Keywords
consultation duration - time - otorhinolaryngology - outpatient
Introduction
The long working hours of employed physicians have recently become a social concern,
and medical institutions must support further streamlining and improvement of the
efficiency of physicians' work. When medical service fees were revised in the fiscal
year 2008, “point addition for medical office assistants” was introduced to reduce
physicians' workload, and advanced treatment and long-term care hospitals employing
medical office assistants (medical clerks) have become eligible to request points
for medical office assistants in medical service fees since 2016. However, in terms
of hospital management, objective data demonstrating the benefits of the introduction
of medical clerks are required. Further, higher revenue is required from increased
medical service fees to justify the additional costs associated with the introduction
of medical clerks in aspects such as payroll, recruitment, and training.
This study aimed to evaluate the proportion of physicians' work that can be taken
over by medical clerks in the otorhinolaryngology outpatient clinics at two hospitals
with different patient characteristics and operational systems wherein a university
hospital used electronic medical records and a city hospital used the ordering system
and paper-based medical records. For this purpose, a medical student at our university
measured the time required to perform individual tasks by directly observing the physicians'
activities, including what they do as well as say, in examination rooms. The consultation
duration and medical service fees for various disease groups in the individual hospitals
were tallied to identify which medical services are best suited to the characteristics
of each hospital.
This study does not fall under the category of clinical research that requires an
ethical review. However, before participating in this study, the medical student who
observed the course of medical treatment in examination rooms to take measurements
took a class in research ethics and the protection of personal information as a part
of the course curriculum.
Materials and Methods
This study included 157 people who visited the otorhinolaryngology outpatient clinic
of Tokyo Women's Medical University Hospital (referred to as the university hospital
hereafter) or a general hospital in Saitama Prefecture with approximately 200 beds
(referred to as the city hospital hereafter) during 15 weekdays in the 22-day period
beginning December 1, 2017 for initial/follow-up examinations and test consultation.
Among the initial-visit patients in the university hospital and the city hospital,
approximately 50 and 30% were referred patients, respectively. Two clinicians accompanied
by a third-year medical school student from Tokyo Women's Medical University conducted
medical examinations in both the university and city hospitals. The Fujitsu electronic
medical record system was used in the otorhinolaryngology department of the university
hospital, and the doctors entered disease names and other pertinent information into
the system to prepare prescription and treatment orders as well as medical records
during each consultation. However, in the otorhinolaryngology department of the city
hospital, only the ordering component of the Fujitsu system, identical to the one
used in the university hospital, was used for preparing prescription orders by the
doctors; medical records and treatment orders were paper-based, and disease names
were entered into the system by Medical Administration Division staff on behalf of
the doctors.
The medical student recorded the start and end times for each task while directly
observing physicians' discourse and actions in the examination rooms. On the basis
of the measured time, the following analyses were performed.
Analysis of the Consultation Duration
The consultation duration was divided into two classes as follows:
Direct consultation duration: This is the time spent in the examination room by the
physician on conversations with the patient, physical examinations, and other examinations/tests.
The time dedicated to conversations with patients included the time required for the
physician to guide patients to the testing rooms as well as the time necessary for
taking history and describing the condition. Ear and nose examinations, laryngeal
endoscopy, and equilibrium function tests were all part of the physical examinations.
The direct consultation duration comprised physical examinations, medical record and
order form preparation, and other tasks performed while conversing with the patient.
Indirect consultation duration: This is the amount of time a physician spends preparing
treatment and prescription orders, medical records, and other documents, such as referral
letters, as well as entering disease names into the system.
Total consultation duration: This is the sum of the direct and indirect consultation
durations.
Time spent on tasks performed by medical staff other than physicians, such as hearing
tests, blood sampling, and intravenous infusion, as well as time spent waiting before
and after tests, was not included in the sum of direct and indirect consultation durations.
For initial- and follow-up-visit patients, the total consultation duration per patient
and the percentage of indirect consultation duration out of total consultation duration
were compared between the university hospital and the city hospital.
The patients were grouped according to diseases as follows: outer/middle ear diseases
(e.g., earwax, outer and middle ear diseases, and tubal stenosis), hearing impairment/tinnitus
(including facial nerve palsy), nasal allergies, nasal and paranasal sinus diseases
other than nasal allergies (e.g., sinusitis and hemostasis for epistaxis), laryngopharyngeal
diseases (e.g., inflammation, abnormal sensations in the laryngopharynx, and evaluation
of swallowing), taste disorders, head and neck tumors, and vertigo/dizziness disorders.
The total consultation duration, medical service fee points, and medical service fee
points per minute were calculated for the disease groups in which at least five patients
were cared for in each hospital to determine whether there were specific tendencies
in those hospitals and disease groups.
Excel for windows 10 and JMP Pro 16.0.0 Microsoft Windows 10 were used for the analysis.
Total consultation duration and medical service fees per consultation duration were
compared using analysis of variance and Tukey's Honest Significant Difference test,
whereas percentage of indirect consultation duration was compared using the χ2 test and residual analysis. In all comparisons, a p-value of <0.05 was considered statistically significant.
Results
Comparisons of the Consultation Duration between the Initial and Follow-Up Visits
and between the Two Hospitals
Comparisons of the Total Consultation Durations
The total consultation duration per initial-visit patient (mean ± 2 standard deviation)
was 11 minutes and 48 seconds ± 8 minutes and 28 seconds (maximum: 33 minutes and
50 seconds) for the university hospital and 6 minutes and 57 seconds ± 3 minutes and
43 seconds (maximum: 7 minutes and 39 seconds) for the city hospital. Successively,
the total consultation duration per follow-up patient was 10 minutes and 41 seconds ± 7 minutes
and 36 seconds (maximum: 40 minutes and 40 seconds) for the university hospital and
3 minutes and 17 seconds ± 1 minute and 28 seconds (maximum: 6 minutes and 39 seconds)
for the city hospital. The total consultation durations per initial-visit patient
and per follow-up-visit patient for the university hospital were significantly longer
than those recorded per follow-up-visit patient for the city hospital. For both the
university and city hospitals, there were no significant differences between the total
consultation duration per initial-visit patient and per follow-up-visit patient; however,
the total consultation duration per initial-visit patient tended to be longer for
the city hospital (see [Fig. 1]).
Fig. 1 Comparison of the total consultation durations between the university and city hospitals.
The total consultation durations per initial-visit patient and per follow-up-visit
patient at the university hospital were significantly longer than those per follow-up-visit
patient at the city hospital. For both the university and city hospitals, there were
no significant differences between the total consultation duration per initial-visit
patient and per follow-up-visit patient; however, the total consultation duration
per initial-visit patient tended to be longer for the city hospital.
Comparisons of the Percentage of Indirect Consultation Duration
The percentage of indirect consultation duration for university hospital initial-visit
patients did not differ significantly from that recorded for university hospital follow-up-visit
patients; however, it was significantly higher than that observed for city hospital
initial-visit patients. For the university hospital, the direct and indirect consultation
durations per initial-visit patient were 5 minutes and 59 seconds ± 5 minutes and
10 seconds and 5 minutes and 48 seconds ± 4 minutes and 26 seconds, respectively;
the indirect consultation duration accounted for 49.2% of the total consultation duration.
The direct and indirect consultation durations per follow-up patient were 6 minutes
and 39 seconds ± 9 minutes and 28 seconds and 4 minutes and 3 seconds ± 7 minutes
and 38 seconds, respectively; the indirect consultation duration accounted for the
remaining 37.8% of the total consultation duration.
In the city hospital, the direct and indirect consultation durations per initial-visit
patient were 5 minutes and 16 seconds ± 1 minute and 2 seconds (maximum: 5 minutes
and 26 seconds) and 1 minute and 41 seconds ± 26 seconds (maximum: 2 minutes and 58 seconds),
respectively, and the indirect consultation duration accounted for 24.2% of the total
consultation duration. The direct and indirect consultation durations per follow-up
patient were 2 minutes and 16 seconds ± 1 minute and 1 second (maximum: 5 minutes
and 26 seconds) and 1 minute and 1 second ± 1 minute and 1 second (maximum: 2 minutes
and 58 seconds), respectively; the indirect consultation duration accounted for 31.1%
of the total consultation duration. The percentages of indirect consultation duration
for both initial- and follow-up-visit patients at the city hospital were significantly
lower than those of the patients at the university hospital, and the percentage of
indirect consultation duration for follow-up patients was significantly lower than
that recorded for initial-visit patients of the city hospital (see [Fig. 2]).
Fig. 2 Comparison of the direct and indirect consultation durations between the university
and city hospitals. The percentage of indirect consultation duration for initial-visit
patients of the university hospital did not differ significantly from that for follow-up-visit
patients of the university hospital; however, it was significantly higher than that
for initial-visit patients of the city hospital.
Comparisons of Medical Service Fee Points and Medical Service Fee Points per Consultation
Duration between the Two Hospitals and between Different Disease Groups
The mean medical service fee points per patient per minute of total consultation duration
were 749/63.6 and 316.8/29.6 points for initial- and follow-up-visit patients of the
university hospital, respectively, and 451/64.9 and 196.8/47.5 points for initial-
and follow-up-visit patients of the city hospital, respectively. The number of medical
service fee points per minute for follow-up patients at the university hospital was
significantly lower than that for initial-visit patients at the university hospital;
furthermore, no significant differences in medical service fee points per minute were
found between initial-visit patients at the university hospital, initial-visit patients
at the city hospital, and follow-up patients at the city hospital.
Medical service fee points and the total consultation duration for different disease
groups in the university hospital are shown in [Fig. 3]. The total consultation duration was longest for head and neck tumors (16 minutes
and 40 seconds), followed by vertigo/dizziness disorders (14 minutes and 13 seconds)
and hearing impairment/tinnitus (13 minutes and 1 second); successively, it was shortest
for the allergic rhinitis group (4 minutes and 37 seconds). The number of medical
service fee points was highest for hearing impairment/tinnitus (535.8 points), followed
by nasal and paranasal sinus diseases (547.7 points) and vertigo/dizziness disorders
(53.8 points); however, it was lowest for nasal allergies (165.3 points). Factors
contributing to the increased medical service fee points included hearing and equilibrium
function tests that were performed at the request of other hospitals on patients in
the hearing impairment/tinnitus and vertigo/dizziness groups as well as endoscopic
examinations that were performed preoperatively and postoperatively on patients with
nasal and paranasal sinus diseases on a routine basis. In contrast, the number of
medical service fee points for nasal allergies was low because many patients required
only prescriptions.
Fig. 3 Comparison of the total consultation duration and medical service fee points among
different disease groups (university hospital). The number of medical service fee
points per minute for the nasal and paranasal sinus disease group was significantly
higher (53.1 points/min) than the other disease groups. The number of medical service
fee points per minute was lowest for head and neck tumors (14.7 points/min) because
patients in this group visited the hospital in the study period primarily to be informed
about test results and treatment strategies and were charged only for consultations.
Successively, for nasal allergies, the number of points was lowest but the number
of points per minute was second highest (35.8 points/min; after vertigo/dizziness
disorders) because the consultation duration was short.
The number of medical service fee points per minute for the nasal and paranasal sinus
disease group was significantly higher (53.1 points/min). Moreover, the medical service
fee points per minute for hearing impairment/tinnitus (45.0 points/min) and laryngopharyngeal
diseases (41.3 points/min) tended to be higher because hearing and endoscopic examinations
were performed on patients with these diseases. Patients with head and neck tumors
had the lowest number of medical service fee points per minute (14.7 points/min) because
they came to the hospital throughout the research period primarily to be informed
about test results and treatment options and were only charged for the consultation.
Meanwhile, the number of points was lowest but the number of points per minute was
second highest (35.8 points/min; only for vertigo/dizziness disorders) for patients
visiting for nasal allergies because the consultation duration was short.
The data obtained for the city hospital are shown in [Fig. 4]. Both the medical service fee points and medical service fee points per minute tended
to be higher for laryngopharynx diseases (610.0 points and 109.8 points/min, respectively),
for which many endoscopic examinations were performed. The number of medical service
fee points for paranasal sinus diseases was low, unlike that observed for the university
hospital, because many patients in this group visited the hospital only to receive
nebulizers. The differences among the other disease groups were not as pronounced
as those observed at the university hospital.
Fig. 4 Comparison of the total consultation duration and medical service fee points among
different disease groups (city hospital). Both the medical service fee points and
medical service fee points per minute tended to be higher for laryngopharynx diseases
(610.0 points and 109.8 points/min, respectively) for which many endoscopic examinations
were performed. The number of medical service fee points for paranasal sinus diseases
was low, unlike that observed for the university hospital, because many patients in
this group visited the hospital only to receive nebulizers. The differences among
the other disease groups were not as pronounced as those observed for the university
hospital.
Discussion
This study showed that the indirect consultation duration accounted for approximately
half of the total consultation duration for initial-visit patients at the university
hospital (mean percentage of indirect consultation duration: 49.2%), whereas the percentage
of indirect consultation duration was only 24.2 and 31.1% for initial- and follow-up-visit
patients of the city hospital, respectively. Moreover, the total consultation duration
for both initial- and follow-up-visit patients of the university hospital was significantly
longer than the total consultation duration for follow-up-visit patients of the city
hospital. These results suggest that hiring medical clerks to take over indirect consultation
tasks can significantly contribute to the improvement of the efficiency of medical
services in the university hospital. As the current study compared the data of two
physicians during their work hours in a university hospital and a city hospital, the
data do not represent the tendencies of physicians of university and city hospitals
in general. Nevertheless, the data obtained in the present study are useful as they
were actual measurements, which are more reliable than the data from common questionnaire
surveys.
According to a survey of hospital doctors' working conditions done in fiscal year
2017,[1] hospital doctors spent approximately 4 hours per week on consultation-related office
work, accounting for approximately 20% of the total consultation duration. The office
work is mostly related to outpatient consultations. Surgeons spent 55.6, 16.7, and
9.7% of day-shift hours (barring hours spent in operating rooms and laboratories)
in outpatient clinics, nurse stations, and patient rooms, respectively, according
to a study in which working hours and associated tasks of surgeons were directly observed.[2] Although the otorhinolaryngology department in which the present study was conducted
is a surgical department, it deals with medical diseases, such as vertigo and dizziness.
Therefore, otorhinolaryngologists' time spent on outpatient consultations and tasks
that can be performed by medical clerks is probably comparable to, if not greater
than, that of doctors in other surgery-related fields.
The introduction of medical clerks has been reported to be effective in reducing doctors'
workload in both wards and outpatient clinics. In terms of ward tasks, a satisfaction
survey of emergency room doctors about medical clerks assigned full-time roles to
a university hospital's otorhinolaryngology critical care center revealed high levels
of satisfaction with their assistance in clinical tasks, such as document preparation
(such as medical certificate preparation and document management), consent form preparation
and informed consent, and entering information into electronic medical records.[3] In terms of a specific workload-reducing effect, the survey revealed that medical
clerks obtained 1,564 consent forms on behalf of doctors in a year, indicating that
the doctors' work was decreased by approximately 130 hours, assuming that each consent
form took 5 minutes to complete.
The effects of introducing medical clerks in outpatient services have been reported
in detail by Makito et al at the Department of Otorhinolaryngology, Kitasato University.[4] The results of their questionnaire survey of doctors as well as analyses of consultation
durations, hours assisted by medical secretaries (medical clerks), and medical service
fee points requested in insurance claims showed decreases in overtime hours for doctors
and nurses in addition to a reduction in the workload of doctors. Furthermore, regarding
insurance claims, medical clerks reduced input omissions by 27% because inadvertent
omissions by doctors caused by “carelessness and lack of time” were reduced. The effects
of introducing medical clerks were not directly measured. However, this study showed
that the percentage of indirect consultation duration was significantly lower in the
city hospital, where nurses took over the doctors' clerical tasks, thereby, allowing
the doctors to consult a greater number of patients, although 30% of first-visit patients
were referred patients and some patients were with a complex medical course.
However, only a limited number of medical institutions currently employ medical clerks.
Approximately only 30% of all medical institutions used the point addition for medical
office assistants as of fiscal year 2018, with 2,828 medical institutions registered
as using it. Regarding the effects of introducing medical clerks, according to the
“Fact-Finding Survey on Medical Office Assistants” report[5] of the NPO Japanese Society of Medical Office Assistants, although most responses
were positive (e.g., reduced physicians' clerical workloads, reduced burdens on nurses
and other medical professionals, and better working environment), 208 of 1,686 institutions
providing valid responses did not introduce or stopped staffing medical clerks for
various reasons, such as difficulty in recruiting and the institution not meeting
the approval criteria for point addition for medical office assistants. It was difficult
to recruit medical clerks because of the varied levels of individual medical clerk
proficiencies because the education system and career paths for medical clerks were
not established and most medical clerk positions (particularly in public hospitals)
had irregular and unstable working conditions. Therefore, the popularization of medical
clerks requires the following conditions: the development of appropriate institution
criteria; establishment of an educational system for medical clerks; and improvement
of pay, benefits, and work conditions.
The comparisons of medical service fee points and medical service fee points per minute
of consultation duration between the two hospitals showed that the medical service
fee points per minute for initial-visit patients of the university hospital did not
differ significantly from those of the city hospital. Moreover, medical service fee
points per minute for follow-up visit patients of the university hospital were significantly
lower than those of the city hospital. These findings suggest that if patients are
immediately referred back to their family doctors after the university hospital has
established a diagnosis and treatment plan, the university hospital will profit more.
The results are also consistent with the national policy of differentiating outpatient
care functions between large hospitals and smaller hospitals/clinics.
Both the university and city hospitals had high medical service fee points per minute
of consultation duration for disease groups involving endoscopic examinations, such
as paranasal sinus and laryngopharyngeal diseases. Because of the coronavirus disease
2019 (COVID-19) outbreak that started in March 2020, followed by the pediatrics department,
the otorhinolaryngology department experienced the second-largest profit decrease.[6] Although the decrease is thought to be primarily due to a reduction in overall infections
and the avoidance of hospital visits related to COVID-19 measures, a reduction in
patients undergoing endoscopy could have been a contributing factor.
Regarding disease-specific tendencies, the medical service fee points per minute for
vertigo/dizziness did not differ significantly from those for other disease groups
because the total consultation duration for vertigo/dizziness was long in the university
hospital; however, many hearing and equilibrium function tests were performed. Successively,
as doctors spent time conversing with patients rather than performing tests or procedures,
the number of medical service fee points per minute of follow-up consultation for
head and neck tumors was low. To respect patients' right to make their own decisions
and avoid patient–doctor conflicts, the importance of having adequate communication
has recently increased. Thus, the time dedicated to patient–doctor conversation was
considered to have medical relevance.
Conclusion
We measured the time taken for outpatient consultations in the otorhinolaryngology
department of a university hospital and a city hospital. The indirect consultation
duration accounted for approximately half (49.2% on average) of the total consultation
duration for university hospital initial-visit patients, whereas it accounted for
only 24.2% of the consultation duration for city hospital initial-visit patients.
In the university hospital, medical clerks and other staff who can take over physicians'
indirect tasks were considered effective in improving the efficiency of clinical services,
particularly of outpatient services for initial-visit patients. High medical service
fee points per unit consultation duration were noted for paranasal sinus and laryngeal
diseases in the university and city hospitals, respectively, because many endoscopic
examinations were conducted. However, low medical service fee points per unit consultation
time were noted for head and neck diseases in the university hospital because adequate
time was spent on conversations with patients.
