Documentation load and clinician wellbeing

Sinsky and colleagues observed 57 physicians across four specialties for 430 hours and reported it in 2016. Direct clinical face time with patients took 27.0 per cent of the office day, and the record and desk work 49.2 per cent. Inside the examination room, 37.0 per cent went to the record. Twenty-one of them kept after-hours diaries and recorded one to two hours of further work most nights.

Arndt and colleagues reported in 2017 from electronic health record event logs for 142 family physicians, validated against direct observation. They spent 5.9 hours of an 11.4-hour workday in the record, 1.4 hours of it outside clinic hours.

Neither study measured burnout as an outcome, and the figures are averages across each cohort.

The World Health Organization classifies burn-out in ICD-11 as an occupational phenomenon with three dimensions: exhaustion, mental distance from the job or cynicism about it, and reduced professional efficacy.

Adler-Milstein and colleagues, reporting in 2020, compared event-log data against clinician-reported burnout. After-hours record time and inbox message volume were associated with the exhaustion dimension, not with cynicism. The design cannot say which way the association runs.

Under the Health Insurance Act 1973, a practitioner before the Professional Services Review is tested against an adequate and contemporaneous records standard: a separate legible entry for each attendance, dated, carrying the clinically relevant information, made at the time or as soon as practicable afterwards.

Good Medical Practice, the Medical Board of Australia's code of conduct, sets the same timing expectation, and the RACGP Standards for general practices carry health-record criteria assessed at accreditation.

The clerical time in both studies covers the note, the correspondence, order entry, results handling and inbox messages. Ambient drafting touches the first two.

• The letter and the note are drafted from the same recorded consultation, not reconstructed from recall.
• Order entry, results handling and inbox volume are untouched, so any change in clerical minutes is bounded by the note and letter share.

• Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Annals of Internal Medicine, 2016.
• Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Annals of Family Medicine, 2017.
• Adler-Milstein J, Zhao W, Willard-Grace R, Knox M, Grumbach K. Electronic health records and burnout: time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians. Journal of the American Medical Informatics Association, 2020.
• World Health Organization. ICD-11 for Mortality and Morbidity Statistics, QD85 Burn-out.
• Health Insurance Act 1973 (Cth) and the Professional Services Review scheme, adequate and contemporaneous records.
• Medical Board of Australia. Good Medical Practice: a code of conduct for doctors in Australia.
• RACGP. Standards for general practices, 5th edition.