Expanding primary care capacity by reducing inefficiency

A study in the November issue of Health Affairs says modest but system-wide improvements could yield dramatic gains in physician capacity while potentially reducing physician burnout and its implications for quality of care.

"If widely adopted, small efforts to empower nonphysicians, reengineer workflows, exploit technology, and update policies to eliminate wasted effort could yield the capacity for millions of additional patient visits per year," said Scott Shipman and Christine Sinsky in their study.

The need to improve primary care capacity is increasingly important with the implementation of the Affordable Care Act in 2014, when millions are expected to become newly insured. Policy researchers have estimated that insurance expansion will generate 15-24 million additional primary care visits each year.

Considerable attention has been placed on the costly and lengthy process of training more physicians to meet this demand. Instead, Drs. Shipman and Sinsky point out, the current workforce could be utilized more effectively, not by asking physicians to work harder but by making systems of care more efficient and focusing physicians' time on activities warranting their expertise.

Straightforward efforts to reduce wasted time, adopted widely across the nation's primary care physicians, could yield tremendous additional capacity.For instance, just 30 minutes of reduced waste per day -- which the authors demonstrate can be readily achieved through efforts such as delegation of certain clerical tasks or improved clinic workflows -- could result in 30-40 million more primary care visits available each year without a single additional provider.

Shipman, through his association with the Association of American Medical Colleges, and Sinsky, through hers with the American Board of Internal Medicine Foundation, suggest solutions to the "remarkable inefficiency" in primary care. The authors conducted nationwide site visits, contacted leaders of innovative primary care practices across the country and reviewed the literature.

The authors highlight several opportunities to improve efficiency in primary care through examples currently in use, albeit in a minority of settings:

Teamwork -- Conservatively, research suggests that other staff members could perform tasks that consume 15 percent of the time physicians spend on patient care outside of visits. Enlisting health coaches, medical assistants or nurses to aid with documentation of office visits enables more time for physicians interact with patients, rather than keyboards and computer monitors. These team members could also review care plans, and provide preventive counseling and other standardized aspects of care.

Redesigned work flow -- Redesigned work spaces that co-locate physicians with the rest of the health care team throughout the day facilitates "real time" communication, and can save a physician 30 minutes each day. Evidence in some systems has shown that simple reconfigurations, such as putting a printer in every examination room or placing large monitors in work areas to continuously show patient visit status, can save 20 or minutes daily for a physician.

Technology -- While electronic records increase efficiency in information retrieval, it has increased inefficiencies in data entry, such as visit notes, billing information, test results. The authors quantify the time wasted daily due to this interface "through which all care must pass."On the positive side, software programs that triage patients and guide treatment decisions without a visit can improve quality of care and reduce the burden on physicians' time.

Reexamination of policies -- Policies, ranging from having a computer automatically sign out a user for security reasons, requiring users to sign in recurrently, to limitations in nonclinicians' ability to assist in routine, protocol-driven care, should be reexamined and more efficient solutions standardized.

For instance, "based on time-motion analysis and interviews and observations in site visits, we estimate that primary care physicians may waste and average 30 minutes for per day, and nurses 60 minutes per physician per day, on prescription renewal tasks that policy changes -- coupled with work flow modifications -- could reduce substantially," the authors said.

"The notion that the physician should be directly in charge of every aspect of care is becoming increasingly outdated," the authors said. There is a great potential in primary care to increase capacity though enhanced efficiency without relying on more physicians, they concluded.