The comprehensive PCP task list presented here was developed so that it could be adapted with minimal effort to other healthcare settings to assist in evaluating clinic workflows relative to patient visits. Specifically, this list provides information about the types of tasks being performed, the sequence in which the tasks might be performed, the data sources used by the physician for a given task, and the contribution of other persons (eg, medical students or caregivers) to the physician–patient visit. Neither the content nor the sequence is meant to be prescriptive or all-inclusive and will likely vary from country to country or even from clinician to clinician. The list is simply a generic formulation of the common tasks performed during a patient visit with the sequence being the most common found in the data sets used for development. In fact, we observed many different sequences, and recognise that many more are possible. We encourage individual practices/organizations to update or modify this list to suit their own circumstances.
This task list is intended to be a flexible tool to assist individuals or groups in analysing physician workflow before and after changes to the structure and processes of healthcare delivery, for example, implementation of health IT like EHRs, a clinic transition to be a PCMH, or other changes implemented during a quality improvement process, to help ensure that the design and implementation of the changes are optimal. The multiple levels of codes allow flexibility to code at a high level of major tasks or more in-depth second-level, third-level or fourth-level coding based on the need to study primary care workflow and the resources available to perform observations and code and analyse data.
Another example of practical application of the task list is that it can be used alone or in conjunction with other workflow analysis tools to gain a deeper understanding of a PCP’s workflow, to see where problems lie and where improvements can be made. Using this list as a workflow study tool, a clinic could determine the flow of their visits and the types of tasks that routinely or irregularly occur. Hence, the clinic could construct specific and valid workflow scenarios of their actual work, which could then be used to determine which, if any, health IT vendor and implementation plan can accommodate their individual needs. Additionally, the data collected with this tool could be used to assist a vendor in tailoring the health IT software to individual needs. At the very least, it would allow clinics to better understand the changes that would occur if health IT that did not meet their specific circumstances was being implemented. That would afford an opportunity for principled decisions about what kinds of workflow changes to make. Importantly, using the tool after implementation would then provide an opportunity to further study the new workflow and work to optimise it.
Workflow analyses using task lists have been performed in a variety of other healthcare settings, such as hospital medical/surgical and intensive care units, and delivering anaesthesia in the operating room.19–22
Zheng et al
developed a task list and performed a time motion study to analyse physician workflow and use of health IT in paediatric intensive care units.21
Battisto et al
used a task list to describe nursing work in the hospital setting to inform the redesign of inpatient rooms and care areas to improve nursing productivity.19
Our task list, similarly, should be useful in similar ways.
There are several limitations to the use of this task list to analyse PCP workflow. First, the density of coding does not represent the relative time spent on tasks during the visit, for example, it may take 5 min for a physician to recommend a test to a patient which is represented by a single code, however, a 5 min discussion about a patient’s current medications may be represented by nine different codes that may be repeated during that time for each medication. Furthermore, simply comparing the number of codes across observations does not imply more or less work being done by a physician; only the type of work. However, the task list could be used concurrently with a system that allows time spent to be captured. This procedure could then be used to better understand time demands.19
Last this task list, although developed and validated from a large, diverse pool of physician–patient visits, may not be a complete listing of all physician tasks. But we believe it represents the majority of tasks. The tasks performed by PCPs during patient visits will vary based on the context of the work system, that is, the country, the organisational characteristics, the tools and technologies in place, the clinical environment, the patient population and individual patient characteristics, and physician characteristics.23
Clinics and individuals using this task list should be aware that additions to the list may be necessary based on the work context and the questions to be answered from the data collection.