I recently came across a Harvard Business Review article detailing an approach to attribution of health care costs around unit of time measurements. That is, if a physician makes so many dollars per hour, then time spent on a minute by minute basis can be calculated. Taking into consideration extender and staff involvement on a unit basis, as well as disbursed cost of overhead, equipment, and other expenses - the cost of a single patient visit could be directly and specifically quantified.
I'm not so sure costs and time spent can be broken down quite so easily. However, this motivated me to consider how patients view time spent by family physicians "with" and "on" them. In an indirect way, I started to question the value and commitment that our patients see within us. Though it is clear that we are not transparent with costs in medicine, I have a suspicion that we are even worse in regards to the transparency of how we utilize our time.
So think for a moment, and put yourself in a patient's shoes. We have all been there, at one stage or another. How much time is really perceived as being dedicated specifically to them? Through the course of an office visit in which a patient is first greeted by a receptionist, nurse, or even a computer terminal. Next up is the inevitable waiting game. The physician visit can be the big finale. But while patients may see the lightshow - I'm not convinced they totally appreciate the prep time and cleanup for the event.
Obviously, tremendous practice-to-practice variation exists. I would never attempt to lay down a blanket statement in regards to work flow and visit dynamics. Rather, I have three specific inquiries:
1) How do patients personally perceive the doctor-patient interaction?
2) To that end - how much of patient perspective is ignored in systems development?
3) Should work transparency be valued as much as cost transparency?
I gather that most do not realize the amount of time spent on paperwork outside of the exam room - billing, coding, pre-visit prep, as well as note completion. This says nothing for time spent on CME, private reading, and newer interfaces with email and phone interactions. I think as physicians, we have done a poor job of demonstrating our actual time spent "per patient"; when the modern visit may mask much of what is done behind the curtain.
How will this interaction and perception change as we drop live EMR into the middle of the patient-physician dynamic? The immediate goal is to increase accuracy and efficiency in note-taking, and provide an at the point of care tool for documentation. Intriguingly, the time spent to make this process more evident has often had the opposite effect - instead of patients feeling more "thankful" for the perception of increased time, they may feel cheated that time isn't spent on face-to-face interaction and counseling.
Certainly, generational and cultural differences are at work here - as are physician preferences in interaction style. However, I think it is worthwhile to take my three aforementioned questions into consideration as we move toward more full adoption of HIT. In recent decades, patients have voiced an increasing discontent with the amount of time spent with their doctors. I think we stand to continue to agitate this discontent if we neglect to acknowledge the patient perspective as a priority in episodic visits.
The next step, then, is to transform this perception from episodes of interaction into a spectrum of continuous oversight and care. I suggest that we should be clear in our efforts, and drive transparency of work to be equivocal with transparency of cost. I believe this to be a huge step in the direction of generating global and perceptively steadfast models of care.