Study: In Family Practice Visits, EHR Time Exceeds Face-to-Face Patient Time

Feb. 26, 2018
Primary care physicians spent more time working in the electronic health record (EHR) than they spent in face-to-face time with patients in clinic visits, according to a recently published study conducted by a team of physician researchers.

Primary care physicians spent more time working in the electronic health record (EHR) than they spent in face-to-face time with patients in clinic visits, according to a recently published study conducted by a team of physician researchers.

The study, titled “A Time-Motion Study of Primary Care Physicians’ Work in the Electronic Health Record Era,” was published in the February issue of Family Medicine, and correlates with previous studies that indicate primary care physicians spend more than half of their workday interacting with the EHR during and after clinic hours. As previously reported by Healthcare Informatics, a study published in the Annals of Family Medicine back in September 2017 found that, in a given 11-hour workday, nearly six of those hours are being spent in the EHR.

In this latest study, led by Richard Young, M.D., from the JPS Family Medicine Residency Program in Fort Worth, Texas, researchers directly observed family physician (FP) attendings, residents, and their ambulatory patients in 982 visits in clinics affiliated with 10 residencies of the Residency Research Network of Texas. The researchers measured total visit time, pre-visit chart time, face-to-face time, non-face time, out-of-hours EHR work time, and total EHR work time.

The study’s co-authors include a number of medical researchers from the University of Texas Health Science Center at San Antonio, within the Department of Family Medicine, as well as Baylor Scott and White Clinic in Temple, Texas.

As EHRs have had mixed effects on the workflow of ambulatory primary care, the researchers aimed to update previous research on the time required to care for patients in primary care clinics with EHRs, according to the study. For the study, the most common chronic conditions the patients had were hypertension (40.6 percent of patients), diabetes (28.2 percent), hyperlipidemia (27.8 percent), depression (18.1 percent), and arthritis (14.1 percent).

Of the 982 physician-patient visits observed, the mean length of visits, excluding resident precepting, was 35.8 minutes. Mean face-to-face time lasted 16.5 minutes during the visit, compared to estimated EHR time per visit of 18.6 minutes. This time has been corrected for estimated non-face/non-EHR time performing other tasks such as filling out forms, the study authors state.

This time breaks down to 2.9 minutes working in the EHR prior to entering the exam room, 2 minutes working in the EHR in the room, 7.5 minutes of non-face time (mostly EHR time), and 6.9 minutes of EHR work outside of normal clinic operational hours. Most than half the visits (64.6 percent) involved EHR work outside of office hours, and physicians worked in the EHR in the exam room during 73.4 percent of the visits.

The total time and total EHR time varied only slightly between faculty physicians, third-year and second-year residents.

“We found that family physicians spent more time in direct ambulatory patient care working in the EHR than they spent in face-to-face time with their patients. The majority of family physicians worked through lunch, stayed late at clinic, or took their work home to complete the day’s EHR work,” the study authors wrote. “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 study authors also note that their results of the time spent by the physicians working in the EHR are similar to a recent study that used EHR time stamp data from 471 primary care physicians. In that study, researchers found physicians logged an average of 3.08 hours on office visits and 3.17 hours on “desktop medicine” each day, which is similar to the ratio we measured.

What’s more, the study authors also contend that all U.S. results stand in contrast to a recent study in the UK, where the average general practitioner consultation included 9.5 minutes of face-to-face time and 3.3 minutes of EHR time. “The UK results are consistent with observed consultation times across six countries in Europe in 2002 of 7.6 to 15.6 minutes total (overall mean, 10.7 minutes). Our results imply that U.S. family physicians spend more time working in the EHR than their European counterparts spend in the entire visit,” the study authors wrote.

In the study, the researchers also noted an unexpected finding was that an important independent predictor of total visit time and non-face time—whether a resident checked out the patient with an attending, even though precepting time was removed from the reported times. “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,” the study authors wrote.

The study authors also contend that the study findings have important economic implications for family physicians. The original studies led that led to the Resource-Based Relative Value Scale (RBRVS) used by the Center for Medicare and Medicaid Services (CMS) to value physician work, were conducted at a time when there was less work performed between visits and before the current evaluation and management (E&M) rules were enacted, the study authors wrote.

In the original studies, non-face time was estimated to be 29 percent of the total visit time for primary care E&M visits, while this study found this figure to be 54 percent of the total visit time. Furthermore, there are no current procedural terminology (CPT) codes that describe when a physician addresses more than three issues in a visit, nor are physicians allowed to submit more than one E&M CPT code per day for payment. “This implies that the relative value weightings of the CPT codes should be recalculated to increase payment for the significant EHR work time required in today’s primary care,” the study authors concluded.

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