Addressing administrative burden in family medicine: a local quality improvement initiative

Abstract

Background

Administrative burden absorbs approximately 40% of family physicians’ time in Canada, reducing direct care and fueling burnout and access challenges. Inconsistent definitions hinder measurement and solutions. This quality improvement (QI) initiative uses an integrated knowledge translation approach to clarify definitions and prioritise actionable, community-level changes.

Specific aims

Collaborate with family physicians to better define administrative burden within the context of one community and identify actionable priorities to share with local stakeholders.

Methods

A QI study using an integrated knowledge translation approach involving five Family Health Organizations within one Family Health Team, located in [redacted]. Results were analysed using qualitative thematic analysis and quantitative results were analysed using descriptive statistics.

Interventions

Facilitated small group stakeholder sessions followed by collection of real-world examples of administrative burden submitted by family physicians.

Results

Eight elements of administrative burden were included in the final revised definition: excess volume, health system inefficiencies, misallocated tasks and responsibilities, impacts on therapeutic or professional relationships, increased cognitive and emotional load, ineffective communication, low-value tasks and inadequate compensation. 146 physician submissions of administrative burden were received, of which 138 were analysed. The most common category of administrative burden was excess volume (n=85).

Conclusion

A locally adapted, physician-informed definition of administrative burden underscores the personal and cognitive impacts often overlooked by system-level descriptions of administrative burden. Excess documentation, especially duplication, and communication failures between stakeholders were the most common and actionable contributors. The design of the study with family physicians resulted in three key recommendations: (1) send it once, send it right; (2) reconnect with family physicians and (3) act now. Researchers also recommended collecting quantifiable data on contributors of administrative burden. These findings inform practical, community-oriented interventions that complement provincial and national efforts to reduce administrative burden, decrease physician burnout and increase time for patient care.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Administrative burden among family physicians has gained nationwide attention due to its impact on the physician workforce, physician burnout and access to primary care; however, addressing this even at a local level is challenging in the absence of a clear, consistent definition.

WHAT THIS STUDY ADDS

• By engaging with frontline family physicians, this study identifies specific elements of tasks that make them burdensome while providing concrete examples which identify small, actionable priorities for change.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• This study hopes to contribute to the development of a larger framework that can be applied to address administrative burden at a community-based or regional level.

Introduction

Problem description

There is growing recognition of the impact of administrative burden on family physicians. A recent survey by the Ontario College of Family Physicians reports that 40% of family physicians’ time is spent doing administrative tasks, taking away from direct patient care.¹ The increasing burden of administrative work has been attributed to physician burnout, a diminishing family physician workforce and has compromised access to primary care for all Ontarians.^2–4 Work is in progress at the national and provincial levels to liaise with stakeholders and address issues identified as burdensome in primary care. Family physicians may be able to share simple, practical steps that can be taken at a smaller, community level to manage administrative workload, but few formalised channels exist to consolidate this feedback and implement change.

Administrative burden is defined inconsistently throughout the literature. The Canadian Medical Association (CMA) defines administrative burden as tasks that demand a disproportionate amount of effort relative to the value they generate for patients and health systems. They include four key elements: excessive volume of administrative tasks, redundancies and inefficiencies in the healthcare system, assignment of low-value tasks to physicians, and tasks that are not appropriately compensated.⁵ In contrast, other professional groups and researchers include routine paperwork, clerical tasks or trying to quantify administrative burden by units of cost or time.³ Such inconsistencies and a lack of clarity in the definition have made it challenging to identify and address administrative burden or compare it across regions.⁶

Available knowledge

The characterisation of administrative burden to date has mainly focused on broad survey data from professional organisations or position papers highlighting low-value tasks.^{1 3} While frameworks like the CMA’s provide a structure for categorisation of administrative burden, there is a lack of understanding of the issue at the community level that allows for comparison between locations.⁶ Recent studies have suggested that characterising administrative burden requires an understanding of specific workflow inefficiencies within the primary care context.⁶

Rationale

This study employed an integrated knowledge translation (IKT) approach, with local family physicians in [location], Ontario, to ensure the methodology was contextually relevant, feasible and minimally disruptive to clinical workflows.^{7 8} IKT is an approach in which knowledge users (eg, family physicians) collaborate across the problem definition, methods, analysis and implementation. It is best used in context-dependent problems where outputs are operational, and adoption depends on partner buy-in.⁷ This project fits well in the IKT model because administrative burden is a local issue and requires physician engagement to both explore and address. Physicians were instrumental in designing the study and its methodology with the goal of maximal participation in ongoing data collection and implementation.

Specific aims

In partnership with the [location] Ontario Health Team, family physicians codesigned this quality improvement (QI) project to define administrative burden and identify contributors to administrative burden from the community’s organisations and institutions. The purpose of this project was to establish important, relevant baseline measures to guide future QI initiatives aimed at decreasing administrative burden for family physicians in [location], Ontario.

Methods

Context

Within the [location in Ontario], there are approximately 80 family physicians working in one Family Health Team (FHT); however, within the FHT, there are five independent Family Health Organizations (FHO)—each with its own administrator and organisational structure. There is marked variability between each FHO by size (ie, number of physicians), level of administrative support and location of its physicians. The groups also vary in their use of electronic medical record (EMR) system with some having tools such as provincial Health Report Manager (HRM) for incoming reports whereas others use faxing exclusively. Unique considerations also needed to be made for each FHO regarding custodianship of health information. The goal of the research team was to foster physician engagement and support development of a standardised methodology that could be applied across each FHO as a QI initiative and later aggregate the anonymised dataset to represent all subgroups within the local FHT.

This project was led by the [Location] Family Doctors’ Think Tank, a physician leadership group that has identified administrative burden as an actionable priority for the local physician workforce. By using an integrated knowledge translation (IKT) approach and small group discussions, the initiative ensured that the problem definition and methodology were borne directly from physicians. This has been recognised as a key factor for the adoption of solutions and increased physician engagement within this context.⁷ This work was supported by the [location] Ontario Health Team, which aims to translate community initiatives into regional policy and guides resource allocation to reflect future healthcare priorities.

Intervention

Aligned with the IKT approach, this study engaged family physicians from the [location] FHT at the outset to co-define scope and identify areas of improvement. This early engagement helped to frame the study within the local context. Stakeholder engagement began with presentations to each participating FHO, where project goals and relevant literature were reviewed. During these sessions, a working definition of administrative burden, based on the Canadian Medical Association Administrative Burden Working Group,⁵ was presented followed by a facilitated, small-group discussion. Detailed notes were made during these discussions to support the development of a revised, collaboratively developed working definition of administrative burden. Once administrative burden was collectively defined, this study aimed to identify specific examples—based on physician submissions—to prioritise potential solutions.

At the project outset, the study team shared examples of existing methodology that aimed to quantify administrative burden, then asked physicians to comment on an approach that would be minimally disruptive and most engaging. Physicians preferred a workflow-integrated submission method to limit interruption of their clinical work and requested that all reviews be conducted internally by members of the existing clinical team to protect patient privacy and data security. As such, data collection was integrated into existing EMR systems through secure internal messaging to a designated member of the FHO, often the team administrator. This mirrored clinic operations for everyday administrative tasks, ensuring that the format and content were complete and comparable across sites. One team also suggested that paper-based alternatives be available for physicians preferring non-digital workflows and to maximise participation. Data collection was scheduled to occur over a 30-day window as agreed upon by physician participants during which physicians could report burdensome tasks. Participants were encouraged to focus on locally addressable issues, and further feedback on the definition and process was welcomed to support iterative validation.

A detailed instruction guide was created and shared to all FHOs to ensure standardisation of the methodology. Each FHO was asked to lead their own data collection as an internal QI exercise. Physicians were given a preliminary draft of the revised definition of administrative burden to guide submissions but were not limited to this. An emphasis was made to ensure submissions were locally relevant.

Measures

For this project, a mixed-methods approach was used to provide rich data necessary to capture some of the quantitative nature of the volume of tasks and the qualitative nature of physician experience. The methodology was designed with stakeholders to ensure that the collection methods were contextually relevant to physicians and minimally disruptive to their workflow. To maximise efficiency and engagement, data were collected by administrators internally, avoiding the need for external portals and additional friction points. Administrators served as intermediaries, collecting anonymised data for the research team to maximise patient privacy.

Analysis

Detailed notes were available from each of the stakeholder engagement sessions and independently coded by two members of the research team. For each session, facilitators captured detailed deidentified notes from participants on issues experienced, examples and proposed fixes. Two research team members independently coded the notes using inductive coding to capture specific themes. After independent coding, discrepancies were resolved through consensus meetings. Thematic analysis was conducted across sessions to group codes into themes. The final themes were used to generate a more comprehensive and locally adapted definition which would guide data analysis for the second part of this study.

To identify and obtain concrete examples of local contributors of administrative burden, a submission process was created. Data collection was standardised across all FHOs using a structured submission guide with predefined fields and examples, ensuring consistent content and format of submissions. Physicians submitted burdensome tasks via EMR messaging to a designated team member or via paper forms. Submissions were deidentified of both participant and patient data prior to sharing with a member of the research team. Data collected included message sent to administrator, document type (eg, lab report, discharge summary), confirmation of it being a local problem, details of the issue and name of external organisation involved including department, if possible. Both quantitative and qualitative analyses were applied to this dataset.

A total of eight themes were identified which were used to analyse the physician submissions. All submissions were categorised in these groupings with potential for new or emerging themes to be included and to validate the newly proposed definition.

Several variables related to time may have impacted submission volume, including the 30-day collection window which may have missed seasonal variations in administrative load. There is no established baseline of EMR data volume in the region making it difficult to assess if the collection window used was during a peak, typical or reduced workload.

Patient and public involvement

Patients and the public were not involved in the preparation and development of methodology of this project. However, patients will be consulted in the plans for dissemination by engaging with Patient and Family Advisory Councils of key stakeholder organisations.

Results

Two adaptations to methodology occurred during the study. First, while the intent was to simply adapt the CMA definition of administrative burden, the feedback from physicians necessitated a complete inductive coding process to ensure local details were not lost. Although low-value tasks and inadequate compensation were agreed to be important and some examples shared, they were not identified as themes after inductive analysis. These elements were still included in the adapted definition to ensure comprehensiveness and consider limitations of generalisability within QI studies. Second, while the local Ontario Health Team (OHT) was originally slated to lead the project, it became evident that physician leadership and engagement were critical. As a result, the project transitioned to being led by physicians through the [location] Think Tank, with the OHT shifting to a supporting role.

Part I: stakeholder engagement – redefining administrative burden

There was a total of four FHO-based facilitated small-group sessions (n=29). While there was general agreement with the original CMA’s definition of administrative burden, many physicians felt that it was vague. Six themes were incorporated as revisions or specifications of the CMA’s definition. Two themes were more descriptive of the experience of family physicians with administrative burden locally. These themes are summarised in table 1.

Table 1. Administrative burden as defined by [location’s] family physicians*.

CMA’s elements of administrative burden	Revisions (post-analysis)
Excess volume of tasks	Excess volume
Redundancies and inefficiencies of the healthcare system	Inefficiencies of the healthcare system
Low-value tasks
Tasks for which physicians do not receive appropriate compensation
	Misallocated tasks and responsibilities
	Impacts on therapeutic or professional relationships
	Increase cognitive and emotional load
	Ineffective communication

Themes #7 and #8 are not included in this table as they do not apply to the definition of administrative burden but are more descriptive of the physician experience.

CMA, Canadian Medical Association.

Six themes that refined the definition of administrative burden are presented below.

Theme #1: excess volume

Physicians described receiving numerous copies of the same documents as well as partial consultation notes. The use of templates which included extensive historical patient information, unnecessary cover pages and identical prescription renewal requests were shared as examples of excess volume. One physician outlined possible consequences of this, “the greater the volume of irrelevant stuff, the less likely we are to catch something we need.” The volume of excess documentation was significant, with individuals describing receiving 10s to 100s pages of irrelevant and unnecessary information. One participant considered the environmental impacts of this cumulative volume of data moving in and out of servers.

Theme #2: inefficiencies of the healthcare system

Family physicians shared examples of inefficiencies in the system that generated work often duplicated elsewhere. Poor interoperability and connectivity between EMRs were discussed. For example, medications or diagnoses changed by a specialist during a consultation, then required a family physician to do the same in their own EMR. Another example involved provincial cancer screening, where recommendations, advice and results are given directly to patients while family physicians are also responsible for the same.

Theme #3: misallocated tasks and responsibilities

There were a few routine practices that were brought into question raising concerns around appropriateness of such tasks for family physicians. This included routine immunisations, prescriptions for orthotics or massage, and occupational health assessments (eg, sick notes). In addition, many family physicians expressed frustration with the downloading of responsibilities. Organisations often send tasks to family physicians to schedule follow-up, arrange testing or seek treatment when such interactions have always previously been initiated by patients (ie, by booking an appointment). The distinction was made in these situations between advocating and simply ‘dumping’ of work onto family physicians.

Theme #4: impacts on therapeutic or professional relationships

Family physicians expressed concerns with occupation-related forms and evaluating fitness for employment. With little or no training to do these assessments and unknown workplace context, many discussed the strain this could place on patient-physician relationships. Third-party requirements for paperwork also come at a financial cost to patients putting family physicians in an uncomfortable position, often choosing to reduce or waive fees altogether. There was a sense that burdensome tasks also compromised important professional relationships. Whether it’s repeated renewal requests from pharmacies, inappropriate delegation of work or referral rejections, these create tension between family physicians and specialists or community organisations.

Theme #5: increase cognitive and emotional load

Participants referred to the cognitive load associated with reviewing redundant documents, filtering through high volumes of information, and discussed the heightened perception of risk—particularly of missing critically important information. As emphasised in one group, “it is so dangerous when you are trying to find the one needle in the haystack.”

Theme #6: ineffective communication

Ineffective communication was evident in discussions of referral processes, prescription refills and formatting of notes. Burdensome activities included anything that required family physicians to exit the EMR for delivery of care—such as unique referral portals. Family physicians shared frustrations when needing to resend the same consultation request to multiple physicians of the same specialty. With no standard turnaround time in place, physicians often receive requests for prescription renewals immediately followed by dispensing notification (eg, extension by pharmacist), and repeated requests for the same medication until the refill is completed.

Participants highlighted changes that arose since hospitals adopted a new EMR and its impact on incoming data. There was frustration with the absence of clear summaries and standardised formatting of notes from hospitals. Many found finding action items and critical information to be challenging. There was some speculation that liability may play a role “there is a game of making notes as complete as possible; not thinking about how this impacts anyone else down the line.”

The following two themes illustrate the experiences of family physicians in discussions of administrative burden.

Theme #7: low morale

Participants voiced exasperation and little confidence in changes by organisations responsible for contributing to administrative burden. In discussing these problems and previous attempts at addressing them, the lack of hope was evident by statements such as “nothing can be done to make this better,” “I just accept this” and “I have no faith.”

Theme #8: limited family physician engagement

There was a perception that decisions and changes in other institutions did not consider the trickle-down effects on community-based family physicians. For example, hospitals’ adoption of new EMR features or the use of portals serve purpose to referral recipients with increased and clumsy new workflows for outpatient practices. The lack of collaboration illustrated by statements such as “everyone [is] trying to get us on their own particular way.”

Part II: characterising administrative burden

A total of 146 submissions of administrative burden were received from family physicians across 5 FHOs. Eight submissions were excluded due to lack of clarity. Each example of administrative burden was categorised into the ‘elements’ of the adapted definition and is illustrated in table 2. The themes were not mutually exclusive with some overlap among submissions. No new themes emerged from this dataset and all submissions could be categorised within the framework applied.

Table 2. Physician submissions of administrative burden (n=138).

Theme	Examples
Excess volume (n=85)	Receiving numerous copies of the same report Sick notes followed up by lengthy forms requesting the same information Inclusion of all results and investigations in a consultation note when also sent individually Internal referrals (eg, family physician to social worker) requiring a form and electronic medical record (EMR) message Irrelevant notification (eg, patient arrived to emergency department)
Inefficiencies of the healthcare system (n=8)	Cancer Care Ontario incorrectly or inappropriately identifying eligible patients for screening Redirecting referral due to first recipient being ‘unable to accept’ New Limited Use (LU) code required after medication switched from Prolia to Jubbonti—a process initiated by the Ministry of Health
Inadequate compensation (n=1)	Exceptional Access Program (EAP) forms
Impacts on professional or therapeutic relationships (n=8)	Practice closures with re-referral requests tasked back to family physicians Pharmacist-initiated prescriptions after pharmacy-initiated consultations with patients (ie, for vaccinations or over the counter medications)
Low value (n=13)	Review of MedsCheck completed by pharmacist Prescription requests for orthotics for insurance
Ineffective communication (n=37)	Use of specialty-specific acronyms in notes Receipt of partial and/or incomplete reports Use of unique portals to send referrals, such as ‘Ocean’ Lack of clarity regarding who is ordering outstanding investigations or arranging follow-up Follow-up repeat faxes within a very short interval Receiving identical reports through multiple channels (ie, Health Report Manager (HRM) and fax)
Misallocated tasks and responsibilities (n=18)	Pharmacy initiated prescription renewal requests which should require patient to follow up and book an appointment Consultants not ordering the appropriate investigations within their scope of practice
Increase cognitive and emotional load (n=12)	Reviewing multiple reports, many of which are the same, to ensure there is no new information

Given the volume of submissions in the category of excess of volume and duplication of tasks, further review was completed. Of the 85 submissions in the category, 56 (66%) were physicians receiving the same report two or three times. There were numerous sources of duplicate reports, but most were from hospitals (68%), community pharmacies (14%) and laboratories (9%).

Applying this methodology, physician submissions undercounted certain categories (eg, compensated tasks) and emphasised those most visible in the inbox. A primary limitation of this dataset is the lack of understanding of the total volume of incoming reports to an inbox per day. This prevents determination of the percentage of total inbox traffic that is contributing to administrative burden. The manual nature of the reporting process may have discouraged submission of every instance of burden experienced by physicians. Given the low number of submissions for total number of participants, this study could not accurately quantify administrative burden but could help characterise examples. Informal feedback received on the process of submissions from team administrators was that the dataset in general was likely an underrepresentation of the true volume of issues that met criteria.

Although this methodology of submissions was developed in collaboration with family physicians, this project likely generated more work for both family physicians and FHO administrators—taking away from routine clinical activities and incurring costs for their time.

Discussion

Summary

This project’s key findings include the creation of a locally relevant definition of administrative burden that captures factors often overlooked by national descriptions. A major strength of the study was the IKT approach which secured physician engagement and generated actionable examples of burden in practice. By identifying excess volume and specific communication challenges, this study provides a baseline for targeted local QI initiatives.

Interpretation

In a recent study by Brown et al, authors studied contributors of administrative burden, which included deteriorating relationships between family physicians and specialists.⁷ This was also reflected in themes from this study—impacts on therapeutic or professional relationships, ineffective communication, and misallocated tasks and responsibilities all illustrate frustration, lack of collaboration and poor coordination between primary and secondary care. Revitalising these meaningful connections may play an important role in tackling administrative burden. Strengthening and offering opportunities for family physicians to be engaged in the development and implementation of workflow processes that impact them may help instil confidence and optimism for change.

Researchers from the USA have cited that up to 75% of physicians with burnout identified electronic health records (EHR) as a source.⁸ Budd⁹ looked at specific contributors of EHR-related burnout, which mirrors the findings of this study. The rising load of clerical tasks associated with EHR use, EHR associated information overload and the cognitive burden of bulky, cluttered and templated notes were identified as contributors to physician burnout.^{9 10} This study attempts to understand these EMR-driven sources of burden by characterising the specific types of inbox data that create an increase in cognitive load, providing a better understanding of how digital workflows translate into information overload.

Volume of documentation, particularly from duplication, was frequently mentioned in this study. The stakeholder engagement sessions highlighted the emotional and cognitive load this carried. Steinkamp et al demonstrated that duplication is not the fault of individuals, but the rational response of clinicians attempting to manage information in a documentation paradigm that may be guided not by delivery of care and efficiency but rather by EMR capabilities, billing and legal requirements.¹¹ The findings from this study validate the sentiments felt by family physicians—information overload and duplication are severe hazards for clinicians.¹¹ Duplicated content increases the time required by clinicians to discern accurate information and may result in valuable information being missed.¹¹

There is growing interest to better understand administrative burden for physicians and its implications. In aiming to quantify administrative work, Gallant et al demonstrated a general increase in administrative workload for physicians between 2011 and 2021 with number of referrals, lab tests and prescriptions per physician increasing by 80.2%, 68.5% and 43.1%, respectively.¹² Although this figure quantifies all tasks, it cannot characterise which of these may be considered burdensome. In a survey of 1924 Canadian physicians, respondents estimated that 47% of their administrative time was spent on unnecessary tasks.¹³ There are concerns of administrative burden impacting the sustainability of the current physician workforce.¹³ In aggregated national data, top drivers of unnecessary administrative work included insurance companies (76%), government forms (59%), pharmacies (58%) and EMRs (51%).¹³ Although the results of this study identified similar drivers, the relative importance assigned locally varies from national-level data.

While the goal is to reduce administrative burden, there is a recognition that successful interventions require a thorough understanding of the local context. This study maximises the relevance of future QI initiatives and represents a shift from anecdotal frustration towards a structured data-driven approach to local, grassroots-level problem solving.

Limitations

The findings of this project are context specific and are intended to understand the contributors of administrative burden within one community likely from its regional healthcare facilities. The small sample size and potential for confounding bias are inherent, as well as limited generalisability outside of the community. To minimise these factors, an approach using inductive coding and consensus meetings were undertaken to ensure trustworthiness of the qualitative results.

Conclusions

This QI initiative explored the perspectives of local family physicians to adapt a definition of administrative burden relevant to their specific context and identify priorities for change. This study provides a useful framework for identifying local priorities and adapting administrative burden definitions to local environments. The implications for practice include the possibility of using the physician led methodology to other local challenges. Long-term sustainability is dependent on transitioning these findings into actionable QI initiatives.

Data availability statement

Data are available upon reasonable request.