Tuesday, February 7, 2012

Is Medicine an Information Science? Perspective from Physician Time Studies

We tend to think of medicine as a health science or a life science, yet in many ways it is an information science, and may be becoming more so with the growth of data generated in the care of patients. If medicine is indeed an information science, then there is a critical role for  biomedical and health informatics, which is the field that uses information to improve some aspect of health, healthcare, and biomedical research.

A couple years ago I reviewed in this blog  two articles that had recently been published about the role of information in medicine. One article, by Stead et al. posited that the quantity and complexity of information in medicine requires a fundamental paradigm shift from the "power of the individual brain" to the "collective power of systems of brains" [1]. The authors noted that the numbers of facts per clinical decision will likely increase exponentially, especially as our knowledge moves beyond the phenotype to include the genotype (e.g., genomic variation, proteomics, etc.). The second article, by Shortliffe, was published about the same time in a special issue of JAMA devoted to medical education [2]. He noted that while medical education (rightly so) goes to great lengths at teaching students how to assess, interact with, and treat patients, it devotes very little effort to obtaining, using, and analyzing another critical component of medical care, namely information.

What evidence is there that medicine is an information science? After all, most modern knowledge workers - i.e, professionals in financial analysis, aviation, and  marketing to name a few - make critical use of information in their work too. A number of studies have looked at how physicians spend their time, and provide clear evidence that information is critically important to their work. Some might think that physicians spend the majority of their time with patients, such as examining them or performing procedures on them. However, these time studies show that physicians spend more time interacting with information, such as reviewing data and documenting patient care, than interacting directly with patients.

These studies assess the tasks of physician work and the time spent doing them. Some of the tasks primarily involve using information. (It  is unfortunate that others in the healthcare environment have not been studies, but as often happens, physicians are the targets whom researchers have chosen to study.) Enough of these studies have been done to lead Tipping and colleagues to perform a systematic review [3]. In addition, four more studies have been done since the completion of the systematic review by Kim et al [4], Tipping et al. [5], Yousefi [6], and Chisholm et al. [7].

The systematic review points out that the studies are heterogeneous and cannot be group to do something like a meta-analysis. Yet the results are surprisingly consistent. The systematic review develops a classification to which most studies relatively adhere. The studies all measure in some manner "direct" patient care, where the physician interacts directly with the patient. They likewise describe "indirect care" of the patient, where the physician reviews patient data, performs documentation, and communicates with various people, such as members of the care team, the patient and/or their family, insurance companies, and others. Finally, most studies have some sort of "other" category that includes travel (either within a healthcare facility or between them), education, and personal time (such as eating). The systematic review and three of the follow-up studies focused physicians who work on hospital wards (i.e., hospitalists), although one of the more recent studies looked at emergency department physicians [7]. The studies have been somewhat though not exclusively weighted toward academic facilities and physicians in training.

Even with the variation in definition of the categories and tasks within them, the results are remarkably consistent. While the range is wide, most of the studies show that physicians spend about 15-17% of their time in direct patient care. Conversely, they spend about 64-67% of their time in indirect patient care, often relatively evenly divided between reviewing results, performing documentation, and engaging in communication. The tasks of reviewing results and carrying out documentation are clearly information-focused in nature, which means that physicians spend about 35-40% of their time engaged with information. One could also probably argue that aspects of direct patient care are information-focused as well, as the physician is gathering information about the patient. The education component of the other category is of course very information-oriented.

Some additional interesting tidbits come of the individual studies. The newer Tipping et al. study took place in a setting of full electronic health record (EHR) implementation and noted 34% of physician time was spent interacting with the EHR [4]. This study and two others by O'Leary et al. [8] and Westbrook et al. [9] in the Tripping et al. systematic review looked at multitasking, finding it was being done during 16-21% of physician work time. O'Leary et al. also found physicians received 3-4 pages per hour [8], while Westbrook et al. noted an average of 2.9 interruptions per hour [9]. Kim et al. found that the amount of direct care was higher at the beginning of shifts while indirect care was higher toward the end of shifts [5]. They also noted that 7% of physician time was spent in travel within the healthcare facility, wondering whether this might be an area where efficiency of work can be improved [5].

In their study of emergency department physicians, Chisholm et al. noted that somewhat more time was spent in direct patient care (31% for academic settings and 38% for community settings) and less in indirect care (55% for academic settings and 50% for community settings) [7]. They also found these emergency physicians were interrupted on the order of 10 times per hour.

These studies collectively show that physicians in hospitals and in emergency departments spend a substantial amount of their time interacting with information. Going forward, the amount and complexity of information is likely to increase. It will come from diverse sources, such as patients entering data into their personal health record (PHR), clinical data coming being provided via health information exchange (HIE), and the growing amount of data from genomics and related areas. This makes the science of biomedical and health informatics even more critical to the medical field.


1. Stead, W., Searle, J., et al. (2010). Biomedical informatics: changing what physicians need to know and how they learn. Academic Medicine, 86: 429-434.
2. Shortliffe, E. (2010). Biomedical informatics in the education of physicians. Journal of the American Medical Association, 304: 1227-1228.
3. Tipping, M., Forth, V., et al. (2010). Systematic review of time studies evaluating physicians in the hospital setting. Journal of Hospital Medicine, 5: 353-359.
4. Tipping, M., Forth, V., et al. (2010). Where did the day go?--a time-motion study of hospitalists. Journal of Hospital Medicine, 5: 323-328.
5. Kim, C., Lovejoy, W., et al. (2010). Hospitalist time usage and cyclicality: opportunities to improve efficiency. Journal of Hospital Medicine, 5: 329-334.
6. Yousefi, V. (2011). How Canadian hospitalists spend their time - a work-sampling study within a hospital medicine program in Ontario. Journal of Clinical Outcomes Management, 18: 159-164.
7. Chisholm, C., Weaver, C., et al. (2011). A task analysis of emergency physician activities in academic and community settings. Annals of Emergency Medicine, 18: 117-122.
8. O'Leary, K., Liebovitz, D., et al. (2006). How hospitalists spend their time: insights on efficiency and safety. Journal of Hospital Medicine, 1: 88-93.
9. Westbrook, J., Ampt, A., et al. (2008). All in a day's work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Medical Journal of Australia, 188: 506-509.

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