C3-1: Footprints in the Sand: Tracking Physician Work Efforts in Primary Care Using Access Logs in an Electronic Health Record

Abstract

Background/Aims

Using EpicCare Electronic Health Record (EHR) data in a large multispecialty ambulatory delivery system, we explore a unique opportunity in which existing EHR data may offer clues on how clinicians use time, a scarce yet critical resource in health services delivery. Traditional means of studying physician time use during clinical encounters (e.g., direct observation) are costly and ignore pre-service and post-service work of physicians’ services. The EpicCare EHR offers an alternative, unobtrusive portal to study time use through analysis of access logs.

Methods

We used EHR access log data for one month in 2013 from 49 physicians in two primary care departments who cared for 22,174 patients in a large multispecialty ambulatory delivery system. Over 3 million EHR transactions are examined to explore individual physicians’ style of time use on different tasks, as reflected by the access log. In-depth key informant interviews are used to complement the access log data on how physicians use the EHR and the activities that are more or less likely to be captured by the access log.

Results

About 43.7% of physicians’ total time for the month involved in-person face-to-face visits, 33.8% involved pre and post visit time, 11.4% telephone calls, 5.6% secure messaging to patients, 2.6% prescription refills, and 1.6% on orders for labs, medications or referrals. The earliest EHR access in the office occurred at 12:00 am and the latest logging out time in the office was at 11:59 am the following day. For each patient visit, an average of 16.7 minutes was logged in the exam room and 7.9 minutes logged outside of the exam room.

Conclusions

The access log is a valuable tool for studying physician work efforts. Our findings highlight the significant amount of time clinicians spend outside of office visits. Unless there is a fixed ratio of in-office to total time, visit-centric FFS payment may undercompensate the significant efforts outside of visits. As “desktop medicine” (e.g., via phone, messaging) increases in the age of the Internet, smart phones, and EHRs, reforming provider payment mechanisms to account for work outside of office visits is warranted.