of our society, and drains the joy from practicing medicine, all to tend to tasks of no value to patients or the profession. We need to start demanding evidence-based practice from our administrators and non-clinical colleagues. Start with this at your next departmental meeting: “why are you taxing my time with the patient and what is the evidence that this [insert new requirement here] will help them?”

References:

1. Sinsky C, Colligan L, Li Ling, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med. Published online 6 September 2016 doi:10.7326/M16-0961

2. Hines, J. Three Sides of Harberger Trinagles. Journal of Economic Perspectives, Vol. 13, no. 2 (Spring 1999): 167-188

3. Rent-seeking. Wikipedia. Accessed online 9/7/16: https://en.wikipedia.org/wiki/Rent-seeking

Sinsky and colleagues (1) in their excellent and provocative study of the allocation of physician time in ambulatory practice point out problems related to electronic health records (EHRs). In an accompanying editorial Hingle (2) encourages strategies to improve physician’s use of EHRs. Clearly there are many benefits to the EHR. However, in at least general internal medicine and geriatrics many perceive the EHR to be too complex, not intuitive and user unfriendly. One suggestion to improve physician efficiency by improved EHRs follows: A major EHR company might sponsor in collaboration with the ACP a two day retreat for active physician users who have only average EHR expertise. About twenty physicians would gather to use the EHR to evaluate standardized patients scheduled in 20-60 minute time slots. A scribe would record the EHR problems that arise both from the perspective of the physician and patient. EHR experts would observe but not speak. The second day would be devoted to reviewing, prioritizing and designing strategies to fix problems.

References
1. Sinsky C, Colligan L, Ling L, Prgomet M, Reynolds S, Goeders L, et al; Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med. 2016; 165: 753-760.

2. Hingle, S; Electronic Health Records: An Unfulfilled Promise and a Call to Action. Ann Intern Med; 165: 818-818.

Sinsky and colleagues (1) have produced important quantification of the amount of hours spent with direct patient care versus electronic health record (EHR) work in modern ambulatory practice. Much of the lay press response to this study (2) has characterized the modern doctor’s work as clerical paper-pushing. A pessimistic interpretation of these data portrays the downfall of “The Good Doctor” at the hands of their own technological advances. The amount of EHR interaction required of all physicians is increasing and will likely continue to increase. This study brings up important questions with regard to physician satisfaction and compensation for EHR work done outside of clinic visits; however, more EHR time does not necessarily equate to worse patient outcomes. While some time on EHRs is spent performing undeniably menial tasks, a larger portion of the time spent in the EHR is on tasks that improve patient care. I feel lucky to have come of age in a completely post-paper chart era. As I see patients at a Veterans Affairs medical center I am endlessly grateful to have access to more than 10 years of organized data on my patients. The difficult truth for some is that there are a new set of skills necessary to be a successful physician. Aside from the eternally important humanistic aspects of patient interaction, foremost among these skills is data collection, management, and interpretation. Much of the information previously obtained through face-to-face patient contact is now found in the EHR; often in a more organized and accurate manner than can be relayed by a patient or a disparate smattering of illegible hand-written notes. Much of the work we do on EHRs is useful, improves patient care, and is extremely worthwhile. Physicians and those in training should expect more EHR time but not assume that it is frivolous.
The piece by Weinberg (3) in the same issue of Annals tells the story of an older classical “good doctor” overwhelmed by an EHR. He is juxtaposed against a cold and distant (but efficient) resident who is exceedingly nimble and proficient with technology. The moral of the story is to focus on human interaction with our patients rather than on getting work done expediently in the EHR. I argue that these two virtues are not mutually exclusive, and that physicians should be expected to achieve both. There is no virtue in running an hour behind schedule, as is the protagonist in that story. Just as I was reprimanded as a medical student for not knowing how to check a pulsus paradoxus, physicians should be expected to know how to chart quickly, extract data accurately, and enter electronic orders precisely as part of the core skills of being a physician.



1) http://annals.org/aim/article/2546704/allocation-physician-time-ambulatory-practice-time-motion-study-4-specialties
2) http://www.forbes.com/sites/brucelee/2016/09/07/doctors-wasting-over-two-thirds-of-their-time-doing-paperwork/#68b1611f6e5d
3) http://annals.org/aim/article/2590891/coeur-d-alene

As an internist, intensivist, and anesthesiologist, I would like to see this study modality applied to the intensive care unit and the operating room. I venture that in the ICU, the ratio of EHR:patient use is much more, and in the OR, it is much less. Presumably these different ratios result from differing amounts of textual, imaging, or conversational information that require processing and documented responses in the three settings of ICU, OR, and clinic (high in the ICU, middle in the clinic, low in the OR), versus the actual hands-on patient interaction and intervention required (high in the OR, low in the clinic).

This simple yet novel study by Sinsky and colleagues studying physician time allocation provides additional objective data underscoring the unreasonable clerical burdens placed upon physicians.(1) Tasks that were formerly handled by phone or via medical office staff are now electronic tasks that can only be entered or handled by physicians (ie, computer order entry), relegating physicians to the role of data entry clerks. The clerical burden on physicians from suboptimal design of EHR's has been exacerbated by additional regulatory burdens from CMS, such as the Meaningful Use program, which did not deliver on its intent to make EHR's better coordinated via interoperability.(1) Medical office staff spent significant time faxing and scanning documents between different EHR systems. Viewing scanned documents proved cumbersome, as it sometimes took several minutes to load each scanned document--flipping through a paper chart would have been faster.

Taking this study together with a recent study by Shanafelt and colleagues that linked clerical burden and physician burnout (2), physician burnout is now a reality, especially when time spent on administrative tasks is double that of patient face to face time.(1) Sinsky's study focused on the administrative time spent on just day to day practice with current EHR technology, and does not include time spent on CMS regulatory mandates. With the increased reporting and regulatory requirements of the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act (MACRA),(3) there is a crisis that threatens the longevity of practicing physicians. Shanafelt and colleagues also showed how burnout between 2011 and 2014 translated to a reduction in the US physician workforce equivalent to about 7 graduating medical school classes.(4)

The perfect storm of poorly designed EHR's, increased physician administrative workload, increased regulatory requirements that directly affect reimbursement, educational debt, and evolving maintenance of certification (MOC) requirements will undo the foundation of health care reform--making health care more accessible and appropriate. Physicians dealing with burnout by cutting their professional work effort via early retirement, pursuing non medical careers, or going part-time will exacerbate the present physician workforce shortage.(4)

1. Sinsky C, Colligan L, Ling L, Prgomet M, Reynolds S, Goeders L, et al; Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med. 2016; 165: 753-760.
2. Finding Meaning in a Flawed Meaningful Use Program: Pathways Toward Physician Compliance. ReachMD website. https://reachmd.com/programs/everyday-family-medicine/finding-meaning-flawed-meaningful-use-program-pathways-toward-physician-compliance/7740/#sthash.8QdlBzeo.dpuf. Published July 29, 2016. Accessed January 4, 2017.
3. Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models; Proposed Rule (CMS-5517-P). Letter to Andrew Slavitt, June 24, 2016. American Medical Association website. https://download.ama-assn.org/resources/doc/washington/macra-state-speciality-sign-on-letter.pdf. Published July 29, 2016. Accessed January 4, 2017.
4. Shanafelt, T.D., Sinsky, C.A., Dyrbye, L.N., and West, C.P. Potential impact of burnout in the US physician workforce. Mayo Clin Proc. 2016; 91: 1667–1668.

We agree with Dr. Luh--many physicians feel they have become data entry clerks. This cannot be good for patients. The rise in burnout between 2011 and 2014[1], driven in part by the implementation of EHRs and associated regulation, translates into a reduction in the US physician workforce equivalent to the loss of 7 graduating medical school classes. If we included the decline in the effective physician workforce, as physicians spend less of their professional effort on work for which they are uniquely trained, the real loss is far greater.

Dr Bishop and colleagues liken the time physicians spend on clerical work to a type of taxation, stealing time away from patients and draining joy from the practice of medicine. We would add that because many physicians try to accommodate the several hours per day of extra clerical work while preserving their time with patients, this “taxation” is often borne by physicians’ families and their personal lives.

Dr. Serota proposes physicians accept that a significant portion of their worklife will be spent on the EHR and suggests learning to get EHR work done faster. We agree that not all time spent on the EHR is frivolous, but we do believe that the 2-3 hours physicians of multiple specialties, ages and settings are required to spend on computer and deskwork for every hour of direct clinical face time [2, 3] is out of balance. Rather than ask physicians to do the wrong work more efficiently, we suggest first asking whether the work adds value to patients and if so, is it being done by the most appropriate person?

Dr Serota suggests data management is a new skill for physicians, when in fact synthesizing, interpreting and contextualizing information has been a part of physician work both before and after the advent of EHRs. What is new is the role of the physician as first responder for incoming information and the responsibility for converting the clinical encounter into discreet digital data for multiple stakeholders and for subsequent audit.

A physician of any generation who strategically delegates tasks according to ability is poised to maximally leverage the investment society has made in their training. And the organized physician community, working with vendors, payers and regulators to lessen the time costs of EHR-enabled healthcare, will support the Quadruple Aim [4]of better care for individuals, better health for the population, at lower costs, with improved well-being of the health professional workforce.

1. Shanafelt, T.D., et al., Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clinic Proceedings. 90(12): p. 1600-1613.
2. Sinsky, C., et al., Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties. Annals of Internal Medicine, 2016.
3. Wenger, N., et al., Allocation of internal medicine resident time in a swiss hospital: A time and motion study of day and evening shifts. Annals of Internal Medicine, 2017.
4. Bodenheimer, T. and C. Sinsky, From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med, 2014. 12(6): p. 573-6.