HPI indicates history of present illness; LVN, licensed vocational nurse; MA, medical assistant; MD, physician; P2, Physician Partner; PSR, patient services representative; ROS, review of systems. Rcopia is an electronic prescribing system (DrFirst).aFor general internal medicine visits, the P2 did not perform checkout functions in the room and referred patients to the front desk to perform these.
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Reuben DB, Knudsen J, Senelick W, Glazier E, Koretz BK. The Effect of a Physician Partner Program on Physician Efficiency and Patient Satisfaction. JAMA Intern Med. 2014;174(7):1190–1193. doi:10.1001/jamainternmed.2014.1315
Despite the advantages of electronic health records, concerns have been raised about the amount of computer time spent documenting care1 and its adverse effects on the physician-patient relationship. Using scribes to reduce physician documentation time has resulted in improved satisfaction among urologists2 and increased productivity among emergency department physicians3 and cardiologists.4 Although scribes have been used in primary care,5 their effects have received little formal evaluation.
We created a new position, a Physician Partner (P2), to facilitate patient care during the office visit and tested this in 2 practices at an academic medical center to determine its effect on physician efficiency and patient satisfaction.
Two P2s, one with a bachelor’s degree and the other a licensed vocational nurse, performed scribing and other administrative functions for 3 geriatricians (D.B.R., B.K.K., and 1 other) and 2 general internists (E.G. and 1 other) in a 2:1 ratio (Figure). During the study, the practices used an electronic health record (cView; Orion Health) that relied primarily on scanned paper outpatient notes.
Each physician had 4-hour clinic sessions with and without P2s, thereby allowing comparisons. Efficiency was measured in a subsample of sessions by (1) direct measurement of physician time in the examining room and (2) retrospective physician diaries of time spent before and after each session. Patient satisfaction was evaluated using questions from the Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey.6
On the basis of time-study data, we calculated the total physician time in the examining room per session. Wilcoxon rank sum tests were used to compare median physician times before, during, and after each session with and without P2s. We used χ2 tests to compare patient responses with survey questions. The project was a quality improvement project and was not considered research by the institutional review board.
From October 29, 2012, through June 28, 2013, the 5 physicians in the 2 practices had 326 sessions that included P2s. Of these, 37 sessions (22 with and 15 without P2s) that included 289 visits had visit times monitored, and 42 sessions (21 with and 21 without P2s) had physician diaries recording the amount of time they spent before and after the session. Surveys were administered to 156 patients (84 visits with and 72 visits without P2s).
In geriatrics, visits with P2s were a median 2.7 minutes shorter than visits without P2s, 18.0 (interquartile range, 14-21) vs 20.7 (15-26) minutes (P = .01). Among internists, the difference was less, 10.0 (8-14) vs 12.0 (8-15) minutes (P = .15). Per 4-hour scheduled session (Table), an estimated 122 minutes (geriatrics) and 75 minutes (internal medicine) were saved during P2 sessions.
Patients were more likely to strongly agree that the physician spent enough time with them during P2 visits (88.1% vs 75.0%, P = .03). Although 17.7% were uncomfortable with P2s in the room, 79.3% of patients agreed that they helped the visit run smoothly.
In this study, adding personnel to perform more administrative components of office practice was associated with less presession and postsession physician time, shorter geriatric visits, and higher patient satisfaction. Despite these positive findings, several issues remain. First, what background and training do P2s need? We have increasingly employed bachelor’s degree–level personnel. Training includes medical vocabulary modules, use of the electronic health record, referral and order entry, and optimizing clinic work flow. A related issue concerns scope of practice regulations. It is possible that documentation requirements of different health care systems and reimbursement regulations may impede diffusion. Finally, what are the financial implications of implementing a P2 program? Some practices have estimated that by adding 2 more visits per session, scribe programs can pay for themselves. However, because of diverse cost and reimbursement structures, the business case may vary.
Limitations of the study include the single site, small sample size, inability to measure actual time spent communicating with patients, and self-reported or measured times for only a subsample of sessions.
In summary, the P2 program provides a potential model to improve physician efficiency and satisfaction in the office setting without compromising patient satisfaction. The program should be tested in larger samples and additional settings.
Corresponding Author: David B. Reuben, MD, Division of Geriatrics, David Geffen School of Medicine at UCLA, 10945 Le Conte Ave, Ste 2339, Los Angeles, CA 90095-1687 (firstname.lastname@example.org).
Published Online: May 12, 2014. doi:10.1001/jamainternmed.2014.1315.
Author Contributions: Drs Reuben and Koretz had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Reuben, Senelick, Glazier.
Critical revision of the manuscript for important intellectual content: Knudsen, Senelick, Koretz.
Statistical analysis: Reuben, Knudsen, Senelick.
Obtained funding: Koretz.
Administrative, technical, or material support: Senelick, Glazier, Koretz.
Study supervision: Reuben, Senelick, Glazier, Koretz.
Funding/Support: This study was supported in part by grant 5P30AG028748 from the UCLA Claude Pepper Older Americans Independence Center funded by the National Institute on Aging.
Role of the Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: Niki Alejo, BS, and Krisan May Soriano, BS, LVN, in their roles as Physician Partners, assisted in defining the choreography and tasks and reviewed the manuscript; Matthew Abrishamian, BA, provided data collection and manuscript review; and Lee Jennings, MD, MSPH, contributed statistical assistance. They received no additional compensation for their roles in this study, and all are affiliated with the Department of Medicine, David Geffen School of Medicine at UCLA, except Mr Abrishamian, who was a volunteer.
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