The myth of standardized workflow in primary care.
OBJECTIVE
Primary care efficiency and quality are essential for the nation's health. The demands on primary care physicians (PCPs) are increasing as healthcare becomes more complex. A more complete understanding of PCP workflow variation is needed to guide future healthcare redesigns.


METHODS
This analysis evaluates workflow variation in terms of the sequence of tasks performed during patient visits. Two patient visits from 10 PCPs from 10 different United States Midwestern primary care clinics were analyzed to determine physician workflow. Tasks and the progressive sequence of those tasks were observed, documented, and coded by task category using a PCP task list. Variations in the sequence and prevalence of tasks at each stage of the primary care visit were assessed considering the physician, the patient, the visit's progression, and the presence of an electronic health record (EHR) at the clinic.


RESULTS
PCP workflow during patient visits varies significantly, even for an individual physician, with no single or even common workflow pattern being present. The prevalence of specific tasks shifts significantly as primary care visits progress to their conclusion but, notably, PCPs collect patient information throughout the visit.


CONCLUSIONS
PCP workflows were unpredictable during face-to-face patient visits. Workflow emerges as the result of a "dance" between physician and patient as their separate agendas are addressed, a side effect of patient-centered practice.


CONCLUSIONS
Future healthcare redesigns should support a wide variety of task sequences to deliver high-quality primary care. The development of tools such as electronic health records must be based on the realities of primary care visits if they are to successfully support a PCP's mental and physical work, resulting in effective, safe, and efficient primary care.
American Academy of Family Physicians, Leawood, KS, USA Department of Industrial Engineering, University of Louisville, Louisville, KY, USA, Email: gtholman@gmail.com tholman@aafp.org.
G Talley
GT
Holman
Department of Family Medicine, School of Medicine and Public Health; and the Department of Industrial and Systems Engineering, University of Wisconsin- (UW) Madison, WI, USA, Email: john.beasley@fammed.wisc.edu.
John W
JW
Beasley
Department of Family Medicine, School of Medicine and Public Health; Department of Industrial and Systems Engineering, and the Center for Quality and Productivity Improvement, UW- Madison, Madison, WI, USA.
Ben-Tzion
BT
Karsh
School of Pharmacy and the Center for Quality and Productivity Improvement, UW- Madison, Madison, WI, USA, Email: jamie.stone@wisc.edu.
Jamie A
JA
Stone
Department of Family Medicine, School of Medicine and Public Health, UW-Madison, Madison, WI, USA, Email: paul.smith@fammed.wisc.edu.
Paul D
PD
Smith
Department of Medicine and Family Medicine, School of Medicine and Public Health; Department of Industrial and Systems Engineering, and the Center for Quality and Productivity Improvement, UW- Madison, WI, USA, Email: tbw@medicine.wisc.edu.
Tosha B
TB
Wetterneck
D017598:Efficiency, Organizational; D006801:Humans; D009819:Office Visits; D011320:Primary Health Care / Q000458:organization & administration; D057188:Workflow
healthcare; patient interaction; primary care; task list; workflow