The myth of standardized workflow in primary care

Holman, G. T.; Beasley, John W.; Karsh, Ben‐Tzion; Stone, Jamie A.; Smith, Paul D.; Wetterneck, Tosha B.

doi:10.1093/jamia/ocv107

Cited by 48 publications

(37 citation statements)

References 43 publications

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“…This extra time equates to an average workday (excluding time providing care to patients in the hospital) of 11.4 hours, representing a considerable encroachment on physicians' personal and family lives. Although others have suggested work task categories for primary care, 13 ours is the first taxonomy proposed to capture routine clinical work in EHR systems. This study extends other work by validating EHR audit data with direct observation data within the same clinical environment.…”

Section: Discussionmentioning

confidence: 99%

Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations

Beasley²,

et al. 2017

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PURPOSE Primary care physicians spend nearly 2 hours on electronic health record (EHR) tasks per hour of direct patient care. Demand for non-face-to-face care, such as communication through a patient portal and administrative tasks, is increasing and contributing to burnout. The goal of this study was to assess time allocated by primary care physicians within the EHR as indicated by EHR userevent log data, both during clinic hours (defined as 8:00 am to 6:00 pm Monday through Friday) and outside clinic hours. METHODSWe conducted a retrospective cohort study of 142 family medicine physicians in a single system in southern Wisconsin. All Epic (Epic Systems Corporation) EHR interactions were captured from "event logging" records over a 3-year period for both direct patient care and non-face-to-face activities, and were validated by direct observation. EHR events were assigned to 1 of 15 EHR task categories and allocated to either during or after clinic hours.RESULTS Clinicians spent 355 minutes (5.9 hours) of an 11.4-hour workday in the EHR per weekday per 1.0 clinical full-time equivalent: 269 minutes (4.5 hours) during clinic hours and 86 minutes (1.4 hours) after clinic hours. Clerical and administrative tasks including documentation, order entry, billing and coding, and system security accounted for nearly one-half of the total EHR time (157 minutes, 44.2%). Inbox management accounted for another 85 minutes (23.7%).CONCLUSIONS Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. EHR event logs can identify areas of EHR-related work that could be delegated, thus reducing workload, improving professional satisfaction, and decreasing burnout. Direct time-motion observations validated EHR-event log data as a reliable source of information regarding clinician time allocation. Ann Fam Med 2017;15:419-426. https://doi.org/10.1370/afm.2121. INTRODUCTIONP rimary care has become increasingly complex, 1 with electronic health record (EHR) systems adding to the complexity. Our patients expect same-day access for face-to-face care during clinic hours and rapid responses to telephone calls, patient portal messages, laboratory result inquiries, and prescription renewal requests both during and after clinic hours. This concurrent face-to-face (synchronous) and non-faceto-face (asynchronous) care, combined with administrative and regulatory work (prior authorizations, billing and coding, performance measurement) results in considerable strain on the primary care team. It is imperative to understand factors contributing to workload and identify practical solutions to these challenges.US physicians spend numerous hours daily interacting with EHR systems, contributing to work-life imbalance, dissatisfaction, high rates of attrition, and a burnout rate exceeding 50%. entry (CPOE), inbox management, patient portals, and a redistribution of tasks previously performed by clinical staff to clinicians has led to more work that is not direct fac...

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Section: Discussionmentioning

confidence: 99%

Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations

Beasley²,

et al. 2017

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“…It reflects the lack of homogeneity in clinical workflow and the discrepancy between CDS and how providers cognitively process their work. [26] Providers are likely to dismiss tools that trigger before or after the decision making process. Providers gather information from the EHR, for example past medical history and vital signs and then later put orders in using the EHR.…”

Section: Discussionmentioning

confidence: 99%

“Think aloud” and “Near live” usability testing of two complex clinical decision support tools

Richardson

Mishuris

O'Connell

et al. 2017

International Journal of Medical Informatics

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Objectives Low provider adoption continues to be a significant barrier to realizing the potential of clinical decision support. “Think Aloud” and “Near Live” usability testing were conducted on two clinical decision support tools. Each was composed of an alert, a clinical prediction rule which estimated risk of either group A Streptococcus pharyngitis or pneumonia and an automatic order set based on risk. The objective of this study was to further understanding of the facilitators of usability and to evaluate the types of additional information gained from proceeding to “Near Live” testing after completing “Think Aloud”. Methods This was a qualitative observational study conducted at a large academic health care system with 12 primary care providers. During “Think Aloud” testing, participants were provided with written clinical scenarios and asked to verbalize their thought process while interacting with the tool. During “Near Live” testing participants interacted with a mock patient. Morae usability software was used to record full screen capture and audio during every session. Participant comments were placed into coding categories and analyzed for generalizable themes. Themes were compared across usability methods. Results “Think Aloud” and “Near Live” usability testing generated similar themes under the coding categories visibility, workflow, content, understand-ability and navigation. However, they generated significantly different themes under the coding categories usability, practical usefulness and medical usefulness. During both types of testing participants found the tool easier to use when important text was distinct in its appearance, alerts were passive and appropriately timed, content was up to date, language was clear and simple, and each component of the tool included obvious indicators of next steps. Participant comments reflected higher expectations for usability and usefulness during “Near Live” testing. For example, visit aids, such as automatically generated order sets, were felt to be less useful during “Near-Live” testing because they would not be all inclusive for the visit. Conclusions These complementary types of usability testing generated unique and generalizable insights. Feedback during “Think Aloud” testing primarily helped to improve the tools’ ease of use. The additional feedback from “Near Live” testing, which mimics a real clinical encounter, was helpful for eliciting key barriers and facilitators to provider workflow and adoption.

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“…64 "Information scatter" described health records cluttered with entries from other health care clinicians. 21,44,66,68 Difficulties finding "buried" information" 21,23,34 led many physicians to simply ask patients for required information instead 23,32,36,44,68 , while others kept memos for themselves on complex cases, or developed tracking systems for important outgoing correspondence, prescriptions, and test requests. 16,19,20,22,25,27,29,30,32,36,44,47,57,63,65,[67][68][69]…”

Section: Synthesizing Argument: Operational Failures Configure Primarmentioning

confidence: 99%

Impacts of Operational Failures on Primary Care Physicians’ Work: A Critical Interpretive Synthesis of the Literature

et al. 2020

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PURPOSE Operational failures are system-level errors in the supply of information, equipment, and materials to health care personnel. We aimed to review and synthesize the research literature to determine how operational failures in primary care affect the work of primary care physicians. METHODS We conducted a critical interpretive synthesis. We searched 7 databases for papers published in English from database inception until October 2017 for primary research of any design that addressed problems interfering with primary care physicians' work. All potentially eligible titles/abstracts were screened by 1 reviewer; 30% were subject to second screening. We conducted an iterative critique, analysis, and synthesis of included studies. RESULTS Our search retrieved 8,544 unique citations. Though no paper explicitly referred to "operational failures," we identified 95 papers that conformed to our general definition. The included studies show a gap between what physicians perceived they should be doing and what they were doing, which was strongly linked to operational failures-including those relating to technology, information, and coordination-over which physicians often had limited control. Operational failures actively configured physicians' work by requiring significant compensatory labor to deliver the goals of care. This labor was typically unaccounted for in scheduling or reward systems and had adverse consequences for physician and patient experience. CONCLUSIONS Primary care physicians' efforts to compensate for suboptimal work systems are often concealed, risking an incomplete picture of the work they do and problems they routinely face. Future research must identify which operational failures are highest impact and tractable to improvement.

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The myth of standardized workflow in primary care

Cited by 48 publications

References 43 publications

Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations

Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations

“Think aloud” and “Near live” usability testing of two complex clinical decision support tools

Impacts of Operational Failures on Primary Care Physicians’ Work: A Critical Interpretive Synthesis of the Literature

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