Footprints in the sand: Tracking Physician Work Efforts in Primary Care using Access Logs in An Electronic Health Record

Background

Physician time is a critical resource in health services delivery. Understanding details about how physicians spend their time during clinic sessions is essential, given the pressing need to align incentives to drive efficiencies in delivery systems and strengthen primary care services. Prevailing means of studying physician time use (direct observation or surveys) are costly and can overlook or underestimate physician efforts on pre- and post-visit services. The EpicCare Electronic Health Record (EHR) offers an unobtrusive alternative portal to study time use, through its user “access logs.” We examine the extent to which access logs capture clinical work activities and report the distribution of physician time on different clinical work activities.

Methods

Using EpicCare data from a large ambulatory delivery system, we examined time-stamped EHR user access log data for one month in 2013 from two primary care departments (internal and family medicine). We included 49 physicians for whom we could account for at least 50% of their worktime, with over 3 million EHR transactions involving 22,174 patients that month. Physicians’ in-clinic workday reflected by the log was divided into time spent on face-to-face visits, desktop medicine (e.g., phone calls, e-messaging, medication orders), and on activities without a record in the log. Desktop medicine time was further divided into pre and post-visit work for patients having a face-to-face appointment and work for a patient on days when the patient is not seen in the office. 

 

Results
Access log data capture details on up to 80% of physicians’ office work time. Within that captured time, in-person face-to-face patient visits took 44% of physicians’ time whereas desktop medicine 55%, and the remaining 1% was not linkable to a specific activity. Within desktop medicine, pre and post-visit services on the day of a patient’s visit took 33.8% of the time. Physicians spent 21.2% of their day on activities related to patients without a visit on that day: 11.4% time on telephone calls, 5.6% on secure messaging to patients, 2.6% on prescription refills, and 1.6% on orders for labs, medications or referrals. For each in-person visit, an average of 16.7 minutes was logged in the exam room and 7.9 minutes outside the room in desktop medicine.

Conclusions:

EHR log data is a valuable resource to study physician work efforts. Log estimates of time spent in face-to-face visits is consistent with direct observations. Logs show that physicians spend the majority of their time on patient care activities outside of direct, face-to-face (billable) visits. Physician payment reform should consider patient care work within and outside the exam room. The increasing importance of desktop medicine to engage patients and coordinate care demands reforming provider payment mechanisms to account for the substantial work outside of face-to-face visits. Indeed, MedPAC has recommended one such reimbursement model:  paying primary care physicians one fee for specific services they perform (such as evaluation and management of problems addressed in office visits) and a monthly or quarterly fee for non-visit-based services (such as phone calls e-messages to patients, and telephone consultations with specialists).