Change Ideas to Reduce Burden on Family Practice Physicians

John Beasley, MD and his colleagues at the University of Wisconsin Department of Family Medicine and Community Health and the Department of Industrial and Systems Engineering recently completed a research project. They investigated the burden of electronic medical record (EMR) systems on family practice physicians at the University of Wisconsin. This burden is one factor driving physician burn-out and dissatisfaction with medicine as a profession.

They used logs from the EMR, validated by direct observation of physician computer use. The researchers found a consistent pattern of “work after clinic”--time spent during evenings and weekends.

Physicians averaged about 10 hours a week in EMR work after clinic over the three-year period of the study.

This research is notable for two reasons. First, it made novel use of EMR logs to quantify the extent of the work after clinic phenomenon.

Second, it described three specific ideas that could reduce primary care physician EMR work by as much or more time than 10 hours per week of work after clinic :

• Transcription with human assistance (Save 6+ hours each week).

• Paper/verbal order entry (Save 3+ hours each week).

• Automatic Log-in (Save 1+ hour each week)

What’s the prospect for successful adoption of these change ideas?

Dr Chris Hayes has made the case that changes in health care practice are more likely to be adopted if they have relatively high perceived value to patients and providers and at the same time don’t add workload (See Chris’s web site and this 2015 article in BMJ Quality and Safety, )

The perceived value and impact on time depend on each other—changes that reduce work seem likely to have more value to providers than changes that are work neutral or worse, add work.

Chris summarizes the situation with this picture:

By Hayes’ theory, the change ideas proposed in the UW research appear to be highly adoptable and sustainable once adopted. However, the two changes with the biggest impact requires other people to do more work and be paid to do so.

In the current situation, physicians are working after clinic “for free.” Longer-term effects like fatigue and burn-out, which lead physicians to seek less than full-time positions or leave the profession altogether, are diffuse and don’t show up in a regular bi-weekly cost statement. Adding cost for support staff, on the other hand, is easy to recognize and resist in a world of cost management.

So administrators and physician leaders will have to convince themselves of the business case for the package of changes.

How to make the business case?

Use the Model for Improvement:  Run tests, starting on a small scale—involve one physician, over one or two days, to iron out logistics. Then test the changes for longer periods of time, with more providers. Measure the impact on physician time using the EMR logs, costs for support staff, and physician perception. Have the administrators and physician leaders observe the tests themselves to inform their decisions.