Some 450 million patient visits to primary care clinics occur in the United States each year. And as the shortage of doctors grows larger each year, primary care teams face increasing pressure both during patient encounters and outside the examining room.

The growing time constraints on primary care clinics — conducting patient consults faster, logging results in EMRs sooner, keeping up with regulatory changes — are worrying patients and physicians alike. 

Stanford Health Policy’s Kathryn M. McDonald and colleagues wanted to better understand the organizational influences of time stressors and the impact they are having on patients.

“Patients get interrupted often when doctors and their care teams are rushed,” said McDonald, MM, PhD, executive director of the Center for Health Policy and Center for Primary Care and Outcomes Research. “They worry about whether their concerns and needs will be addressed adequately. Getting the right diagnosis, treatment and support are all important to patients, so any risk of experiencing suboptimal care due to time stressors is worth understanding better.”

In a study published in the American Public Health Association journal, Medical Care, McDonald and her colleagues wrote that despite concern about the impact time pressure has on the delivery of health care, “scant evidence exists about types of time stress, the organizational factors that shape such stressors in routine care settings, and consequences for patients and practitioners alike.” 

So the researchers analyzed cross-sectional survey data collected from January to August 2016 from primary care teams at 16 randomly selected primary care practices associated with two large Accountable Care Organizations (ACOs) and their patients with cardiovascular disease, diabetes, or both. Through April 2016, they gathered data from 353 physicians and staff members of the clinics.

Then from May to August 2016, the researchers surveyed 1,291 patients by mail and telephone follow-up calls to ask about their concerns.

They determined that the responses translated into two types of stressors related to the lack of time: practice-level time pressure and encounter-level time pressure.

“The stressor condition is similar to the weather—determined by both barometric pressure and temperature — in potentially different way,” they posited.

They found that different organizational factors are associated with each form of time pressure. A patient-centered culture, for example, may include specific patient engagement initiatives, and is associated with reductions in encounter-level time pressure. Similarly, health information systems that provide true support for clinical workflow and good teamwork also corresponded with less encounter-level time pressure. A different organizational influence — leaders that are responsive to the clinic teams — was associated with reductions in practice-level time pressure.

The potential consequences for patients are missed opportunities in patient care and inadequate chronic care support — two very important factors behind successful health care.

“The findings underscore the importance of linking all levels and aspects of physician practice organizations to mitigate  the negative effects of time pressure on patient care” said Stephen Shortell, principal investigator of the Patient Centered Outcomes Research Institute (PCORI) grant that funded the study.  Their other co-author is Hector Rodriguez at the UC Berkeley School of Public Health.

They discovered that one-third of medical team respondents indicated they work in a chaotic practice atmosphere, juggling patient calls, documentation, quality reporting, and many other tasks. The more senior the staff member was, reports of working in a chaotic environment lessened.

Only 31 percent of those respondents said that during patient visits, it was very unlikely for the team to miss all seven specific opportunities related to screening, diagnosis or treatments. 

“Doctors’ offices may increase their chances of preventing adverse effects of time stressors by becoming more patient-centered, coordinating care among team members better and assuring that information technologies make work easier,” McDonald said in an interview about how the results might lead to some solutions. 

“I was struck by the importance of leadership’s responsiveness to their frontline team’s input about changes needed when doctor’s offices are more chaotic,” she said. “Likewise, for clinics that are part of larger groups, like Accountable Care Organizations, the corporate office’s decisions seem to play a role in the perception of time stressors at the practice level.”