Primary care practices typically measure productivity according to the number of visits, which also drives payment. Work that does not involve a visit from a patient is invisible to those who support and purchase primary care. Several studies have estimated the amount of time that primary care physicians devote to nonvisit work.1,2 To provide a more detailed description, my colleagues and I used our electronic health record to count units of primary care work during the course of a year.

Practice Profile

Greenhouse Internists is a community-based internal medicine practice employing five physicians in Philadelphia. In 2008, we had an active caseload of 8440 patients between 15 and 99 years of age. Of these patients, 68.6% were women; 59.5% were black, 29.8% were white, and 10.7% were another racial or ethnic group or were not identified. Our payer mix included 7.2% of payments from Medicaid (exclusively through Medicaid health maintenance organizations), 21.5% from Medicare (of which 14.0% were fee-for-service and 7.5% capitated), 64.7% from commercial insurers (34.5% fee-for-service and 30.2% capitated), and 6.5% from pay-for-performance programs. With the exclusion of copayments and fee-for-service payments received on behalf of patients in capitated plans, 35.2% of our total revenue came through capitation.

Throughout 2008, our physicians provided 118.5 scheduled visit-hours per week, ranging from 15 to 31 weekly hours each. We regard this schedule as equivalent to the work of four full-time physicians, with physicians typically working 50 to 60 hours per week. Our staff included four medical assistants, five front-desk staff, one business manager, one billing manager, one health educator (hired midyear), and two full-time clerical staff. Our staffing ratio was approximately 3.5 full-time support staff per full-time physician. We had no nurses or midlevel practitioners. We saw patients from 7 a.m. to 7 or 8 p.m. on weekdays and from 8 a.m. to noon on Saturdays and did not provide hospital care.

Methods

We use an electronic health record, which we adopted in July 20043 and use exclusively to store, retrieve, and manage clinical information. Our electronic system came with 24 “document types” that function like tabs in a paper chart to organize documents, dividing clinical information into categories such as “office visit,” “phone note,” “lab report,” and “imaging.” Since all data about patients is stored in the electronic record (either as structured data or as scanned PDFs) and each document is signed electronically by a physician, we are able to measure accurately the volume of documents, which serve as proxies for clinical activities, in a given time period. We queried our electronic health record for the volume of various document types during the 2008 calendar year. We performed a detailed review of all telephone calls and e-mails during a 1-week convenience sample to describe the work, content, and actions associated with these activities.