William Hersh, MD, Professor and Chair, OHSU
Blog: Informatics Professor
A recent study of work hours of medical interns in the new era of duty hour regulations produced an interesting side finding, which is that modern medical interns spend about 40% of their time at a computer [1]. To some, this prompted concern that computers were drawing medical trainees away from patients and their care.
A finding like this certainly warrants attention. However, I wonder whether many expressing concern are asking the wrong question. The proper question is not whether this is too much time at a computer, but rather if this amount of time compromises the interns’ care of their patients or of their learning experience.
Implicit among those who raise the question of too much time with computers is the assumption that computers are taking physicians away from patients. It is instructive, however, to consider historic data of how much time physicians spend in direct vs. indirect care of patients. It turns out that physicians have historically spent most of their working time in activities other than in the presence of their patients.
Time studies of hospital [2-6] and emergency [7] physicians show physicians spend about 15-38% of their time in direct patient care versus 50-67% of their time in indirect patient care, divided among reviewing results, performing documentation, and engaging in communication. Likewise, studies of outpatient physicians find that 14-39% of work takes place outside the exam room [8-9]. In addition, work related to patients when they are not even present at the hospital or office consumes 15-23% of the physician work day [9-11].
Therefore, this new study does not necessarily indicate the computers are drawing physicians away from patients. It is difficult to compare the proportions of these interns’ time devoted to direct and indirect care with those of other physicians who have completed their training. However, it is worthy to note that the four-fold ratio of indirect to direct care is not too far off what was document for practicing physicians in the other studies. Interns have different time demands anyways, not only working longer hours but also devoting more time to educational activities.
Furthermore, we also have to consider the premise that there good reason for spending more time in front of computers, as some evidence supports the notion that there may be value to patients as well as clinician education in having access to knowledge in unprecedented ways that previous generations of physicians did not have [12-13]. There is no question that we must pay more attention to physician workflow with computers so that they are not unduly wasting time, especially time that could be better spent with patients. But we must also consider the benefits of computers, and try to determine the most appropriate amount of time for physicians to spend using them during their working hours.
References
1. Block, L, Habicht, R, et al. (2013). In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? Journal of General Internal Medicine. 28: 1042-1047.
2. Ammenwerth, E and Spötl, HP (2009). The time needed for clinical documentation versus direct patient care. A work-sampling analysis of physicians’ activities. Methods of Information in Medicine. 48: 84-91.
3. Tipping, MD, Forth, VE, et al. (2010). Systematic review of time studies evaluating physicians in the hospital setting. Journal of Hospital Medicine. 5: 353-359.
4. Tipping, MD, Forth, VE, et al. (2010). Where did the day go?–a time-motion study of hospitalists. Journal of Hospital Medicine. 5: 323-328.
5. Kim, CS, Lovejoy, W, et al. (2010). Hospitalist time usage and cyclicality: opportunities to improve efficiency. Journal of Hospital Medicine. 5: 329-334.
6. Yousefi, V (2011). How Canadian hospitalists spend their time – a work-sampling study within a hospital medicine program in Ontario. Journal of Clinical Outcomes Management. 18: 159-164.
7. Chisholm, CD, Weaver, CS, et al. (2011). A task analysis of emergency physician activities in academic and community settings. Annals of Emergency Medicine. 18: 117-122.
8. Gilchrist, V, McCord, G, et al. (2005). Physician activities during time out of the examination room. Annals of Family Medicine. 3: 494-499.
9. Gottschalk, A and Flocke, SA (2005). Time spent in face-to-face patient care and work outside the examination room. Annals of Family Medicine. 3: 488-493.
10, Farber, J, Siu, A, et al. (2007). How much time do physicians spend providing care outside of office visits? Annals of Internal Medicine. 147: 693-698.
11. Chen, MA, Hollenberg, JP, et al. (2010). Patient care outside of office visits: a primary care physician time study. Journal of General Internal Medicine. 26: 58-63.
12. Buntin, MB, Burke, MF, et al. (2011). The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Affairs. 30: 464-471.
13. McCoy, AB, Wright, A, et al. (2013). State of the art in clinical informatics: evidence and examples. Yearbook of Medical Informatics. 8: 13-19.
This article post first appeared on The Informatics Professor. Dr. Hersh is a frequent contributing expert to HITECH Answers.