NEJM -- What's Keeping Us So Busy in Primary Care? A Snapshot from One Practice

The Work of Primary Care

Document Types

The volume and types of documents that we receive, process, and create are listed in Table 1, reported as the number of services per visit, per physician per day, and per patient per year. Some high-volume categories of documents are not reported, largely because they are not carefully indexed. Such documents include administrative forms (e.g., for physical examinations for work, camp, and school and Family Medical Leave Act forms), correspondence received from health plans (e.g., disease-management letters), and reports on home care and physical therapy. Although such documents are not reported here, they represent a substantial amount of work in a practice.4 It is illuminating to describe the work by physicians that is associated with taking responsibility for these documents.

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Table 1. Volume and Types of Services for an Active Caseload of 8440 Patients at Greenhouse Internists in 2008.

 
Telephone Calls

Telephone calls that were determined to be of sufficient clinical import to engage a physician averaged 23.7 per physician per day, with 79.7% of such calls handled directly by physicians. Table 2 shows an analysis of telephone calls, according to which staff member handled the call, subject matter, and associated activity. Of these calls, 35.7% were for an acute problem, 26.0% were for administrative purposes (e.g., prior authorization for insurance or employer-required documents), 6.3% were for discussion with other members of the treatment team (e.g., emergency room physicians or specialists), 17.5% were for discussion or interpretation of test results (which is also performed by mail or e-mail), 9.5% were for discussion of advice from specialists or clinical decisions faced by patients, and 5.0% were for clinical follow-up. A total of 27.7% of calls resulted in the writing of a prescription, and 7.8% of calls resulted in the ordering of a test; 21.9% of calls involved an exchange of information with no change in management.

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Table 2. Sample of 462 Telephone Calls Logged at Greenhouse Internists for 1 Week in 2008.

 
E-Mails

Physicians averaged 16.8 e-mails per day. Of these electronic communications, 59.3% were for the interpretation of test results, 21.7% were for response to patients (either initiated by patients through the practice's interactive Web site or as part of an e-mail dialogue with patients), 9.3% were for administrative problems, 5.0% were for acute problems, 2.8% were for proactive outreach to patients, and 1.9% were for discussions with consultants.

Prescription Refills

Each physician processed 12.1 refills of prescriptions per day, not including refills that were handled during a visit or requested as part of a telephone call involving other issues; multiple medications that were refilled at the same time were counted as a single refill. Each refill request required some level of chart review (e.g., determining the patient's history with the drug and whether any required monitoring had been performed).

Laboratory Reports

Each physician reviewed 19.5 laboratory reports per day, including those ordered through our office (which are delivered to us through an electronic interface and are automatically posted to the database of the electronic health record as numerical values) and those ordered outside our office (which enter our chart as scanned PDFs and are not posted as numerical values). The work cycle of responding to a laboratory result includes interpretation by telephone, letter, or e-mail. (Our office sent 12,541 letters communicating test results, about a third of which were sent by e-mail.) For noninterfaced laboratories, we must decide which values need to be entered manually into the electronic health record by a staff person; the values of scanned results cannot be graphed or searched without this step. Laboratory results frequently trigger a review or adjustment of a medication, which requires access to accurate, current medication lists with doses.

Imaging Reports

Each physician reviewed 11.1 imaging reports per day, which usually required communication with patients for interpretation. Such review may require updating problem lists (e.g., a new diagnosis of a pulmonary nodule) or further referral (e.g., fine-needle aspiration for a cold thyroid nodule), which generates additional work, since results and recommendations are communicated to patients and consultants.

Consultation Reports

Each physician reviewed 13.9 consultation reports per day. Such reports from specialists may require adjustments to a medication list (if a specialist added or changed a medication), changes to a problem list, or a call or e-mail to a patient to explain or reinforce a specialist's recommendation. Some consultation or diagnostic reports relate to standard quality metrics (e.g., eye examinations for patients with diabetes) and need to be recorded in a different manner to support ongoing quality reporting and improvement.5