Abstract
Background
The time spent and complexity of work done by primary internal medicine physicians between office visits has not been well studied.
Objective
To measure the time and complexity of this care.
Design
Cross-sectional study.
Setting
General internists practicing on primary care teams with electronic medical records at a tertiary Veterans Health Administration Medical Center.
Participants
Ten physicians.
Main Measures
The project was designed to measure physician work between office visits. The electronic record was used to record the number and complexity of work events by physicians for 1 month. Complexity of work was measured on five levels ranging from Level I with no change in management, Level II with change in management of one disease, Level III of two diseases, Level IV of three diseases, and Level V of four or more diseases. Time sampling was done over 5 days to determine the time spent by level of complexity. Total time per physician was calculated by multiplying the number of events each physician captured by the average time for that physician for that level of complexity.
Key Results
Physicians worked a median of 7.9 h per week between office visits. Work was apportioned among Level I (18.3%), Level II (38.3%), Level III (36.5%), Level IV (4.6%), and Level V (2.3%).
Limitations
Single VA population and self-reported data. Findings may not be generalizable to other practice settings.
Conclusion
Primary internists spent a median of 7.9 h per week in work between office visits with 82% of the time involved in changes in management.
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Acknowledgements
Technical support was provided by Peter W. Wilson, Jerome Van Ruiswyk, Yvette Williams, and Marie Giarniero.
Funding
All funding of this project was provided as part of the VHA salaries of the physicians involved.
Conflicts of Interest
None disclosed
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Appendix
Appendix
Coding rules for physicians for patient care between visits
Rules for transactions including mailed letters, faxes, or telephone calls to and from the patient:
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Level I:
Focus on simple transactions with no change in new diagnostic testing and/or management.
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Communication to or from physician including laboratory, imaging, or procedure results.
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Results essentially normal. No further follow-up orders or workup required.
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No interpretation of results is really necessary.
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Prescription renewals
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Level II:
Focus on one disease requiring new diagnostic testing and/or change in management
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Communication to or from physician including laboratory, imaging, or procedure results.
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Usually, physician interpretation of results is brief and simple.
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Change in management involves new diagnostic testing and/or change in therapeutic regimen for single disease and instructions for follow-up.
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Level III:
Focus on two diseases, both requiring new diagnostic testing and/or change in management
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Communication to or from physician including laboratory, imaging, or procedure result.
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Results mostly uncomplicated, but do require some follow-up orders and/or further workup.
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Physician interpretation of results is usually basic and straightforward, and communicated in layman's terms.
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Level IV:
Focus on three diseases, with at least three requiring new diagnostic testing and/or change in management.
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Communication to or from physician including laboratory, imaging, or procedure result.
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Results mostly complex with more extensive follow-up and additional orders required.
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Physician interpretation of results is usually lengthy, detailed, and communicated in layman's terms.
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Level V:
Focus on four or more diseases requiring new diagnostic testing and/or change in management or extensive communication or counseling requiring 45 min.
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Communication to or from the physician, including laboratory, imaging, or procedure result.
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Results mostly complex with more extensive follow-up and additional orders required.
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Physician interpretation of results is usually lengthy, detailed, and communicated in layman's terms.
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Level V episodes are expected to be infrequent.
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Time can be used as the basis of coding for that small percentage of situations involving time-consuming paperwork for extensive patient-specific medical review and/or documentation issues not involving change in management. Examples include: insurance, disability, or work documentation requirements, review of inside or outside hospital discharges or consultant reports, and conversion of multiple VA prescriptions to non-VA prescriptions at patient request for patient cost-saving purposes. The latter is a time-consuming three-step process involving rewriting of prescriptions for non-VA pharmacies, discontinuation of VA prescriptions, and new recording of outside prescription orders in a different file within CPRS.
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Level I:
under 2 min
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Level II:
2–8 min
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Level III:
8–15 min
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Level IV:
15–45 min (infrequent)
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Level V:
>45 min (rare)
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Doerr, E., Galpin, K., Jones-Taylor, C. et al. Between-Visit Workload in Primary Care. J GEN INTERN MED 25, 1289–1292 (2010). https://doi.org/10.1007/s11606-010-1470-2
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DOI: https://doi.org/10.1007/s11606-010-1470-2