"Work that does not involve a visit from a patient is invisible to those who support and purchase primary care." That's according to internist Richard Baron, M.D., who spent a year collecting data from his practice's electronic health record system to document all the work that falls outside of actual patient visits.
Baron's observation's were recorded in his article, "What's Keeping Us So Busy in Primary Care? A Snapshot From One Practice,"(content.nejm.org) which was published in the April 29 New England Journal of Medicine.
Although he's not a family physician, parallels can be drawn between the uncompensated work that fills the days of the physicians and office staff at Baron's internal medicine practice and that seen in just about any U.S. family medicine practice of a similar size. Both specialties practice primary care, and, "At a time when the primary care system is collapsing and U.S. medical school graduates are avoiding the field, it is urgent that we understand the actual work of primary care and find ways to support it," according to Baron's article.
In 2008, the year from which Baron's practice group pulled data, the practice -- Greenhouse Internists -- reported an active caseload of 8,440 patients between 15 and 99 years of age. The practice had five physicians, 14 staff members, and no nurses or midlevel professionals.
The practice's EHR system stored all patient data documents in one of 24 categories, including office visits, phone notes, lab reports and imaging reports, so it was easy for the physicians to query the EHR to determine the volume of documents in each category.
According to the article, in 2008, the practice generated
- 16,640 visits,
- 21,796 phone calls,
- 11,145 prescription refills,
- 15,499 e-mail messages,
- 17,974 lab reports,
- 10,229 imaging reports, and
- 12,822 consultation reports.
Every day, each physician received about 17 e-mails; processed slightly more than 12 prescription refills; and reviewed nearly 20 lab reports, slightly more than 11 imaging reports, and almost 14 consultation reports.
For the study, the practice also reviewed all telephone calls and e-mails during a one-week sample "to describe the work, content and actions associated with these activities," wrote Baron.
A sample of 462 phone calls logged at the practice during that week showed nearly 80 percent of such calls were handled directly by a physician.
Subjects of incoming calls included
- acute illnesses (35.7 percent),
- administrative tasks (26 percent),
- test interpretation (17.5 percent),
- consultation on treatment (9.5 percent),
- discussion with another member of the treatment team (6.3 percent), and
- patient follow-up (5 percent).
Telephone calls prompted a variety of actions, including writing or modifying a prescription, completing a form or calling a subspecialist. Calls also resulted in ordering tests, referring patients to another physician, advising patients on a course of action or completing a form.
"Our snapshot reveals both the magnitude of the challenge and the need for radical change in practice design and payment structure," concluded Baron.
After completing the practice's self-analysis, Baron and his colleagues made some changes in their practice. "We have redefined 'full-time physician' as one who offers 24 scheduled visit hours per week," wrote Baron, adding that the practice's internal compensation system "now recognizes telephone calls and e-mails as part of our productivity metric."
Baron said that the primary purpose of the practice's EHR shifted from "word processing and progress-note generation to information management and active support of clinical-practice activities."
The group also hired a registered nurse to do "information triage" of lab reports, phone calls and consultation notes.
Baron told AAFP News Now that before the study, he wouldn't have imagined needing an R.N. in that role, but the statistics collected made it obvious "that there is this barrage of information coming at us every day, and we need some help with that."
He said an R.N. is well qualified to make decisions about what information the physician needs to be alerted to and what pieces of data -- such as a normal mammogram -- can be shared with the patient and then placed in the patient's chart for later access by the physician.
Baron said he hoped the study results would spur payers to look at how they do business. "The message to the payment community is, 'You're not going to get higher value primary care if you don't figure out a way to buy it differently,'" he said.
There's plenty of work ahead for primary care physicians, as well. "We have organized our practices -- more than we realize, I think -- around what we get paid for and what we don't get paid for," said Baron. Unfortunately, too many physicians look at any work other than direct patient contact as "hassle factor" work, he said.
"Face-to-face interactions are not the only way we take care of our patients, and we shouldn't make our patients suffer because the delivery system won't reward this (other kind of work)," Baron said.
Baron would like to see primary care physicians partner with other stakeholders in the health care system to help design patient-care models that will deliver high-value care, pay physicians appropriately and meet patient needs.