Docs with their Eyes on the Clock? Effects of Time Pressure on Primary Care Provider Behavior

Primary care providers may face significant time pressures. Workforce statistics imply a growing shortage of PCPs, and PCPs have lamented the limited time they have with their patients. Inadequate time for primary care encounters may reduce the opportunity for thorough examination, diagnosis, communication, and shared decision making between the PCP and the patient and may result in poorer quality of care and less-favorable health outcomes. This paper explores the effects of unanticipated changes to a PCP’s schedule as a source of random variation in time pressure. We focus on the effect of time pressure on several measures of productivity and quality of care.

Whether or not a PCP experiences time pressure in a clinical encounter is inherently subjective, influenced by multiple factors, and difficult to directly assess. We therefore use unique Electronic Health Record (EHR) data from a large healthcare provider organization to measure variation in unanticipated time pressure driven by the flow of no-shows, same-day cancellations, and same-day appointments. We employ a causal research design that exploits these unanticipated changes in the amount of time a PCP has scheduled for treating patients during a given shift as a random determinant of the amount of time pressure a PCP faces during pre-scheduled, anticipated appointments, controlling for other determinants of visit outcomes. We find that more time pressure reduces the number of diagnoses recorded within an encounter. More time pressure increases the likelihood that follow-up appointments are scheduled, and that unscheduled return appointments occur. We do not find consistent evidence of effects on specific measures of appropriate or inappropriate services. This project provides important insight into the behavior of PCPs and how external constraints affect patient health.