WhiteCoat

How Time is Spent During an Emergency Department Shift

During one shift last week, I felt as if I was spending too much time doing computerized charting, computerized order entry, and computerized admit orders [contractually required to write them - don't ask] and not enough time with patients and their families.

This week, I decided to account for every minute of my time during a 12 hour shift in a moderately busy emergency department where I was the only physician working. I had to scrap the first time I tried it because I kept forgetting to write things down. The next shift, I put the notes where I wouldn’t forget – right next to the computer keyboard with portable clock sitting on top of them.

There is a little bit of overlap between categories when I was multitasking. For example, if I was speaking to a doctor on the phone while charting, I counted the time as only speaking to the doctor. Out of a total of 720 minutes in the shift, I calculated that I spent the following amount of time performing the following tasks:

Seeing patients: 247 minutes
Time on computer: 365 minutes including …
–Charting/entering orders and labs to be done: 219 minutes
–Looking up old medical records: 42 minutes
–Entering discharge instructions/prescriptions: 41 minutes
–Entering admit orders/completing transfer forms: 63 minutes
Discussions with other physicians: 69 minutes
Researching medical issues: 13 minutes
Eating lunch: 5 minutes
Personal phone call: 4 minutes
Miscellaneous down time: 12 minutes
Sign out to oncoming physician: 5 minutes

Longest time between patient exams: 47 minutes
Involving: 24 combined minutes charting patient’s condition and entering orders, 13 minutes discussing the patient condition with three physicians, 10 minutes completing transfer documents and giving report to medics

I probably write more than most docs on my patient charts. Even so, more than half of my time was spent making sure that the charts were documented sufficiently to satisfy hospital administrators, to please governmental payors, and to smite plaintiff attorneys.
I’ve had some nurses tell me that I spend too much time with patients. My shift averaged 7-11 minutes per patient, with a few outliers. In total, I spent only one-third of my 12 hour shift with patients and their families. That’s too much?

Kind of disappointing to realize how the practice of medicine has “evolved.”

46 Responses to “How Time is Spent During an Emergency Department Shift”

  1. M3 says:

    WhiteCoat, how much do you think this would vary from one shop to another?

    I’m a few months away from my last year of med school, am planning on EM, and have a fourth year rotation in it which I’m counting on to help me decide for sure.

    • WhiteCoat says:

      Moderate variance based upon ease of use of the EMR. However it is a shifting dynamic. If you have an easier EMR interface, you’ll probably lose revenue because Medicare says you forgot to check one box that the more cumbersome interface would have caught.
      EM is a rewarding residency. If you can find an EM/IM or EM/FP residency, take it.

  2. ThorMD says:

    How many patients did you see during that shift?
    No bathroom breaks – or is that miscellaneous down time?

    • WhiteCoat says:

      I didn’t keep track of number of patients. We average 1.9-2.5 per hour when all the rooms are full.
      Bathroom breaks were in down time.

      • ThorMD says:

        I was just curious because it takes me about 10-15 minutes per patient to complete my note (using populated templates, typing and dragon). We have the option of using scribes, but I find that they slow me down because of having to spend so much time editing about things like Baby A & O x 3.

        Of course there’s always more computer time for orders, looking up old records, and discharge instructions. If (when) I get downtime, I’m constantly updating my templates to hopefully save time in the future.

  3. Vladimir von Winkelstien says:

    Five hours out of twelve on the computer seems like a long time. Do you think that having a better designed user interface would reduce that significantly?

    • WhiteCoat says:

      Probably a moderate reduction in time – maybe an extra 1-1.5 hours. The problem is that there is so much information that has to be captured with each visit in order to get compensated from payors and to make sure that the government agencies don’t cite you for something that the time it takes to enter the information becomes more and more unwieldy.

  4. Linda says:

    That really is sad. I did not realize how much time you spend doing other things. One problem I know ER doctors have is seeing patients that can’t afford a doctor visit so they go to the ER because that is the only way they can get help. They should also have someone that can do clerical work, and save the busy doctor sometime. My last visit to the ER was for something I had been going to the doctor for, for a year. I simply ask them to run a thyroid test on me, and there was my problem. I hate I had to go to the emergency room, when everything could have been taken care of in the doctor’s office, if they would have only ran a few test, instead of randomly prescribing me medications that only made the problem worse. I feel the reason they did not run the test was because I had no insurance and had to pay out of pocket. I work almost full time at my job, but am on call, so I get no benefits. Bless you, and I hope a solution to your problem can be found.

  5. Matt says:

    WC, question for you. In that shift, how much was billed? And how was it billed – ie. per procedure, per hour, etc?

    • WhiteCoat says:

      Billing is always by codes which depend on what is done and what is documented. Billing codes take into account what information is gathered from history, what is documented on physical exam, and the medical decisionmaking. Time is generally not calculated in billing ED visits – except to a minor degree in critically ill patients (which average only 3-5% of all ED patients).
      Procedures are billed separately (one reason that doctors who do procedures earn more than those who do not).
      Billing in no way reflects reimbursement, though. Medicare has set fees it will pay. Medicaid pays pennies on the dollar regardless of what is billed. Insurance companies are now switching to a percentage of Medicare allowable charges. And many states are creating laws that forbid physicians from billing patients for the balance of the charges that insurance does not pay. Self pay patients as a whole pay less than 10% of what is billed.

      • Matt says:

        ” Self pay patients as a whole pay less than 10% of what is billed.”

        So why did physicians sign on to the original change?

      • ThorMD says:

        Matt, I don’t understand your comment.

        Self pay patients are uninsured and they can’t/don’t pay their bills.

        What “original change” are you referring to?

      • Matt says:

        Before Medicare/Medicaid became so prevalent, how did physicians get paid?

      • ThorMD says:

        I don’t understand your comparison of the medical economics of 1965 vs 2012? Can you explain yourself?

      • Matt says:

        I’m asking why the majority of physicians cannot reject Medicare/Medicaid and simply go to private pay? If the third party payment system is serving you so poorly, with no improvement in sight, why not reject it wholly? (with the exception of ED, which has wrinkles due to the potential inability of the patient to competently contract)

      • ThorMD says:

        Aren’t we talking about the ED though?

        By federal law, I must evaluate and stabilize you before I am allowed to talk to you about money. Most patient would choose to go somewhere else if they are insured but must pay in cash. And if they inquire and we answer questions about payment methods before evaluation, we are violating federal law.

        Private offices are different as most do a wallet biopsy prior to making an appointment.

  6. Nurse K says:

    Just an observation…

    The doctors that whine about the amount of time spent charting are also the ones that order so much miscellaneous crap that they need to follow up on. If you don’t order an X-Ray for a dry cough x 12 hours in a 20 year old, you don’t need to chart anything about it on the computer, etc. Multiply this by the 10-15 patients you’re responsible for and, yeah, your charting is going to be going crayzee.

    If you’re CTing and USing and XRaying everything and order 12-15 labs on everyone that looks moderately ill or worse, yeah, there’s going to be more charting…

    Also, if you’re not using the computer’s features such as pre-programming assessments and stuff like that, it’s going to be worse.

    • WhiteCoat says:

      I wish it were that simple.
      Low yield testing may cause a small amount of extra time documenting and ordering, but it doesn’t take that long to type “normal” into the “results” field.
      The big time killer is adding free-form text to the HPI and clicking all the necessary boxes so that the data can be analyzed by everyone.
      Most EMRs have pre-programmed templates for data entry, but with several dozens of fields to populate and making sure that nothing is inadvertently included in the chart that doesn’t apply (baby is A+O x 3) or didn’t happen (CNs 2-12 intact) takes extra time.

    • ThorMD says:

      I have to disagree with this. It takes me a second to click on the order and about 5 seconds to put the result in my note.

      I have a spot on my templates for X-rays, so if I don’t order an X-ray it takes about 5 seconds to delete that section of the chart.

      So the time spent is really a wash.

  7. JustADoc says:

    Matt,

    How much was billed is a fairly irrelevent number.

    How much will ultimately actually be collected is interesting but that has to be weighed against the overhead of course.

    • Matt says:

      It’s not irrelevant at all. It ought to be something a physician considers when weighing payment models. As well as collection rates, I agree. As an independent professional I routinely analyze different payment models and given my product is my time, much like a physicians, I always want to know what I can bill for it.

      I’m not asking because I’m trying to figure out how much he makes. I’m asking because I’d like to understand the business side better. All taxpayers should.

      • ThorMD says:

        There are a lot of ER docs who are salaried – so there’s really no incentive for them to calculate how much they bill on a particular shift.

        I get paid by how much I bill, so I do track it so I know how much my paycheck will be at the end of the month. But in my experience, my payment model is in the vast minority.

      • Matt says:

        I understand what you’re saying. But even a salaried employee is ultimately receiving a portion of their gross, or at least that’s how the person paying their salary looks at it. They ought to know that when it comes to salary negotiation time.

    • WhiteCoat says:

      Payment models are not going to change.
      Insurance is a monopsony. Government will pay as little as possible for services provided. Forget to click a box about patient’s smoking history, you get “downcoded.” Don’t document enough areas of a physical exam, you get “downcoded” again.
      It is a game of cat and mouse where the patients will be the ultimate losers as more and more physicians get fed up with the process and either stop taking Medicare or leave medicine altogether.
      The feds would be happy with such an arrangement because less providers means less availability of care which translates into less care provided and less care paid for.

      • Matt says:

        Payment models can change if physicians take charge. You guys are the wealthiest, most respected profession in the world. You’re the gatekeepers to medicine, the front lines.

        You’ve been poorly served by your lobbyists, namely the AMA. But you still have immense unrealized power. Leave Medicare en masse and go back a generation to how the majority of you used to provide services and get paid. You still can.

      • SeaSpray says:

        I really like what you said here Matt. I have long been advocating that they UNITE and fight back on some of these issues. Because ..if they don’t …who will?

        Something has to happen to reverse this or at least improve the process.

        It is sad that physician-patient time is compromised the way it is. It also seems you spend more time doing the administrative work vs actual diagnosis and treatment. Assuming it is routine and not an all consuming life and death emergency.

        The threat of physicians leaving MDCR is alarming …considering the aging baby boomer population.

        If this new health care bill stays in place …I wonder how much worse it will get?

      • scalpel says:

        Emergency physicians are not allowed to leave Medicare.

      • WhiteCoat says:

        The problems with leaving Medicare are that many physicians need to practice in hospitals and the hospitals can’t or won’t leave Medicare.
        Also, if you make the decision to leave Medicare, you aren’t allowed to participate in Medicare again for two years after you leave. So if things don’t work out like you planned, a large portion of your income is gone.
        I have long advocated hospitals dropping Medicare. Smaller community hospitals without residency programs (or receipt of other government funding) then wouldn’t be subject to EMTALA laws and would be able to charge fair prices for their services. It would be especially effective if smaller hospitals in remote areas banded together and did this collectively, but then I could foresee governmental regulators making some type of conspiracy allegations against the hospitals and forcing them to continue accepting Medicare at the threat of litigation.
        So leaving the government water trough behind is theoretically feasible, but not likely to happen.

      • Matt says:

        I understand the fear of leaving Medicare and the declining income, but aren’t you facing that anyway?

        At some point you have to take the leap, just like your predecessors took the leap into the third party payment/Medicare model 40 years ago. I get that it’s worked out great, and even today you’re still well paid based on average incomes. But the path you’re on is not one toward increased job satisfaction or income. It will take some risks to get off it, don’t you think?

      • scalpel says:

        I previously posted a reply on this topic that was eaten when your website got a bug, but emergency physicians really cannot opt out of Medicare. It isn’t just the two year thing. If I opt out, all that allows me to do is send prospective Medicare patients a contract saying that they agree to pay me outside the Medicare system. I cannot ask them to sign the contract when they present with an urgent or emergent condition. They have to sign it before they come in to the ER, if they sign it at all. But they DO NOT have to sign it, and if they do not, I have to bill Medicare for their visit anyway, and I CAN NOT balance bill the patient even if I have “opted out.” So why would they sign such a contract that ensures they will have to pay more for services?

        We are slaves, and this seems to be unconstitutional to me, but that is the law. See section 40.28:

        https://www.cms.gov/manuals/Downloads/bp102c15.pdf

      • Matt says:

        I think from am emergency dept perspective it is problematic because there is so much government involved in the delivery of services, from the ambulance service, often paid for with tax dollars, to the fact that the recipient of the services is not able to consent in some cases.

        So I see where you’re unique. I still think you fail to recognize your power as the gatekeeper though, and that you have a stronger voice than you give yourself credit for.

        I do not believe it’s unconstitutional.

  8. igloodoc says:

    WC
    What would be interesting is a comparison of your charting times of paper form vs computerization. In all my testing I have found that computers at least double the paper chart time (which in your case would free up 180 min or 3hr to spend with patients).

    If the JC were worth a spit they would publish average EMR interaction times for a few standard diagnosis of varing complexity. This would give a more valid comparison of EMRs. Guess they are too busy.

    • ThorMD says:

      When I used a paper chart, I could complete the ED note in about 4 minutes. And it was easy to do a lot of it while multitasking (talking on the phone etc) so really less than 4 minutes.

      My computer charting is 10-15 minutes per note. And I can’t do it while multitasking.

  9. hashmd says:

    Our Urgent Care technically is part of the ED, even though we are across the street. We have to use the same charting, called T-sheets. Because of all the bureaucracy, all the requirements for “education”, JC requirements, etc., a 3 minute visit for a cold takes me 4 minutes to chart and 15-20 min for the poor discharge person to input the data, print 10 pages of JC required “education” before the patient finally can be checked out. And that does not count the wait to get into the exam room!

    Our EMR for our clinics would add another 4-8 min. of charting, even with Dragon! There is no double blind, placebo controlled trial ever done showing that EMR saves time or lives!

    • WhiteCoat says:

      EMRs were never intended to save time or lives. They were intended to create data that can be analyzed.
      Why do you think that the government is paying bonuses to those practices that implement EMRs? Once data can be analyzed, then it can be weaponized.

  10. That is brilliant. I think I may attempt to do the same thing. Everyone always complains about how much time they spend charting, getting interrupted by RN’s, making calls, etc but it’s nice to see the raw data. I imagine some people are actually not charting as much as they think and vice versa.
    Incidentally, I am a fairly fast charter/typist on our EMR and I am sure that helps me cut down on that time. One of our older docs can’t type for shit. He does the single finger peck method and is always having to chart at home remotely since he can never finish his charts.
    ER docs should all take computer/typing classes to improve this skill if they are weak at it.
    Another trick I employ is to start charting before I see the patient – especially the medical history, meds, allergies, etc that usually is already done from prior visits and from the triage RN.

  11. Dave Bryant says:

    I am a workhorse and used to see 3.5-4 pts per hour. Then CPOE hit and now I see 3 pts per hour, if I am working on all cylinders and the stars are properly aligned.
    I too have timed my shifts and I also found that most of my time is spent entering some form of data into a computer. I spend less and less time at the bedside.
    I start with 600 minutes.
    I spend between 150 and 180 minutes entering orders. (This compare with about 30 minutes when we used a paper order system.)
    Another 150 or so minutes charting. (our EMR has been here for 20 years and for me is much faster than paper charting, while yielding a better chart.)
    About 45 minutes reviewed old records.
    About 60 minutes trying to acquire and speak with other physicians.
    I cannot tell how much time I lose due to interruptions which occur about every 30 to 45 seconds.
    So that leaves me about 5 minutes for each pt bedside.

  12. n.gill says:

    One word: scribes.

    • ThorMD says:

      Our group uses scribes, but they do not save that much time. In fact, for me, I am quicker than the scribe, so don’t use them. I generally spent more time telling them what to write and editing what they did than it took me to do it myself. In our pool of 30 scribes, only 1 person actually saved me time. And, of course, everyone wants to work with him.

      Most scribes are transient (applying to med school etc). Because who else would work near-mininum wage? It takes at least 3-6 months to get them to get familiar with the jargon, and more time to get familiar with the docs styles. By the time they are hitting their groove, they leave for their next job or med school. Most realize they can work as an ED tech and earn 2-3x as much money and get the same exposure to medicine that will help them get into med school.

      • Yes, I think this will likely be the case if and when we get scribes. There will be times, like when I am on the phone or doing a procedure that a scribe could get charting done for me and save time but if I am actually able to sit down to chart, I can do it pretty damn fast.

  13. Ted Switzer, MD, FACEP says:

    I find it interesting that ED physicians and nurses continue to pick up the chores of the clerical staff.
    Order entry and searching for medical records has traditionally been a clerical function.
    Why should the advent of EMRs change that?

  14. Laura Bryan says:

    Anybody remember transcriptionists? We’ve been providing a valuable service to doctors for decades until we were deemed an “expense.” Then docs started hiring scribes (med students). there is a vast workforce already trained in the jargon and documentation styles with excellent keyboard skills, and we’re not transient. Why don’t CFOs see the irony of paying a physician to do documentation because they think paying $20/hr to an MT is too expensive?

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