Use of Internist's Free Time by Ambulatory Care Electronic Medical Record Systems

Physicians complain about the time costs and other effects of electronic medical records (EMRs).^1-3 In a small survey,⁴ family practice physicians reported an EMR-associated loss of 48 minutes of free time per clinic day (P < .05). We collaborated with the American College of Physicians (ACP) to revise the instrument from this study and surveyed the ACP’s national sample of internists to determine the extent of this problem.

The ACP invites 1% of its members, including internal medicine attending physicians and trainees (resident and fellows), into its research panel,⁵ narrows the candidates by random sampling to ensure balance, and then adds nonmember internists. On December 12, 2012, the ACP mailed a 19-question survey to its panelists (900 ACP member and 102 nonmember internists at that time) who provided ambulatory care, and left it in the field for 10 days. The survey (Q11-Q12) focused on free time to get a sense of the EMR’s overall effect on internist’s time budget, including nonclinic time (Table 1). The National Institutes of Health’s Office of Human Research Subjects Protections declared the protocol “not human subjects research.” We used R statistical package for all statistical analyses, the Wilcoxon 2-sample test and the χ² test to assess univariate associations, and the Wilcoxon 1-sample test to assess time change within responses.

Of 845 invitees, 485 opened the e-mail (a 62.5% contact rate). We removed 69 who reported no EMR use or no ambulatory practice (a 53.6% response rate [416 of 776]), and 5 who did not answer the main outcome question, to yield 411 respondents for analysis. While most (3 of 4) were attending physicians, trainees were more likely to respond. Except for the proportion of ACP members (P < .001), respondents and nonrespondents did not differ overall across 8 measured characteristics (Table 2).

The respondents used 61 distinct EMR systems (Q4) and came from a broad range of practice types (Q1). Nine EMRs were used by 20 or more respondents, accounted for 324 (78.8%) of all users, and users of each of these lost free time (P < .05 for all). Of these 9, the Veterans Affairs’ Computer Patient Record System (CPRS) was associated with the least free time loss (−20 minutes) (P = .04). Respondents were experienced EMR users. Most (70.6%) used all of the EMR functions listed in Q4, and 82.5% had EMRs in their practice for more than a year (Q7).

Among all respondents, 89.8% reported that at least 1 data management function was slower post-EMR adoption, and 63.9% reported that note writing took longer. Surprisingly, a third (33.9%) reported that it took longer to find and review medical record data with the EMR than without, and a similar proportion, 32.2%, that it was slower to read other clinicians’ notes.

The mean time loss for attending physicians was −48 minutes per clinic day (P < .001), or 4 hours per 5-day clinic week. The mean loss for trainees was −18 minutes per day, less than that of attending physicians (P < .001). For the 59.4% of all respondents who did lose time, the mean loss was −78 minutes per clinic day, or 6.5 hours per 5-day clinic week.

The loss of free time that our respondents reported was large and pervasive and could decrease access or increase costs of care. Policy makers should consider these time costs in future EMR mandates. Ambulatory practices may benefit from approaches used by high-performing practices⁶—the use of scribes, standing orders, talking instead of e-mail—to recapture time lost on EMR. We can only speculate as to whether better computer skills, shorter (half-day) clinic assignments with proportionately less exposure to EMR time costs, or other factors account for the trainees’ smaller per-day time loss.

Corresponding Author: Clement J. McDonald, MD, Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, 8600 Rockville Pike, MSC 3828, Building 38A, Room 7N707, Bethesda, MD 20894 (clemmcdonald@nlm.nih.gov).

Published Online: September 8, 2014. doi:10.1001/jamainternmed.2014.4506.

Author Contributions: Drs McDonald and Callaghan had full access to all of 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: McDonald, Weissman, Goodwin, Kuhn.

Acquisition, analysis, or interpretation of data: McDonald, Callaghan, Weissman, Goodwin, Mundkur.

Drafting of the manuscript: McDonald, Callaghan, Weissman, Goodwin, Kuhn.

Critical revision of the manuscript for important intellectual content: McDonald, Callaghan, Weissman, Goodwin, Mundkur.

Statistical analysis: McDonald, Callaghan, Weissman. Obtained funding: McDonald.

Administrative, technical, or material support: McDonald, Weissman, Goodwin, Mundkur, Kuhn.

Study supervision: McDonald.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research was supported in part by the Intramural Research Program of the National Institutes of Health and National Library of Medicine (NIH-NLM), and the American College of Physicians (ACP).

Role of the Sponsor: The NIH-NLM and the ACP 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.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the ACP, NIH-NLM, or the US Department of Health and Human Services.