Ambulatory Physician Documentation Time
Recent research has attempted to estimate time spent documenting by ambulatory physicians, including EHR use.
Introduction and Background
The passage of the HITECH act in 2009, and the CMS meaningful use incentive program, facilitated dramatic increases in the adoption of electronic records in the ambulatory care setting. From 2008 to 2014 EHR use in ambulatory practices approximately doubled, reaching 83% of practices in 2014. 
At the same time, ambulatory physicians, particularly those in primary care, have face numerous additional challenges:
• It has been estimated that primary care physicians who provide all recommended care for an average panel size would work over 20 hours per day. 
• A landmark 2003 study showed that adults receive only about half of recommended services. 
• Burnout is prevalent leading a group of leading primary care transformation scholars and advocates to conduct research on known best practices that create and maintain ‘joy in practice’, and advocate for a ‘quadruple aim’. [4,5]
For these reasons, it is important to try to understand how much time clinicians spend documenting in the ambulatory care setting. A study by Sinsky and colleagues contributes significantly to this effort. The study included a careful description of the work of 57 physicians in 16 practices, including primary care and specialty groups, in four U.S. states.  A combination of self reporting (for after hours work) and time and motion methodology (for work during office hours) were used. Findings included:
• Physicians self reported 1-2 hours spent working after hours, mainly using the EHR.
• Physicians spent nearly half of their time during the office day on EHR and other desk work. This time was mostly accounted for by review and documentation, as opposed to orders and test results (which accounted for a smaller portion of time).
• Less than a third of physician time was spent face-to-face with patients without documenting.
• Over a third of physician time in the exam room was spent on EHR and desk work.
• Alternative documentation strategies such as dictation or scribes were present in the specialty care settings observed, but not ambulatory care.
Time and Motion
Time and Motion, the research method used in this paper, is a strategy that quantifies workflow through observation. It is meant to improve on or add a quantitative aspect to qualitative methods such as survey or self-report. One issue with the use of time and motion studies to assess the impact of health IT is that because time and motion typically quantifies the allocation of time, it can miss some of the cognitive impact of task switching, which may be an additional burden. 
Time and motion is one of several research methods that aims to describe workflow. See also Methods to capture workflow
EHR Documentation strategies
Various strategies have been employed to try to improve the efficiency of documentation in the EHR. See also Physicians and EHR Documentation strategies
1. ‘Office-based Physician Electronic Health Record Adoption: 2004-2014’, Health IT Dashboard, Office of the National Coordinator for Health IT. http://dashboard.healthit.gov/quickstats/pages/physician-ehr-adoption-trends.php. Accessed October 16, 2016.
2. Altschuler J., Margolius D., Bodenheimer T., & Grumbach K., Annals of Family Medicine. 10 (5), 2012, 396-400.
3. McGlynn EA, Asch SM, Adams J, et al. ‘The quality of health care delivered to adults in the United States.’ New England Journal of Medicine. 348 (26), 2003, 2635–2645.
4. Sinsky C., Willard-Grace R., Schutzbank A., Sinsky T., Margolius D., Bodenheimer T. ‘In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices’, Annals of Family Medicine. 11 (3), 2013, 272-278.
5. Bodenheimer T. & Sinsky C., ‘From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider’, Annals of Family Medicine 12 (6), 2014, 573-576.
6. Sinsky C., Colligan L., Li L., Prgomet M., Reynolds S., Goeders L., Westbrook J., Tutty M., & Blike G.; ‘Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties.’ Annals of Internal Medicine. 2016. doi: 10.7326/M16-0961. http://annals.org/aim/article/2546704/allocation-physician-time-ambulatory-practice-time-motion-study-4-specialties
7. Zheng K., Haftel H., Hirschl R., O’Reilly M., & Hanauer D. ‘Quantifying the impact of health IT implementations on clinical workflow: a new methodological perspective.’ Journal of the American Medical Informatics Association 17(4), 2010, 454-461.
Submitted by (Stacie Carney)