Where Did the Day Go?--A Time-Motion Study of Hospitalists
Where Did the Day Go?--A Time-Motion Study of Hospitalists
Hospital Medicine represents the fastest-growing specialty in the history of medicine in the United States, with approximately 28,000 hospitalists now working in over half of American hospitals. Hospitalists increasingly fill the gap between demand for care of hospitalized patients and the deficit of physicians previously available—primary care physicians in community hospitals and residents in teaching hospitals. This growth has also been driven by hospitalists' ability to increase clinical efficiency. Research consistently demonstrates a reduction in overall costs and length of stay with the use of hospitalists. Additionally, many teaching hospitals have implemented nonteaching hospitalist services in an effort to comply with the Accreditation Council for Graduate Medicine Education (ACGME) program requirements regarding resident duty hours. Given the potential for improved clinical efficiency and the need to comply with revised ACGME program requirements, the Hospital Medicine Service at Northwestern Memorial Hospital (NMH) was established in 2003. Today, this service cares for more than half of hospitalized medical patients at NMH.
Although extensive research documents that implementation of a hospitalist program improves the efficiency of hospital care delivery, there is little data to explain how hospitalists achieve this level of efficiency or how efficiency might be increased further. Several authors have suggested potential explanations for hospitalists' efficiency gains, but none has yet received strong empirical validation. The only previously published study to directly observe more than a small portion of the activities of hospitalists was conducted at NMH in 2006. O'Leary et al. used time-motion methodology to study ten hospitalists for 75 hours total. They found that hospitalists spend a large amount of time on communication when compared to nonhospitalist physicians. However, the study only reported partial information about how and with whom this communications was performed. Similarly, the authors reported that documentation occupied about a quarter of hospitalists' time, but did not report more detailed information about what was being documented and how. Additionally, they noted that hospitalists spent 21% of their time multitasking, but did not report what types of activities were performed during these episodes. Finally, at the time of that study hospitalists at NMH saw about 40% fewer patients per day than they do now. Increasing the number of patients each physician sees in a day is an obvious way to increase productivity, but it is unclear how this affects hospitalist workflow and time spent in various clinical activities.
Another important trend in hospital care delivery is the implementation of electronic medical records (EMR). NMH was just transitioning to a fully integrated EMR and computerized physician order entry (CPOE) system when the previous time-motion study was performed. Now that the system is in place, a significant proportion of hospitalists' time has shifted from using a paper-based record to sitting in front of a computer. However, we do not know exactly how hospitalists interact with the EMR and how this alters workflow; an increasingly important issue as hospitals across the U.S. implement EMRs at the behest of the federal government and aiming to improve patient safety.
To better understand the workflow of hospitalists and validate the findings of the O'Leary study in a larger sample of hospitalists, we undertook this study seeking to collect data continuously for complete shifts, rather than sampling just a few hours at a time. We hypothesized that this would reduce observer effects and provide us with a more complete and accurate assessment of a day in the life of a hospitalist.
Introduction
Hospital Medicine represents the fastest-growing specialty in the history of medicine in the United States, with approximately 28,000 hospitalists now working in over half of American hospitals. Hospitalists increasingly fill the gap between demand for care of hospitalized patients and the deficit of physicians previously available—primary care physicians in community hospitals and residents in teaching hospitals. This growth has also been driven by hospitalists' ability to increase clinical efficiency. Research consistently demonstrates a reduction in overall costs and length of stay with the use of hospitalists. Additionally, many teaching hospitals have implemented nonteaching hospitalist services in an effort to comply with the Accreditation Council for Graduate Medicine Education (ACGME) program requirements regarding resident duty hours. Given the potential for improved clinical efficiency and the need to comply with revised ACGME program requirements, the Hospital Medicine Service at Northwestern Memorial Hospital (NMH) was established in 2003. Today, this service cares for more than half of hospitalized medical patients at NMH.
Although extensive research documents that implementation of a hospitalist program improves the efficiency of hospital care delivery, there is little data to explain how hospitalists achieve this level of efficiency or how efficiency might be increased further. Several authors have suggested potential explanations for hospitalists' efficiency gains, but none has yet received strong empirical validation. The only previously published study to directly observe more than a small portion of the activities of hospitalists was conducted at NMH in 2006. O'Leary et al. used time-motion methodology to study ten hospitalists for 75 hours total. They found that hospitalists spend a large amount of time on communication when compared to nonhospitalist physicians. However, the study only reported partial information about how and with whom this communications was performed. Similarly, the authors reported that documentation occupied about a quarter of hospitalists' time, but did not report more detailed information about what was being documented and how. Additionally, they noted that hospitalists spent 21% of their time multitasking, but did not report what types of activities were performed during these episodes. Finally, at the time of that study hospitalists at NMH saw about 40% fewer patients per day than they do now. Increasing the number of patients each physician sees in a day is an obvious way to increase productivity, but it is unclear how this affects hospitalist workflow and time spent in various clinical activities.
Another important trend in hospital care delivery is the implementation of electronic medical records (EMR). NMH was just transitioning to a fully integrated EMR and computerized physician order entry (CPOE) system when the previous time-motion study was performed. Now that the system is in place, a significant proportion of hospitalists' time has shifted from using a paper-based record to sitting in front of a computer. However, we do not know exactly how hospitalists interact with the EMR and how this alters workflow; an increasingly important issue as hospitals across the U.S. implement EMRs at the behest of the federal government and aiming to improve patient safety.
To better understand the workflow of hospitalists and validate the findings of the O'Leary study in a larger sample of hospitalists, we undertook this study seeking to collect data continuously for complete shifts, rather than sampling just a few hours at a time. We hypothesized that this would reduce observer effects and provide us with a more complete and accurate assessment of a day in the life of a hospitalist.
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