PURPOSE Primary care physicians spend nearly 2 hours on electronic health record (EHR) tasks per hour of direct patient care. Demand for non-face-to-face care, such as communication through a patient portal and administrative tasks, is increasing and contributing to burnout. The goal of this study was to assess time allocated by primary care physicians within the EHR as indicated by EHR userevent log data, both during clinic hours (defined as 8:00 am to 6:00 pm Monday through Friday) and outside clinic hours. METHODSWe conducted a retrospective cohort study of 142 family medicine physicians in a single system in southern Wisconsin. All Epic (Epic Systems Corporation) EHR interactions were captured from "event logging" records over a 3-year period for both direct patient care and non-face-to-face activities, and were validated by direct observation. EHR events were assigned to 1 of 15 EHR task categories and allocated to either during or after clinic hours.RESULTS Clinicians spent 355 minutes (5.9 hours) of an 11.4-hour workday in the EHR per weekday per 1.0 clinical full-time equivalent: 269 minutes (4.5 hours) during clinic hours and 86 minutes (1.4 hours) after clinic hours. Clerical and administrative tasks including documentation, order entry, billing and coding, and system security accounted for nearly one-half of the total EHR time (157 minutes, 44.2%). Inbox management accounted for another 85 minutes (23.7%).CONCLUSIONS Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. EHR event logs can identify areas of EHR-related work that could be delegated, thus reducing workload, improving professional satisfaction, and decreasing burnout. Direct time-motion observations validated EHR-event log data as a reliable source of information regarding clinician time allocation. Ann Fam Med 2017;15:419-426. https://doi.org/10.1370/afm.2121. INTRODUCTIONP rimary care has become increasingly complex, 1 with electronic health record (EHR) systems adding to the complexity. Our patients expect same-day access for face-to-face care during clinic hours and rapid responses to telephone calls, patient portal messages, laboratory result inquiries, and prescription renewal requests both during and after clinic hours. This concurrent face-to-face (synchronous) and non-faceto-face (asynchronous) care, combined with administrative and regulatory work (prior authorizations, billing and coding, performance measurement) results in considerable strain on the primary care team. It is imperative to understand factors contributing to workload and identify practical solutions to these challenges.US physicians spend numerous hours daily interacting with EHR systems, contributing to work-life imbalance, dissatisfaction, high rates of attrition, and a burnout rate exceeding 50%. entry (CPOE), inbox management, patient portals, and a redistribution of tasks previously performed by clinical staff to clinicians has led to more work that is not direct fac...

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Purpose The purpose of this paper is to explore the concept of information chaos as it applies to the issues of patient safety and physician workload in primary care and to propose a research agenda. Methods We use a human factors engineering perspective to discuss the concept of information chaos in primary care and explore implications for its impact on physician performance and patient safety. Results Information chaos is comprised of various combinations of information overload, information underload, information scatter, information conflict, and erroneous information. We provide a framework for understanding information chaos, its impact on physician mental workload and situation awareness, its consequences, discuss possible solutions and suggest a research agenda which may lead to methods to reduce the problem. Conclusions Information chaos is experienced routinely by primary care physicians. This is not just inconvenient, annoying and frustrating; it has implications for physician performance and patient safety. Additional research is needed to define methods to measure and eventually reduce information chaos.

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PURPOSEThe number of problems managed concurrently by family physicians during patient encounters has not been fully explored despite the implications for quality assessment, guideline implementation, education, research, administration, and funding. Our study objective was to determine the number of problems physicians report managing at each visit and compare that with the number refl ected in the chart and the bill.METHODS Twenty-nine members of the Wisconsin Research Network reported on encounters with 572 patients using a physician problem log. The patient chart notes and the diagnoses submitted for billing from the encounters were compared with the information in these logs. RESULTSThe physicians reported managing an average of 3.05 problems per encounter and recorded 2.82 in the chart and 1.97 on the bill. For all patients, 37% of encounters addressed more than 3 problems, and 18% addressed more than 4. For patients older than 65 years, there was an average of 3.88 problems at each visit, and for diabetic patients there was an average of 4.60. There was evidence for the selective omission of mental health and substance problems from the diagnoses used for billing.CONCLUSIONS Family medicine involves the concurrent care of multiple problems, which billing data do not adequately refl ect. Our fi ndings suggest a mismatch between family medicine and current approaches to quality assessment, guideline implementation, education, research, administration, and funding. Activities in all these areas need to address the physician's task of prioritizing and integrating care for multiple problems concurrently. INTRODUCTIONT o measure quality realistically, develop and implement guidelines, educate physicians, design research, and administer and pay for services, it is important to understand the number of problems addressed concurrently during primary care encounters. It is also important to assess whether the commonly used data sources, such as chart review and billing data, adequately refl ect this aspect of the complexity of care.Based on previous work, including that of Flocke et al 1 and Zyzanski et al, 2 we hypothesized that family physicians manage multiple problems during routine outpatient visits. We further hypothesized that there are considerable differences from what actually occurs during primary care encounters (as measured by physician report), what is recorded in the chart, and what is listed on the bill.We therefore set out to describe the numbers of problems family physicians report managing during outpatient encounters and compare this number with the number generated from the more standard assessment of the content of the visit; that is, reviewing charts and billing data. This method is somewhat different from that used in direct observation studies, 406PROBLEMS PER ENCOUNTER as our study attempted to "get inside the physician' s head" to ascertain the problem content of the visit, regardless of whether it was observed or recorded. For example, a physician might see a depressed patient...