Time-motion analysis of paper-based clinical workflows in a multi-specialty academic ophthalmology practice

Abstract

Purpose : Efforts to improve electronic health record (EHR) use in ophthalmology can be enhanced by deeper understanding of clinical workflows and documentation that rely on traditional paper-based methods. While time requirements associated with EHR use in ophthalmology have been characterized, data for paper-based documentation are lacking. The objectives of this study were to assess time requirements for patient encounters, after-hours utilization, and relative efficiencies and inefficiencies of paper-based clinical workflows in outpatient ophthalmology.

Methods : Prospective mixed-methods study entailing time-motion observations and survey of attending ophthalmologists using paper-based documentation in an academic ophthalmology department in September 2018. Manual time-motion observations were conducted for seven attending ophthalmologists from six subspecialties (414 patient encounters). Total time spent by attending ophthalmologists per patient was recorded, as well as time spent on documentation, examination, procedures, and time talking with patients, staff, and trainees. The survey covered clinical workflows and after-hours documentation.

Results : Among the 7 attending ophthalmologists in this study (6 men and 1 woman, mean [SD] age, 43.9 [7.1] years), the mean (SD) total time spent per patient was 8.1 (4.8) minutes, with 2.8 (1.4) minutes (38%) for documentation, 1.2 (0.9) minutes (17%) for examination, 3.3 (3.1) minutes (37%) for talking with patients, and the remainder on other activities (i.e. performing procedures or talking with staff). Linear mixed effects models revealed that new patient evaluations required significantly more time than routine follow-up visits and post-operative visits. Higher clinical volumes were associated with reduced time per patient. Based on survey results from 12 attending ophthalmologists, 9 (75%) of respondents endorsed doing no documentation-related work on weeknights. On weekends, 8 (66%) did no work, 3 (25%) worked <1 hour, 1 (8%) worked 1-2 hours, and none worked >2 hours.

Conclusions : Paper-based documentation comprises a substantial portion of the total time spent for patient care in outpatient ophthalmology clinics but is associated with minimal after-hours work. Understanding paper-based clinical workflows may help inform targeted strategies for improving EHR use in ophthalmology.

This abstract was presented at the 2019 ARVO Annual Meeting, held in Vancouver, Canada, April 28 - May 2, 2019.