Residents Spend More Time on Computer Than With Patients

Diana Phillips

January 30, 2017

Medical residents at a Swiss teaching hospital spend almost half of their workday on the computer, which is approximately three times the amount of time they spend with patients, according to a study published online today in the Annals of Internal Medicine.

On average, residents spend 1.7 hours per day with patients, compared with 5.2 hours using computers, and 13 minutes doing both.

The findings, reported by Nathalie Wenger, MD, from the Department of Internal Medicine at Lausanne University Hospital in Switzerland, and colleagues mirror patterns seen among internal medicine residents in the United States.

"That so much of residents' time is spent on the computer, rather than on direct patient care and interaction, suggests we need to rethink how residents' time is allocated to achieve a more reasonable balance," Dr Wegner said in an interview, noting that resident burnout and dissatisfaction are unacceptable costs of increased technology.

To estimate how much time residents spend on the computer and with patients, Dr Wegner and colleagues conducted an observational time-and-motion study between May and July 2015 in the Internal Medicine Department of Lausanne University Hospital. The study focused on the activity of 36 residents (23 women and 13 men) during day (8:00 a.m. - 6:00 p.m.) and evening (4:30 - 11:30 pm) shifts.

Trained observers recorded the residents' activities in real time, using a tablet, based on 22 predefined activities across six categories: directly related to the patient, communication, indirectly related to the patient, academic, nonmedical, and transition. For each activity, the observers recorded whether a patient or colleague was present and whether the resident was using a telephone or computer.

During the course of the study, observers collected data for nearly 700 hours of residents' time from 66 shifts (49 day, 17 evening) and determined that day shifts lasted an average of 11.6 hours (95% confidence interval, 11.2 - 12.0 hours), and evening shifts lasted an average of 7.6 hours (confidence interval, 7.0 - 8.2 hours), indicating that most residents needed more time than their scheduled shift to fulfil their duties, the authors report. After-hours activities consisted mostly of writing in the EMR, they observe.

For the day shifts, 28.0% of residents' time was spent on tasks that were directly patient related, including clinical procedures, admissions, and rounds, whereas 52.4% of their time was spent on tasks indirectly related to patient care, including writing in the electronic medical record (EMR), looking for information, and handoffs.

"Two of the longest activities (>1 hour) were daily patient rounds and writing in the EMR," the authors note. The amount of time residents spent per patient per day on direct care was approximately 14.6 minutes, they write.

The remainder of the residents' time was spread across academic (6.3%), nonmedical (6.1%), transition (5.1%), and communication (2.3%) activities, the authors report.

The time allocation was similar for evening shifts for all categories except academic activities, which accounted for almost none of the residents' time.

"Overall, for every hour the residents spent with patients, they spent an average of 5 hours on other tasks," the authors write. "For day shifts, writing in the EMR and writing the discharge summary were the most time-consuming activities, amounting to approximately 2 hours per shift."

Although the percentage of direct patient care time was similar between day and evening shifts, the distribution of that time differed. "During day shifts, most of the time residents spent with patients corresponded to daily patient rounds in the morning and admissions in the afternoon. For evening shifts, time spent with patients was more evenly distributed among late patient admissions, unstable patient care, and emergency situations," the authors explain.

The residents tended to use their after-hours time on computer tasks, such as entering notes. "Possible reasons include a better summing up of the clinical issues encountered, not being interrupted, and not needing to interact with other members of the medical team," the authors suggest.

Unlike in the ambulatory care setting, residents rarely used the computer and interacted with patients simultaneously, which is likely a function of the hospital setting, as it "does not facilitate use of a computer during interaction with the patient."

The disproportionate amount of time residents spend on computer tasks is concerning compared with direct patient care is concerning, according to the authors. "[T]he large amount of time dedicated to computer use or other activities not centered on the patient could lead to dissatisfaction of residents due to the limited medical value of such activities and could also increase the risk for burnout," they write.

This concern is supported in the literature linking physician burnout to their dissatisfaction with the clerical burden of electronic health records and associated technology, as reported previously by Medscape Medical News. It also points to the need for academic health systems to "rethink residents' work organization to fit the digital age," the authors stress.

The authors suggest several interventions for improving the allocation of residents' time, including increasing the number of residents per patient, although doing so may be cost-prohibitive; delegating administrative tasks, which account for 40 minutes per day of residents' time in the current study; optimizing documentation support via speech or writing recognition systems or scribes; and improving/redefining documentation procedures and the "ergonomics" of EHRs, which "still fail to capture and synthesize the growing amount and complexity of clinical data."

EHRs and other technology "are meant to increase the efficiency of health care practice, not detract from it," Dr Wegner said. "Our findings indicate organizational and technology changes are needed to make sure that doesn't happen."

The authors have disclosed no conflicts of interest.

Ann Intern Med. Published online January 30, 2017.

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