Primary care physicians treat patients in more ways than just via face-to-face office visits, and now researchers have gathered more evidence to show that payment should reflect this reality.
A new study(content.healthaffairs.org) published in the April issue of Health Affairs indicates that primary care physicians spend 49 percent of their clinical time on face-to-face visits with patients and 51 percent on what authors called "desktop medicine." This includes communicating with patients through secure portals, responding to online requests for refills or advice, ordering and reviewing tests, and sending staff messages. The article, "Electronic Health Record Logs Indicate That Physicians Split Time Evenly Between Seeing Patients and Desktop Medicine," indicated that over the course of a day, the average time spent on face-to-face visits was 3.08 hours compared to 3.17 hours for desktop medicine.
- A study published in the April issue of Health Affairs indicates that primary care physicians spend 49 percent of their clinical time on face-to-face visits with patients and 51 percent on "desktop medicine."
- Researchers estimated the time split by reviewing the electronic health record usage of 471 primary care physicians who work in a community health care system.
- Much of the desktop work, including care coordination and secure communication with patients, has high value that should be reflected in better payment.
Although every minute of a physician's time cannot be accounted for, the researchers were able to get an estimate by reviewing use of electronic health records (EHRs) by 471 primary care physicians who work in a community health care system. Combining these data with findings from a 2016 study(annals.org) published in Annals of Internal Medicine "produces an approximation of how physicians spend time in ambulatory practice," said the authors. Namely, 40 percent of their time is spent on face-to-face visits, 40 percent on desktop medicine and the remaining 20 percent on activities that are not recorded in an EHR.
Much of this work is not accounted for in traditional fee-for-service payment, they pointed out.
"While working on progress notes could be considered pre- or post-service efforts, desktop medicine activities not linked to a face-to-face visit are not reimbursable under typical fee-for-service contractual and regulatory arrangements," the authors wrote. "Many of those activities -- such as care coordination and responding to patients' email -- are of high value to the delivery system and to patients, so the staffing, scheduling and design of primary care practices should reflect this value."
In explaining their methods, the authors said reviewing EHR data was less obtrusive than previous tactics for studying how much time physicians spend on various activities, which have included asking physicians to make records using hand-held barcode or radio-frequency devices. Instead, this study examined EHR time stamps associated with patient care. The length of each face-to-face consult was estimated by tracking the first and last time the EHR was accessed in an exam room on a day the patient saw the physician. One limitation researchers noted was that time when a physician was not accessing an EHR could not be allotted to any specific activity.
Addressing the issue of physician burnout, the authors said some organizations reduce physicians' documentation burdens by hiring medical scribes. They noted that the previously cited 2016 study showed physicians who work with scribes spend 44 percent of their time on face-to face visits compared to 23 percent among physicians without scribes.
As physicians juggle multiple tasks, much of the time they spend on desktop medicine is required but uncompensated, a conundrum the authors noted should be addressed by policymakers.
"While it may be good or bad that physicians are spending more time documenting care and communicating with other staff members than they are in face-to-face visits with patients, that fact highlights the misalignment of a payment policy that reimburses only office visits, lab work and procedures while overlooking much of desktop medicine work," they wrote.
The authors cited CMS' Comprehensive Primary Care Plus initiative(innovation.cms.gov) as one model that allows practices to move away from reliance on office visits for payment. This initiative is designed to pay practices a per-beneficiary-per-month care management fee combined with fee-for-service payments.
The authors noted that such new payment models are necessary to appropriately pay for "critical aspects of patient care" that occur outside office visits. They cited a 2013 survey in which 74 percent of respondents said they preferred virtual consults over face-to-face visits.
"Compensation models should make delivering services in ways that meet patients' preferences the easy thing to do," the authors wrote.
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