Primary care physicians spend less time interacting face-to-face with their patients than they do working on electronic health records (EHR), according to a cross-sectional study published in the February issue of Family Medicine.
“The majority of family physicians worked through lunch, stayed late at clinic, or took their work home to complete the day’s EHR work,” write Richard A. Young, MD, from the JPS Family Medicine Residency Program in Fort Worth, Texas, and colleagues.
“Significant predictors of visit length included the number of reasons for the visit, new patients to the practice, the number of medications prescribed, whether the physician was Hispanic, whether a resident physician presented the patient to an attending physician, whether the patient had one or multiple physicians caring for him or her, and a few other factors,” the authors explain.
“Our findings have important economic implications for family physicians.”
The researchers visited clinics affiliated with 10 Residency Research Network of Texas residencies to observe attending family physicians, their residents, and their patients, and to measure time spent on different clinic-related tasks. The researchers made explicit efforts to choose physicians with a diversity of patient care styles and observed every other visit on observation days. Tasks timed included the following: total visit time, previsit chart time, face-to-face time, nonface time, out-of-hours EHR work time, and total EHR work time.
Of the 982 visits observed, residents saw 667 of the patients, and faculty members, with a mean 16.6 years of experience, saw 315 patients. The most common chronic conditions the patients had were hypertension (40.6% of patients), diabetes (28.2%), hyperlipidemia (27.8%), depression (18.1%), and arthritis (14.1%).
The mean length of visits, excluding resident precepting, was 35.8 minutes. Mean face-to-face time per visit lasted 16.5 minutes compared with an average 18.6 minutes of EHR work per visit. More discrete time breakdowns included 2.9 minutes in the EHR before going into the exam room, 2.0 minutes of EHR work in the room, and 7.5 minutes of nonface time, most of which involved EHR work. Physicians also spent an average 6.9 minutes of EHR time outside regular clinic hours, although this finding is limited by estimates reported by the physicians rather than direct observation.
More than half of the visits (64.6%) involved outside EHR work, and the physicians worked in the EHR in the exam room during 73.4% of the visits. Yet faculty physicians and second- and third-year residents had similar amounts of total time and total EHR time, ranging from 33.1 to 38.2 minutes for the former and 17.4 to 20.5 minutes for the latter.
These findings are similar to those in other studies for both face-to-face time and EHR time among US providers, but they are substantially longer than times seen in the United Kingdom, with an average 9.5 minutes of face time and 3.3 minutes of EHR time, and in Europe, where one study found total visit time to be an average 10.7 minutes.
“Our results imply that US [family physicians] spend more time working in the EHR than their European counterparts spend in the entire visit,” the authors write.
They also point out a factor affecting total visit and nonface time related to resident practices: “An unexpected finding was that an important independent predictor of total visit time and non-face time was whether a resident checked out the patient with an attending, even though precepting time was removed from the reported times,” the authors note. “This could reflect that we should have attributed more time to precepting, that patient visits that were checked out to attendings were more complex than average and required more thought and time, or that the attending changed some of the residents’ assessments and plans.”
Funding for the research came from the Texas Academy of Family Physicians Foundation, the National Center for Advancing Translational Sciences and the National Institutes of Health. Young is sole owner of Entire, LLC, “which is developing a novel documentation, coding, and billing system for primary care.” The remaining authors have disclosed no relevant financial relationships.
Fam Med. 2018;50:91-99. Published in the February 2018 issue. Abstract
