EHR Time Split Evenly Between Patient Visits, Other Work

Ken Terry

April 04, 2017

Approximately half of the time physicians spend on electronic health record (EHR) tasks each day occurs during patient visits, according to a study published online April 3 in Health Affairs. The other half of their EHR time is taken up by nonpatient desk tasks.

The authors emphasize that such nonpatient time must be accounted for in compensation models going forward.

The study, by Ming Tai-Seale, PhD, MPH, associate director of the Palo Alto Medical Foundation Research Institute in Mountain View, California, and colleagues, is one of the first to look at how established doctors — as opposed to trainees — use EHRs. It is also among the first to use the time stamps in EHR access logs to measure physician work effort. Most similar studies have relied on physician reports, time and motion studies, or video and audio recordings.

Dr Tai-Seale and colleagues analyzed over 31 million EHR transactions recorded by 471 primary care doctors, including internists, family physicians, and pediatricians, in a California healthcare delivery system between 2011 and 2014. During that time, physicians worked on EHRs for 765,129 patients, of whom 637,769 had at least one in-person visit among the more than 2.8 million ambulatory care visits included.

On average, physicians used their EHRs an average of 3.08 hours for office visits each day and 3.17 hours for desktop medicine activities, such as typing progress notes, logging telephone encounters, messaging online with patients, refilling prescriptions, ordering tests, reviewing test results, and making referrals.

By combining the results of a direct-observation study sponsored by the American Medical Association with their own results, Dr Tai-Seale and colleagues estimated that physicians spend 40% of their clinical time on face-to-face visits, 40% on desktop medicine, and 20% on other activities when not logged into their EHRs.

The investigators considered EHR access to have occurred during a face-to-face visit if a patient's chart was opened on a day when the patient saw the physician. The length of the visit was measured by comparing the time of the first EHR transaction for that patient in the exam room on that day to the time of the last such transaction.

The average number of visits per physician per day, including both full-time and part-time clinicians, was 12.3 (median, 12; standard deviation, 5.3). The average recorded length of a face-to-face visit in the exam room was 15 minutes (standard deviation, 10.7).

To validate this approach, the researchers compared it with the results of in-person observation and audio recordings of visits. The log-based estimates were 2 to 3 minutes shorter than the other measurements. In general, physicians spend about 3 additional minutes with patients in the exam room before they open the EHR and after they close it, the study said. That would bring the average visit time up to 18 minutes. Nevertheless, the coauthors used only logged computer time in their analysis.

Desktop medicine activities normally occur before or after a patient's visit, the researchers noted. However, they may not be performed on the day of the visit. Of the time spent on desktop medicine, the study found, an average of 2.82 hours were spent in the clinic, of which 1.42 hours were devoted to patients seen the same day and 1.4 hours were spent on other patients. Physicians also spent an average of 0.35 hours per day working on remote computers connected to their EHR.

Face-to-face visits accounted for 49% and desktop medicine for 51%, of the total EHR time. Thirty-four percent of EHR time was spent on progress notes, 9% on documenting phone calls, 3% on secure messaging with patients, 2% on prescription refills, and 3% on other tasks.

There were no significant differences between the time allocations for internists and family doctors, but pediatricians spent less time on face-to-face visits. Physicians whose practices had been recognized as patient-centered medical homes spent more time with patients than those in practices that were not medical homes, whereas the latter spent more time on desktop medicine. Having more years of experience using the EHR was associated with slightly less time spent on desktop medicine.

"The [EHR] logs suggest that physicians allocate equal amounts of their clinically active time to desktop medicine and to face-to-face ambulatory care visits," the researchers write.

In their view, this finding shows that a lot of physician work is not being reimbursed under the fee-for-service payment system. While progress notes have always been considered part of the work effort associated with a patient visit, other desktop medicine activities are not reimbursed under fee-for-service contracts and regulatory arrangements, the coauthors said.

"Many of those activities — such as care coordination and responding to patients' e-mail — are of high value to the [healthcare] delivery system and to patients, so the staffing, scheduling, and design of primary care practices should reflect this value," they stated.

Under the Medicare Access and CHIP Reauthorization Act (MACRA) and Medicare's Comprehensive Primary Care Plus demonstration, they added, the Centers for Medicare & Medicaid Services is moving away from payment for visits only. "This is…an acknowledgment that critical aspects of patient care that happen outside the visit require appropriate compensation," they said.

Health Affairs. Published online April 3, 2017. Abstract

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