Administrative burden in primary care

Abstract

Objective

Administrative burden contributes to the current primary care crisis. This critical review of the literature explores how primary care administrative burden is discussed, including how it is defined and what drivers and solutions have been identified.

Data sources

A systematic search of MEDLINE and CINAHL electronic databases for peer-reviewed original research articles, literature reviews, and commentaries that discuss administrative burden in the context of primary care or primary health care.

Study selection

Searches identified 321 articles in MEDLINE and 109 in CINAHL, resulting in a total of 351 articles after duplicates were removed. Based on title and abstract screening, 228 articles were retained for full-text screening; 136 were ultimately included in the analysis.

Synthesis

Most articles focused on perspectives of physicians (72.8%), followed by those of other primary care clinicians (14.7%) and patients (12.5%). Few articles explicitly defined administrative burden (n=6), although most illustrated the concept with examples. One relevant definition of administrative burden distinguishes compliance, learning, and psychological costs. This definition was proposed in the context of people interacting with bureaucracies generally, but these categories are also relevant to primary care specifically. Primary care administrative burdens most often included compliance costs (forms and information management), but learning costs (finding information, navigating processes, and adapting to and implementing new technology) and psychological costs (stress and burnout) were also discussed in the literature. Identified drivers of administrative burden included health system requirements, technological tools available to do administrative work, and complexity of patients or patient populations. Technology and task shifting were discussed as both drivers of administrative burden and solutions to administrative workload.

Conclusion

Examples of administrative burden in primary care underscore that this work often supports central functions of continuity and coordination of care. Attention often focuses on compliance costs, but learning costs (eg, finding information and learning new technology) and psychological costs must not be overlooked. That technology and task shifting can function as both drivers of and solutions to administrative burden highlights why this issue is challenging to address. Solutions should consider costs broadly and evaluate implications from multiple perspectives, including those of patients and caregivers.

Expansion of administrative workload, including time spent on indirect patient care (eg, charting, forms, referrals) and practice operations, is contributing to the primary care crisis in Canada.^1,2 The cumulative administrative burden—including costs, time, and effort involved with completing this work—has been described as a source of burnout for clinicians and reduced access to care for patients,^3-5 and this may push family physicians to choose career options other than comprehensive community-based practice.⁶ While this issue is receiving growing attention throughout Canadian health care systems,^7-9 research designed to understand both drivers of and solutions to administrative burdens remains limited, particularly in the context of primary care. There is also no recognized, commonly accepted definition of administrative burden. In describing the issue of administrative burden, the Canadian Medical Association has focused on reducing unnecessary administrative tasks.¹⁰ This does not recognize time-consuming and inefficient but necessary administrative tasks that are essential to maintaining continuity and coordination, which are foundational elements of primary care.¹¹

While recent research and advocacy efforts have focused on the administrative burden of physicians,^12-14 the substantial administrative burden that patients and caregivers experience has long been recognized,^15-17 including the costs, time, and effort involved in accessing services.^18,19 These burdens may be experienced inequitably by patients and caregivers. Those who have more complex health needs, are economically marginalized, and experience oppression, discrimination, or health injustices tend to face disproportionately high administrative burdens. In situations where administrative processes operate to reproduce structural inequities, this has been labelled administrative violence.^20,21 In the context of the primary care crisis, there is evidence that structural inequities in primary care are growing wider,^22,23 which may reflect administrative burden involved in navigating access to care. While patient complexity is often mentioned in discussions of clinician administrative burden,^24,25 how patient and caregiver administrative burden is considered in primary care research is unknown.

We conducted a critical review of the research literature to explore administrative burden in primary care and analyze how it is defined, what drivers and solutions have been identified, and the extent to which clinician, patient, and caregiver experiences are reflected. While we are not aware of a commonly accepted definition of administrative burden in primary care, in research about patient and public administrative burdens Moynihan et al define administrative burdens as costs associated with accessing services, including learning costs, compliance costs, and psychological costs.²⁶ Instead of defining administrative burdens as onerous processes themselves, their framework considers their effects and recognizes these are shaped by contextual factors.²⁶ It was developed to describe interactions with systems broadly, and to our knowledge it has not been widely applied in primary care. We believe it is useful for classifying definitions and examples of primary care administrative burden to help distinguish administrative work itself from learning, compliance, and psychological costs experienced as a burden. Our overarching objective is to advance research and practical solutions that address administrative burden contributing to the current primary care crisis, while acknowledging the often necessary functions of these tasks and the varying burden these tasks place on diverse populations.

METHODS

Data sources and study selection

We conducted a critical review, which provides interpretive analysis of existing literature and an opportunity to evaluate existing literature, develop concepts, and consider practical solutions, consistent with our objectives.²⁷ Methods reported here are based on the PRISMA Extension for Scoping Reviews (PRISMA-ScR) checklist, as there is no checklist specific to critical reviews.²⁸

Eligibility criteria. To be included, sources had to be related to primary care or primary health care. We define primary care as the first level of contact with the health system to promote health, prevent illness, provide care for common illnesses, and manage ongoing health problems, while primary health care also includes broader integration of public health and population-based prevention and health promotion.²⁹ This could include administrative burden or workload of clinicians and team members delivering primary care as well as that of patients or caregivers accessing primary care. In addition, sources had to define or discuss administrative burden, or related concepts of administrative workload or administrative violence, here considered as the mechanisms through which structural inequities in access to services are reproduced through legal mechanisms.^20,21 Sources had to be published in English. All source types were included, and we did not place limits on date of publication, research methods, or study locations.

Search strategy. The search was developed with a medical librarian. It was initially developed within MEDLINE and subsequently translated to CINAHL. The full search strategy operationalizing the concepts of primary care and administrative workload, conducted on July 15, 2024, is included in Appendix 1, available from CFPlus.^*

Study selection. In title and abstract screening, sources were included if they mentioned administrative workload, burden, or violence in primary care settings. In full-text screening, sources that did not discuss administrative burden or mentioned it only in passing, or where the setting was not primary care, were excluded. All screening and data extraction was completed by a single reviewer (O.S.).

Data extraction. Data from each source were extracted according to a structured template (Appendix 2, available from CFPlus^*). Data extracted included publication information, definitions of administrative workload, primary care context of administrative workload, identified drivers or solutions, and discussion of patient or population complexity, including connections to social or structural determinants of health.

Analysis

We report sample characteristics (eg, publication type, study location) with descriptive statistics. Elements of definitions were analyzed deductively, mapping key concepts and components found within definitions specific to primary care to the broader categories of information, compliance, and psychological costs included in existing patient-focused definitions of administrative burden.²⁶ We grouped drivers and solutions inductively and presented descriptions for each identified category and examples in Appendix 2.^*

SYNTHESIS

The search identified 321 articles from MEDLINE and 109 articles from CINAHL, with 79 duplicates, for a total of 351 articles. After title and abstract screening, 228 full-text articles were assessed and 136 were included in the review (Figure 1).

Figure 1.

Flowchart for literature search and study selection

Among the 136 articles extracted, 111 (81.6%) were peer-reviewed journal articles reporting original research. Of the 136 articles, 67 (49.3%) were located in the United States, followed by 19 (14.0%) in the United Kingdom, 9 (6.6%) in Australia, 7 (5.1%) in Canada, and 34 (25.0%) in other countries. Representing nearly three-quarters of the articles, 99 (72.8%) focused on physicians as the study population, particularly physician administrative burden, followed by 20 (14.7%) on other primary care clinicians and 17 (12.5%) on primary care patient populations. Examples of study types and subsequent tallies are shown in Table 1.

Table 1.

Source characteristics

CHARACTERISTIC	n (%)
Publication type (n=136) Original research Literature review or commentary Dissertation Other (monograph, guides)	111 (81.6) 21 (15.4) 1 (0.7) 3 (2.2)
Study type (within original research, n=111*) Quantitative survey Mixed or multiple methods Qualitative Quantitative routinely collected data Intervention study Other (eg, report, pilot study)	62 (55.9) 23 (20.7) 20 (18.0) 11 (9.9) 1 (0.9) 3 (2.7)
Study location (n=136) United States United Kingdom Australia Canada Other (eg, Belgium, Japan, Nigeria)	67 (49.3) 19 (14.0) 9 (6.6) 7 (5.1) 34 (25.0)
Primary care setting (n=136) Comprehensive community-based care Focused practice area within primary care (eg, mental health, veterans’ health) Focused practice population within primary care (eg, individuals with disabilities, elderly patients)	98 (72.1) 20 (14.7) 18 (13.2)
Primary care population (n=136) General “Complex” patient population† Older adults Pediatric Other (veterans, cancer patients, immigrants)	110 (80.9) 9 (6.6) 5 (3.7) 4 (2.9) 8 (5.9)
Study population (n=136) Physicians Patients Other primary care clinicians (eg, nurses, social workers)	99 (72.8) 17 (12.5) 20 (14.7)

^*Articles were counted across multiple categories, and so do not total 111.

^†Definitions of complex patient populations varied but typically included multiple characteristics such as age, chronic conditions, mental health care needs, and social or economic marginalization.

Definitions of administrative burden

Few (n=6) articles explicitly defined administrative burden, although most illustrated the concept with examples. Most definitions described or listed tasks, and some connected these tasks to implications such as stress or burnout. While the purpose or intended outcomes of the tasks was usually implicit (eg, obtaining access to services or obtaining information to inform health care decisions), this information was not included within definitions. One source referred to the definition of administrative burdens as the learning, compliance, and psychological costs associated with receiving services or accessing programs³⁰ previously proposed by Moynihan et al in research about patient and public administrative burdens.²⁶ Based on this definition to classify sources, most articles focused on compliance costs, with fewer mentioning learning or psychological costs. Explanations of each category of costs and examples relevant to primary care are presented in Table 2.^26,31-36

Table 2.

Categories of administrative burden, relevance to primary care, and examples from review

CATEGORY OF ADMINISTRATIVE BURDEN	RELEVANCE TO PRIMARY CARE	PRIMARY CARE EXAMPLES FROM REVIEW
Learning costs: search processes people engage in to figure out what services they might need and how to access them26	Search process to obtain information needed to access services Obtaining information to support clinical decisions (eg, identifying places accepting referrals, navigating unfamiliar processes to obtain insurance or other benefits) Learning costs associated with new technology, often implemented to address administrative burdens	“Administrative burden encompasses the onerous experience of determining eligibility.”31 “[I]t was unclear who must wait, for how long exactly, when applications could be submitted, and which administrative processes to follow.”32
Compliance costs: typical examples of people’s negative encounters with systems, telephone calls, and paperwork26	Documentation, data entry, and maintenance of patient records Information exchange with other parts of the health system, including management of clinical messages, referrals, billing, and insurance claims Completion of forms to access insurance or other supports Compliance costs can be exacerbated by inefficient tools and inadequate technology for management of information and associated tasks	“Administrative burden refers to the amount of documentation, especially paperwork, that an individual provider must complete.”33 “These administrative burdens arise from: detailed clinical documentation and data entry; inefficient user interfaces; … and management of clinical messages and inboxes.”34
Psychological costs: stress and frustration that come from navigating these systems26	Changing scope of work for general practitioners, which makes this area of medicine seem less desirable, more stressful, less supported, and contributes to experiences of burnout Stress of navigation and coordination within complex and disconnected health systems, and associated worries that “balls are being dropped” Lack of adequate support and resources for patients and caregivers Limited health, reading, and technological literacy for patients that make the navigation of health systems stressful and challenging Social and structural determinants of health: income, housing security, gender, race, ethnicity, and more as barriers to health systems, which in turn foster stress, frustration, and disproportionate access	“[O]ther stress from applying or maintaining a benefit such as health insurance.”31 “[C]ognitive burdens caused by reminders and irrelevant or redundant patient data.”34 “This is captured in the concept of treatment burden defined as the workload of treatment and self-management for chronic conditions, its impact on patient functioning, and stressors that exacerbate it like healthcare financial concerns.”35 “High workload, such as long working hours, complex job functions, poor communication, and administrative burdens are associated with burnout symptoms and stress.”36

Drivers

Drivers of administrative burden fell into 3 broad categories: health systems, technology, and patient complexity, as summarized in Table 3 (with illustrative examples provided in Appendix 3, available from CFPlus^*). These drivers predominantly reflected a focus on physician or clinician administrative burden. Health system drivers include documentation and administrative requirements of health systems, notably funders and insurers. Many articles from the United States focused on Medicare and Medicaid billing requirements, as well as prior authorizations for insurers. Similar examples from public insurers and supplementary insurance providers are relevant to Canada. Discussion of health system drivers tended to address the cumbersome nature of administrative tasks from the clinician perspective, with less attention to implications for administrative staff, patients, or caregivers. Canadian studies also emphasized delays in accessing diagnostic imaging and referred services as health system drivers of administrative burden.

Table 3.

Overview of drivers of and solutions for primary care administrative burden, as noted in reviewed literature

ADMINISTRATIVE BURDEN CATEGORY	DRIVERS	SOLUTIONS
Health systems (n=116)
Documentation and patient records	Requirements for documentation and work to maintain and interact with patient records	Changes to documentation requirements (health system), enhanced use of EMRs and AI scribes (technology), and task shifting
Billing, coding, and insurance interactions	Billing requirements and insurance interactions, particularly in health systems with multiple payers	Changes to documentation required for payment, streamlined processes, and simplified payment models (health system)
Referrals	Cumbersome and varied processes for referrals to other specialists, imaging, laboratory tests, and services or programs	Simplified referral processes (health system), enhanced use of EMRs and e-referral tools (technology)
Prior authorization	Unreasonable prior authorization requirements, cumbersome and varied prior authorization processes	Elimination, reduction, or streamlining of requirements (health system, involving various insurers and payers), enhanced EMR use, and integration of forms (technology)
Technology (n = 28)
EMRs	EMRs were frequently mentioned as both drivers and solutions Solutions included efforts to optimize EMR use, use of both AI and human scribes, and task shifting
Implementation of new health technology or platforms	Implementation of new platforms to share information (eg, e-referrals) was also mentioned as both a driver and solution. While they may address compliance costs, they often come with additional learning or compliance costs or shift burden among people using the platforms Ensuring platforms are user-friendly and integrating AI technology data management were discussed as solutions
Telemedicine	While telemedicine has become an important point of access for patients, it may be associated with additional administrative burden	EMR integration and task shifting are potential solutions
Patient complexity (n=21)
Elderly patients and patients with comorbidities	These patients often require additional time to meet their care needs, including documentation, insurance interactions, referrals, and prior authorization	Solutions included changes to health system requirements, as well as new models of practice organization and team-based care
“Complex” patients	Definitions of “complex” patients varied but typically included multiple characteristics such as age, chronic conditions, and mental health needs alongside social or economic marginalization. Presence of more complex care needs shape administrative work to coordinate care within health systems and to help patients access social programs and other support services external to health systems	Solutions included collaborative team-based approaches that address social determinants of health as well as streamlined processes for access to social programs
Task shifting
Task shifting	Task shifting was frequently proposed as a solution to administrative burden. Given that it does not directly reduce workload, task shifting is a solution for some and a driver for others

AI—artificial intelligence, EMR—electronic medical record.

Electronic health records or electronic medical records (EMRs) and telemedicine were both noted as technological drivers of administrative burden. Technology both exacerbated compliance costs and introduced learning costs as people learned to use new technology.

Patients and populations were in some cases mentioned as drivers of administrative burden. Elderly patients, patients with comorbidities, and socially or economically marginalized patients were often considered to require more indirect patient care.³⁷ Patient complexity was sometimes noted but not always defined.

Solutions

Solutions to administrative burden largely corresponded to drivers. Health system solutions were often broad and simply acknowledged that efforts were required to minimize administrative burdens placed on primary caregivers and in some cases patients or populations, particularly with respect to documentation, insurance, and prior authorization requirements.

Technology was commonly observed as both a driver of administrative burden and a solution. Solutions included e-consultation and referral platforms, EMR optimization, and patient monitoring platforms. Some uses of technology proposed as solutions to health system compliance costs (eg, EMR optimization and e-consultation and referral platforms) were themselves noted as drivers of administrative burden in other studies.

A third category of solutions focused on task shifting, including incorporating scribes, involving allied health professionals in administrative tasks, or having greater administrative staff support. Redistribution of administrative work may be a solution for some while being a driver for others.

In response to patient complexity as a driver of administrative burden, potential solutions included embracing collaborative and team-based care, paying attention to patients’ social determinants of health, and streamlining processes to enhance access to social support services.

DISCUSSION

Administrative burden is often discussed but not clearly defined in primary care literature. Most primary care sources focused on physician experiences of administrative burden, with fewer considering other clinicians’ experiences and even fewer considering patient or caregiver perspectives. Without a consistent definition, it may be helpful to consider learning, compliance, and psychological effects to understand primary care administrative burden. Drivers of administrative burden include requirements of health systems, inadequate technological tools available to do administrative work, and complexity of patient populations. Solutions similarly include changes to requirements of health systems, optimization of technology, and task shifting, in alignment with recommendations in the grey literature.³⁸

Technology was frequently identified as both a solution to and driver of administrative burdens, which suggests technology may be being used to address compliance costs but is inadvertently adding learning costs or unintentionally shifting tasks. For example, e-referral platforms may add administrative workload in primary care while reducing administrative workload among referred specialties,³⁹ or EMRs may shift tasks that might previously have been the responsibility of administrative staff to primary care clinicians.⁴⁰ Given this, solutions to administrative burdens should consider costs broadly, including learning and psychological costs, alongside compliance. They should also evaluate any possibility of unintentional task-shifting from multiple perspectives, including those of clinicians, administrative staff, patients, and caregivers. Capacity of those expected to take on tasks and what support is needed must be considered.

Social and structural determinants of health underpin health systems, access to technology, and patient complexity, but these considerations were infrequently discussed even where closely connected to administrative burden.³⁷ One example is forms required to access services or resources, which were often mentioned as sources of administrative burden.⁴¹ Where forms must be completed by primary care providers, this may compound inequities, given that access to primary care is unevenly distributed.²³ As patients with more complex needs already experience additional administrative burdens,⁴² priorities and choices with respect to addressing administrative burdens may have direct implications for equity in health care.⁴³ Looking at how social and structural determinants shape administrative burdens and examining the equity implications of strategies intended to address administrative burden are both areas that would benefit from further research.

Limitations

This review offers a timely synthesis of literature on a topic gaining attention in the primary care sector, but there are limitations to this work. While we conducted a systematic search of academic sources, incorporating grey literature such as advocacy documents from health professional associations, reports, and working papers could further strengthen discussion. Having only a single author screen articles allowed for consistency with the extraction and screening processes, but an additional screener may have enhanced replicability of results. A contribution of this review is a description of the varied costs associated with administrative burdens and broad categories of drivers and solutions. This review included sources from varied health system contexts, and so it cannot directly be used to inform immediate solutions relevant to specific practice or policy environments. For example, the context for insurance interactions in the United States differs substantially from that in Canada. Given that administrative roles have been traditionally occupied by women, and a growing percentage of primary care clinicians are women,⁴⁴ lack of attention to the function of administrative work mirrors broader societal patterns of making women’s work invisible and unsupported. Also, some evidence points to female physicians experiencing additional administrative burden, including time documenting patient encounters, writing notes, and using EMR systems.⁴⁵ A gendered lens would strengthen further research. Finally, more Canadian research looking at experiences of patients and caregivers—as well as those of nonphysician team members, including administrative staff—is clearly needed.

Conclusion

Administrative burden is not merely “unnecessary” paperwork, as it also includes functions that support continuity and coordination, which are central to primary care. Attention is often focused on compliance costs of forms and paperwork, but learning costs (eg, finding information and learning new technology) and psychological costs should not be overlooked. Solutions should consider costs broadly and evaluate implications from multiple perspectives, including those of patients and caregivers.