Most family physicians likely have wondered at the end of a particularly frustrating day why certain technologies or systems -- say, for instance, electronic health records (EHRs) -- that were created with the best of intentions to make providing health care easier instead make patient encounters more cumbersome and inefficient.
The answer, according to authors of new research(jamia.oxfordjournals.org) published Sept. 2 online in the Journal of the American Medical Informatics Association, is the unpredictable nature of the primary care physician's (PCP's) workflow.
In an article titled "The myth of standardized workflow in primary care," authors said, "In order to develop solutions to address care delivery problems, e.g., EHR integration, it is critical to understand the details of primary care workflows. This can only happen if the basic science of the primary care workflow is understood."
Corresponding author Talley Holman, Ph.D., M.B.A., an industrial engineer and senior e-health systems analyst for the AAFP's Alliance for eHealth Innovation, told AAFP News that the people who design workflows for physician offices -- such as industrial engineers and computer scientists -- have, for years, created tools such as EHRs assuming that PCPs worked in a linear or predictable fashion.
"Workflows were not understood, and designers made the assumption that patient encounters were similar," said Holman.
- According to new research, patient encounters in primary care are nonlinear and unpredictable and have for years been misunderstood by systems designers charged with making practices more efficient.
- To develop solutions to address care delivery problems, the basic details of primary care workflows must be studied and better understood.
- In the future, designers, engineers and scientists who design tools and technology such as electronic health records need to interact more closely with physicians engaged in direct patient care.
That's why the research team set out to determine scientifically whether there was a standardized workflow in primary care. "If you design a tool assuming that there is that standardization, it forces people to work according to the tool, not to the patient," said Holman.
Study Setup, Findings
The study's authors, all of whom are members of the International Collaboration to Improve Primary Care Through Industrial and Systems Engineering(www.fammed.wisc.edu), conducted a postanalysis of data collected in two separate primary care studies: the first involving 15 primary care clinics in 2008-09 and the second involving 16 clinics from 2008-10.
Researchers observed the work of family physicians and internal medicine physicians during patient visits and recorded all tasks performed during the visit. Some clinics used an EHR, others did not.
The 12 major tasks PCPs performed during the course of patient visits included entering the exam room, gathering patient information, reviewing patient information, performing actions such as a conducting a physical exam or procedure, recommending and discussing treatment options, and giving the patient information and instructions.
Researchers discovered a "strong theme" among primary care patient visits.
"Many individual subobjectives of each visit were driven by either the PCP or patient and the interactive conversation between them," wrote the authors. "The specific tasks associated with each stage of the PCP-patient interaction were unpredictable."
For instance, during one 35-minute visit in which the PCP saw a patient with 10 different problems, the physician gathered information several times during the visit and intermittently performed physical examinations to evaluate particular problems.
"In the 'middle' of the patient visit, the PCP attempts to end the visit, but then re-engages with the patient, due to a communication failure regarding what was believed to be a resolved problem," wrote the authors.
The patient rehashed three problems during the visit even after each problem had been resolved to the physician's satisfaction.
Authors noted that PCPs often have trouble resolving a patient problem and moving on in the course of one patient visit. "This causes the PCP to rethink his/her approach to the patient on the fly, while still considering how to address the remaining patient problems in the time available in the visit,' wrote the authors.
Family Physician Perspective
In an interview with AAFP News, co-author John Beasley, M.D., of Madison, Wis., said that family medicine is "patient-centric" and all about "responding to the patient's needs."
As such, "We need systems and technologies that recognize that this workflow is nonlinear and nonpredictable. There is no way that as the patient and I engage in a dialogue -- if I'm responsive to the patient -- that I can say what going to happen next," he added.
Beasley recounted the comments of one of the research reviewers, who, after noting the
patient-centric nature of a typical primary care office visit as outlined in the study, said the research merely showed that primary care physicians couldn't control the pace and content of their patient encounters.
"Our response was, 'And they shouldn't,'" said Beasley, a professor in the department of family medicine and community health at the University of Wisconsin-Madison School of Medicine and Public Health.
Beasley also works closely with the university's department of industrial and systems engineering in researching the complexity of primary care, EHRs and patient safety.
"Primary care physicians need to have some partnership with the patient and should not be in total control of the process. That doesn't mean you let it run loose, but you've got to have what we termed this 'dance' with the patient," said Beasley.
Indeed, authors describe that dance this way:
"The introduction of new information (during an encounter) always has the potential to restart the cycle, to address a known patient issue, or start a new cycle to address a new patient issue. This constitutes, in essence, a 'dance' between the physician and the patient, each taking the lead at different times, thus resulting in in an unpredictable workflow.
"Consequently, sometimes PCP workflow resembles the perfect timing and elegant grace you might see between two ballroom dancers, in tune with one another and anticipating the timing and the steps one another will take. At other times, it looks like a father trying to dance with his 13-year-old daughter to her favorite pop music -- the father trying to lead but unable to anticipate the changes in tempo and what steps should come next."
Authors urged stakeholders to consider the breadth and depth of primary care. "PCPs are expected to manage and treat a patient for what has happened since their last visit during at a 15- to 60-minute consultation, when many times, patients are unorganized or unprepared to set or negotiate an agenda, are unwilling to or cannot effectively convey information, or become confused or upset," they wrote.
"As a result, the PCP must be able to adapt to these dynamic changes and adjust their goals for the visit accordingly," said authors.
Based on their findings, the researchers made three suggestions on how to improve the efficiency of primary care visits. They called for an end to the requirement that physicians spend time on administrative tasks such as order entry and the typing of progress notes because those activities increased distractions and interruptions.
They suggested primary care practices establish each patient's agenda before the appointment to help determine in advance how much time will be needed for the visit.
Lastly, they urged primary care practices to engage in previsit planning to ensure that physicians have in hand all the necessary patient information during the patient visit.
Creating a Better Future
Beasley shared a personal example of how good intentions paired with interventions designed to solve a problem could make things worse when the people pushing the intervention don't understand the workflow in a family medicine clinic.
In the past year, his organization implemented some best-practice alerts for hypertension. "So if a patient comes into my office with a blood pressure of 141/70, I get this big yellow screen that says, in essence, 'What are you going to do about her blood pressure?'
"Now bear in mind that at this point in time, I really should be dealing with the patient's fractured ankle first, and I really don't give a rip about blood pressure right now," said Beasley. Bottom line, alerts need to fit into a physician's workflow, not disrupt it, he added.
For his part, Holman noted that past assumptions about standardized physician workflow have led to one-size-fits-all designs that have forced physicians into inefficient processes.
Moving forward, he suggested a new protocol. "All specialists -- including designers, engineers and scientists who are designing tools to improve health care encounters -- should work more closely with those medical professionals who are seeing the patients," said Holman.
After all, he added, "The tools and technology that we design need to support our physicians, not dictate what they do."
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