Two hours of desk work for every hour with a patient

In 2016 Christine Sinsky and colleagues did something unusual: rather than survey physicians about their time, they followed them around with a stopwatch.

Fifty-seven physicians across family medicine, internal medicine, cardiology and orthopedics. Four hundred and thirty hours of direct observation. The result, published in Annals of Internal Medicine, is still the most-cited number in the administrative burden literature:

| During the office day | Share of time | | --- | --- | | Direct clinical face time with patients | 27.0% | | EHR and desk work | 49.2% |

For every hour of direct patient contact, nearly two hours went to the EHR and paperwork — and that is before the one to two hours of clerical work most did at home in the evening.

Why a nine-year-old study still matters

Because it was observed rather than reported. Self-reported administrative time is unreliable in a predictable direction. This was counted.

And because the ratio has not obviously improved. Later work on EHR audit-log data — a different method again, measuring what the software actually recorded — has found comparable or higher totals.

The measurement nobody has done

Here is what strikes us about that study: it measured the physician.

Nobody has done the equivalent for the person at the front desk. There is no time-motion study of a medical receptionist, no observed breakdown of how a front-office day divides between the patient standing in front of them and everything else.

We would guess the imbalance is worse, because the front desk absorbs whatever does not fit anywhere else — the phone, the fax queue, the insurance checks, the records requests, the prior authorizations, the pharmacy callbacks. But we would be guessing, and we would rather say so than invent a number.

What the 2:1 ratio actually implies

If you take the physician finding seriously, the interesting question is not "how do we make the doctor faster at paperwork". It is which of that 49% has to be done by a physician at all.

The same question applies one desk over. The person checking a patient in is doing patient-facing work that has to happen there. The same person, ten minutes later, is chasing a payer portal — work that has to happen, but not necessarily there, and not necessarily by them.

Separating those two things is most of what we do.

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Source: Sinsky C, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Annals of Internal Medicine, 6 September 2016.