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Editor's Note
November 2016

Eliminating Unnecessary Processes in Primary Care

Author Affiliations
  • 1Department of Medicine, University of California-San Francisco, San Francisco
  • 2Department of Medicine, Uniformed Services University, Bethesda, Maryland
JAMA Intern Med. 2016;176(11):1722-1723. doi:10.1001/jamainternmed.2016.5883

Primary care physicians and their clinic staff face a considerable workload burden. One study1 estimated that it would require primary care physicians 21.7 hours of their day to complete all acute, chronic, and preventive care duties for a typical patient population. It is therefore no surprise that practices have allocated many tasks to nonphysician staff and developed standardized clinic policies for screening patients, responding to patient inquiries, and following-up on tests results. However, little has been done to scrutinize the value of seemingly benign clinic processes, many of which are likely unnecessary and could be streamlined to provide higher-value care.

For example, in this issue of JAMA Internal Medicine, Wofford et al2 demonstrate that routine clinic glucometer testing for diabetic patients is of questionable benefit. At their institution, it had been the policy for staff to perform finger stick glucometer testing before rooming every patient with diabetes. Changing this policy to leave glucose testing to the discretion of the patient and nurse resulted in a decrease of 300 glucometer tests per month, saving the clinic $2000 and 25 hours of nursing time. Equally important, this change saved many patients from undergoing unnecessary finger sticks. These benefits were achieved with no known adverse consequences.

While this may seem like a somewhat trivial process change, there are a number of other clinical routines of questionable significance that should be critically reevaluated. Almost all routine clinic procedures could be streamlined by prioritizing patients at high risk for abnormal findings. For example, a patient without a history of chronic lung disease or pulmonary symptoms probably does not need pulse oximetry. Patients without infectious symptoms likely do not need their temperature taken, and we probably do not need to elicit a pain severity scale in patients without an active complaint of pain.

Instead, other issues could take priority, such as medication reconciliation; collection of important psychosocial information, such as screening for commonly undiagnosed illnesses like depression; discussing advanced directives; and preparing the patient to be more active and engaged in addressing their agenda for the visit.

With an already overwhelming number of tasks facing primary care practices, we must be mindful not to add unnecessary and time-consuming procedures when allocating duties and responsibilities to medical staff. Every second counts. Eliminating unnecessary procedures is critical to allow adequate time for the procedures that more optimally promote the most effective care in the most efficient manner.

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Article Information

Corresponding Author: Adam J. Schoenfeld, MD, Department of Medicine, University of California-San Francisco, 3333 California St, Ste 265, PO Box 0936, San Francisco, CA 94118 (adam.schoenfeld@ucsf.edu).

Conflict of Interest Disclosures: None reported.

Yarnall  KSH, Østbye  T, Krause  KM, Pollak  KI, Gradison  M, Michener  JL.  Family physicians as team leaders: “time” to share the care.  Prev Chronic Dis. 2009;6(2):A59.PubMedGoogle Scholar
Wofford  JL, Martin  MJ, Campos  CL.  Eliminating routine glucometer readings in the office setting: correcting a foolish consistency  [published online September 26, 2016].  JAMA Intern Med. doi:10.1001/jamainternmed.2016.5883Google Scholar