My educational background was in the field of industrial/organizational psychology. That generally meant that we could mess with the minds of an entire work force instead of being constrained to just one person at a time like a clinical psychologist.

But the discipline also dealt with time and motion studies as part of looking at the design of jobs and work flow.

Now I am not a real detail oriented guy. OK, I have virtually no capacity for operational detail.I tended to dodge any class that had 'time and motion' in the course description.

So when I found myself interested in an article about this type of study, I wondered if I was slipping, or growing.

The article, featured in the April 29, 2010 issue of The New England Journal of Medicine, is about a small internal medicine practice that did a detailed analysis of their work for a week. Specifically, they looked at the extra work they have to do that is directly related to patient care that is not included in the visit.

You can read the study as it is a) not very long, and b) not written by a time and motion engineer, so it is actually readable. But here are the headlines...

The physicians work 50-60 hours per week and each see about 18 patients per day.

If you assume the average internist gets 15-20 minutes for each visit, patient visits account for about 22-30 hours a week, somewhere around 40-50% of their work time.

That is the part of a physician's work week that is actually compensated.

Do you know what you call a lawyer or a consultant that is only 'billable' 40-50% of the time?  Unemployed.

So what is up with these physicians? Are they playing a lot of Solitaire on their PCs? Where does the rest of the time go?

This little study sheds at least some light.

The practice in the study, Greenhouse Internists in Philadelphia, focused specifically on the clinical work that happens outside the visit but that is related to patient care. They did not look at office administration tasks or human resource management time or professional development activities.

Instead, they kept meticulous records on the physician's direct involvement with a defined set of documents and tasks related to the care of their patients. Specifically, the study looked at the physician's participation with the following: phone calls, emails, prescription refills, lab results, imaging results, and consult reports.  Here is what they found.

What comes along with those 18 visits per doctor per day is:

• 23.7 patient care related phone calls to be made
• 16.8 patient care related emails to be sent
• 12.1 prescription refills to be written
• 19.5 lab results to be reviewed and processed
• 11.1 imaging results to be reviewed and processed
• 13.9 consult reports to be reviewed and processed

That is, for every physician, every day, in addition to seeing those 18 patients, there are 97.1 of these patient care related documents or transactions or communications that must also be handled.

These numbers are for an internal medicine practice and they might move around here and there based on specialty, but the basic point is likely the same.

How long do those tasks take? A minute each? Two minutes?

That one to two minute range would put you at somewhere between 8 and 16 hours a week, per physician, on clinical work that is outside the scheduled and reimbursed visit. That is a material chunk of time.

This leads to first a question and then a thought.

First the question - Who pays for this work?

I know the argument from payers is that this time is built into the fees paid for the visit itself. Sort of like the lawyer and the consultant building into their hourly rate the non-billable work that they have to do. And I understand the technicality of that response, but have to ask again, 'Really?'

Did you really build this into the reimbursement rate? Did you really even have a clue as to how much of this 'extra' stuff is required?

We've worked through the hourly physician compensation calculation before, so I won't rehash that math. I am guessing the answer from those who pay for care, if we could administer that magic truth serum, would be, 'Probably not, but so what? We aren't changing the model or paying you for that work.'

And I knew they would say that, which leads to the comment.

Physician practices understand that part of the business involves direct contact with patients, but must also understand that you are a 'clinical information processing' company as well. Flowing alongside the work that drives the revenue, work that goes on the claim form, is this information processing work. Information comes in, information goes out. Inside the practice it flows to the medical assistant and the nurse, but sometimes the physician (about 97.1 sometimes a day), and then it flows out again, to medical records or the fax machine or the mail or somewhere else. But it flows.A lot.

When you wrap your mind around this fact, the reality of this information flow, two things come to mind:

• First, you better make sure you have designed your work flow and your staff responsibilities to optimize the physician's time with this stuff. Otherwise, you're going home late and working Saturdays. For free.
• Second, if you are considering an EMR, think about how that tool can help you manage this issue. Controlling the flow of the information, maximizing your productivity in dealing with it, and making sure important stuff doesn't fall through the cracks is more important than ever.