Road to Better Work-Life Balance? Lean Redesigns and Daily Work Time among Primary Care Physicians

Purpose To assess the impact of Lean primary care redesigns on the amount of time that physicians spent working each day. Methods This observational study was based on 92 million time-stamped Epic® EHR access logs captured among 317 primary care physicians in a large ambulatory care delivery system. Seventeen clinic facilities housing 46 primary care departments were included for study. We conducted interrupted time series analysis to monitor changes in physician work patterns over 6 years. Key measures included total daily work time; time spent on “desktop medicine” outside the exam room; time spent with patients during office visits; time still working after clinic, i.e., after seeing the last patient each day; and remote work time. Results The amount of time that physicians spent on desktop EHR activities throughout the day, including after clinic hours, decreased by 10.9% (95% CI: −22.2, −2.03) and 8.3% (95% CI: −13.8, −2.12), respectively, during the first year of Lean implementation. Total daily work hours among physicians, which included both desktop activity and time in office visits, decreased by 20% (95% CI: −29.2, −9.60) by the third year of Lean implementation. Conclusions These findings suggest that Lean redesign may be associated with time savings for primary care physicians. However, since this was an observational analysis, further study is warranted (e.g., randomized trial) —to determine the impact of Lean interventions on physician work experiences.

Preferences of Iranians to select the emergency department physician at the time of service delivery

Background Understanding patient preferences in emergency departments (EDs) can provide useful information to enhance patient-centred care and improve patient’s experience in hospitals. This study sought to find evidence about patients’ preference for physicians when receiving services in EDs in Iran. Methods In this discrete choice experiment survey, 811 respondents completed the scenarios with 5 attributes, including type of physicians, price of services, time to receive services, physician work experience, and physician responsibility. Analyses were conducted for different social and economic groups as well as for the total population. Results This study showed that the willingness to pay (WTP) for being visited by a physician with a high sense of responsibility was 67.104US$. WTP for being visited by an emergency medicine specialist (EMS) was 22.148US$. WTP for receiving ED services 1 min earlier was 0.417US$ and for being visited by 1 year higher experienced physician was 0.866US$. WTP varied across different age groups, sex, health status, education, and income groups. Conclusion As the expertise and experience of providers are important factors in selecting physicians in EDs by the patients, providing this information to patients when they want to select their providers can promote patient-centred care. This information can decrease patients’ uncertainty in the selection of their services and improve their experience in hospitals.

Novel Nonproprietary Measures of Ambulatory Electronic Health Record Use Associated with Physician Work Exhaustion

Background Accumulating evidence indicates an association between physician electronic health record (EHR) use after work hours and occupational distress including burnout. These studies are based on either physician perception of time spent in EHR through surveys which may be prone to bias or by utilizing vendor-defined EHR use measures which often rely on proprietary algorithms that may not take into account variation in physician's schedules which may underestimate time spent on the EHR outside of scheduled clinic time. The Stanford team developed and refined a nonproprietary EHR use algorithm to track the number of hours a physician spends logged into the EHR and calculates the Clinician Logged-in Outside Clinic (CLOC) time, the number of hours spent by a physician on the EHR outside of allocated time for patient care. Objective The objective of our study was to measure the association between CLOC metrics and validated measures of physician burnout and professional fulfillment. Methods Physicians from adult outpatient Internal Medicine, Neurology, Dermatology, Hematology, Oncology, Rheumatology, and Endocrinology departments who logged more than 8 hours of scheduled clinic time per week and answered the annual wellness survey administered in Spring 2019 were included in the analysis. Results We observed a statistically significant positive correlation between CLOC ratio (defined as the ratio of CLOC time to allocated time for patient care) and work exhaustion (Pearson's r = 0.14; p = 0.04), but not interpersonal disengagement, burnout, or professional fulfillment. Conclusion The CLOC metrics are potential objective EHR activity-based markers associated with physician work exhaustion. Our results suggest that the impact of time spent on EHR, while associated with exhaustion, does not appear to be a dominant factor driving the high rates of occupational burnout in physicians.

Adaptations of Breast Imaging Centers to the COVID-19 Pandemic: A Survey of California and Texas

Objectives To determine the early impact of the COVID-19 pandemic on breast imaging centers in California and Texas and compare regional differences. Methods An 11-item survey was emailed to American College of Radiology accredited breast imaging facilities in California and Texas in August 2020. A question subset addressed March-April government restrictions on elective services (“during the shutdown” and “after reopening”). Comparisons were made between states with chi-square and Fisher’s tests, and time frames with McNemar’s and paired t-tests. Results There were 54 respondents (54/240, 23%, 26 California, 28 Texas). Imaging volumes fell during the shutdown and remained below pre-pandemic levels after reopening, with reduction in screening greatest (ultrasound 12% of baseline, mammography 13%, MRI 23%), followed by diagnostic MRI (43%), procedures (44%), and diagnostics (45%). California reported higher volumes during the shutdown (procedures, MRI) and after reopening (diagnostics, procedures, MRI) versus Texas (P = 0.001 - 0.02). Most screened patients (52/54, 96% symptoms and 42/54, 78% temperatures), and 100% (53/53) modified check-in and check-out. Reading rooms or physician work were altered for social distancing (31/54, 57%). Physician mask (45/48, 94%), gown (15/48, 31%), eye wear (22/48, 46%), and face shield (22/48, 46%) use during procedures increased after reopening versus pre-pandemic (P < 0.001 - 0.03). Physician (47/54, 87%) and staff (45/53, 85%) financial impacts were common, but none reported terminations. Conclusion Breast imaging volumes during the early pandemic fell more severely in Texas than in California. Safety measures and financial impacts on physicians and staff were similar in both states.

COVID-19 Diagnostic Clinical Decision Support: a Pre-Post Implementation Study of CORAL (COvid Risk cALculator)

Background Isolation of hospitalized persons under investigation (PUIs) for COVID-19 reduces nosocomial transmission risk. Efficient PUI evaluation is needed to preserve scarce healthcare resources. We describe the development, implementation, and outcomes of an inpatient diagnostic algorithm and clinical decision support system (CDSS) to evaluate PUIs. Methods We conducted a pre-post study of CORAL (COvid Risk cALculator), a CDSS that guides frontline clinicians through a risk-stratified COVID-19 diagnostic workup, removes transmission-based precautions when workup is complete and negative, and triages complex cases to Infectious Diseases (ID) physician review. Pre-CORAL, ID physicians reviewed all PUI records to guide workup and precautions. Post-CORAL, frontline clinicians evaluated PUIs directly using CORAL. We compared pre- and post-CORAL frequency of repeat SARS-CoV-2 nucleic acid amplification tests (NAATs), time from NAAT result to PUI status discontinuation, total duration of PUI status, and ID physician work-hours, using linear and logistic regression, adjusted for COVID-19 incidence. Results Fewer PUIs underwent repeat testing after an initial negative NAAT post-CORAL than pre-CORAL (54% vs. 67%; aOR 0.53, 95% CI: 0.44-0.63, p<0.01). CORAL significantly reduced average time to PUI status discontinuation (adjusted difference: -7.4 [SE 0.8] hours/patient; p<0.01), total duration of PUI status (adjusted difference: -19.5 [SE 1.9] hours/patient; p<0.01), and average ID physician work-hours (adjusted difference: -57.4 [SE 2.0] hours/day; p<0.01). No patients had a positive NAAT within 7 days after discontinuation of precautions via CORAL. Conclusions CORAL is an efficient and effective CDSS to guide frontline clinicians through the diagnostic evaluation of PUIs and safe discontinuation of precautions.