Workflow Changes Could Relieve Primary Care Physician Shortage

Primary care physicians waste on average about 30 minutes each day, and nurses waste 60 minutes per physician per day, on tasks that could be altered to take substantially less time, a study finds.

Red-flagging and eliminating inefficiencies to improve patient flow may go a long way toward relieving the looming shortage of clinicians in the primary care workforce.

A study in this month's Health Affairs says easily implemented, system-wide changes that save a few minutes here and there during the workday could yield dramatic gains in physician capacity while reducing physician burnout and improving care.

"Very little attention is paid to opportunities to get more out of our current workforce, not by working harder, but by working more efficiently," says study co-author Scott Shipman, MD, a pediatrician and director of primary care affairs and workforce analysis at the Association of American Medical Colleges in Washington, DC.

See Also: 'Alarming' Physician Shortages Lie Ahead

By some estimates there will be 15 million to 24 million additional primary care visits each year in the near future when millions of people are expected to gain access to health insurance under the Patient Protection and Affordable Care Act, further stressing an already overworked primary care clinical workforce.

After observing first-hand the workflow at physicians' offices and interviews with clinicians, Shipman and co-author Christine A. Sinsky, MD, a general internist at Medical Associates Clinic and Health Plans in Dubuque, IA, estimated that primary care physicians waste on average about 30 minutes each day, and nurses waste 60 minutes per physician per day, on prescription renewal tasks that policy changes could substantially reduce.

The two physicians believe that eliminating 30 minutes of wasted time each day could translate into 30–40 million more primary care visits available each year without a single additional provider.

"Other efforts to overcome the primary care shortage, by training more, losing fewer, or finding someone else, they all have their place but in and of themselves those are relatively inefficient strategies," Shipman says. "Training more physicians takes a long time and a lot of resources and with current trends in terms of specialty choice it may not yield the workforce we most need."

"Losing fewer physicians has a lot of potential if we change the model of practice to address burnout. But driving inefficiencies out of practice will have a secondary effect on that… The non-physician clinicians such as nurse practitioners and physicians' assistants have an important role, but that too requires training and cost of training and bringing more people in when we can do a lot more with the people we have if we just look critically at how to root out even some of these inefficiencies on a widespread basis."

The study identified these ways to improve efficiency:

• Teamwork and delegation, because research suggests that staff could perform tasks that consume 15% of the time physicians spend on patient care outside of visits.
• Redesigned work flow that co-locates physicians with the rest of the healthcare team throughout the day and facilitates "real-time" communication, which can save a physician 30 minutes each day.
• Acknowledging the double-edge of technology, including the "time sink" that can be created for physicians entering patient data in electronic medical records, while also seeing efficiencies created by software programs that triage patients and guide treatment decisions and don't require an office visit, which can improve care quality and reduce the burden on physicians' time.
• Re-examining policies ranging from having a computer automatically sign out a user for security reasons, requiring users to sign in recurrently, to limitations in non-clinicians' ability to assist in routine, protocol-driven care.

In a phone interview, Shipman discussed the study and some of the themes that emerged from it. The following is an edited transcript of that conversation.

HLM: Has primary care workflow always been inefficient, or has it gotten worse because of the increased demands and because the practice of medicine has gotten more complicated?

Shipman: It's some of both. There has been an element of inefficiency that hasn't been highly prioritized in medicine. This goes beyond primary care but is certainly relevant for primary care. Because both demographic demands and recognition of the unsustainability of the rising cost of healthcare have become more prominent the focus on where to root out inefficiency becomes more prevalent.

Complexity is an important part of this in two perspectives. There is complexity in terms of how a primary care practice best meets the needs of its patients. As we advance in our understanding of the many dimensions that include health above and beyond the typically narrow medical care that doctors have always provided, we think more and more about how to serve those needs and it is increasingly impossible for a physician as single person to meet the narrow medical needs and broader social needs that a patient has in maximizing their health and wellness.

From that standpoint it is more complex and certainly advances in medicine have made care more complex and mastering care more complex.

As a single technological advancement, the electronic medical records is one that we have to be honest about, because so far its implementation has been not an aid to efficiency of the physicians' time.

Unfortunately, we have taken yesterday's model of documentation where the doctor did the documentation and continued that with electronic medical record and that has been shown time and again, in both quantitative and qualitative ways, to be a burden on physicians cognitively and on their time, way out of proportion to what documentation used to be. There is an added complexity that has been brought on by that tool as well.

HLM: Will these inefficiencies be addressed more quickly with the advent of physician-employees, or will it make matters worse because salaried physicians will lose their sense of urgency?

Shipman: All employed settings aren't the same and it is not intrinsically the case that private practice doctors have more of an incentive to be efficient than the employed physicians. In some cases, the risk of changing the practice model feels greater in a private practice setting.

What is needed is a revamping of the way medicine is practiced and what a physician does on an hour-to-hour, day-to-day basis. That change may be more risky when everything is on the line by virtue of your role as the breadwinner for the practice. Whereas, in an employed or larger setting, there may be greater opportunity to push for those changes or to enable those changes in the way care is delivered.

HLM: Who needs to lead this efficiency movement?

Shipman: It's an opportunity that physicians shouldn't pass up. They have an opportunity to be in the lead here. They understand better than anyone where their inefficiencies are.

The problem for primary care physicians is that they spend so much of their time running at full speed just to keep up they don't have the time to reflect on how it can be done better. At some level if the physicians don't take the initiative and the screws keep getting tightened down in driving for greater efficiency in overall healthcare delivery and reduced or controlled costs others will step in and push forward.