Last month, a group of investigators from the American Academy of Family Physicians and the University of Wisconsin led by Holman1 published a study entitled, “The myth of standardized workflow in primary care.” The researchers directly observed 20 primary care physician (PCP) visits and coded the usual tasks physicians perform during a visit. For some physicians, they observed 2 encounters to see if individual physicians followed a consistent pattern. What they found won’t surprise any of you:
“…We found no consistent workflows when analyzing visits individually or by PCP, or visits conducted at clinics with or without an [electronic medical record (EMR)]. The workflow for tasks is dictated not by the type of chart, the patient, or the physician. Instead, workflow emerges from the interaction between the patient’s and the physician’s agendas.”
This rang true for me. For example, sometimes a patient immediately pulls out her bag of pills, so I do the medication review first. Other times, social chat comes first. Often, asking, “Is there anything else you need today?” leads to another round of history-taking and test-ordering.
The physicians in this study approached patient visits as a conversation rather than adhering to a rigid protocol, as the EMR vendors imply we should do. Frankly, that has never made sense to me. Why shouldn’t the EMR companies adapt their tools to the needs of patients and physicians? It was so heartening to read that experienced family physicians are not kowtowing to EMR experts’ insistence that we change our workflow to adapt to the realities of EMRs. We still approach patient encounters in a patient-centered way, following the thread of the conversation to fully respond to our patients’ needs. (Can the same be said for medical students? See last month’s Guest Editorial, “Med students: Look up from your EMRs”.)
"Workflow" was a foreign concept to me until the advent of EMRs. I never worried much about the order in which I was performing "tasks," and I still don't.
Holman et al1 describe the interplay between physicians and patients during office visits as a “dance” in which patients and physicians take turns leading. Let’s invite EMR vendors to join our dance—and follow our lead.