Computer-based work occupies a larger share of emergency physicians’ shifts than direct patient care in an observational assessment of emergency department workflow. A cross-sectional time-motion study at a high-volume urban emergency department tracked 20 attending physicians during one daytime shift each and supplemented direct observation with electronic health record event logs. Physicians spent more than one-third of observed shift time using computers, while direct patient interaction accounted for just over one-quarter. Computer work also continued after scheduled shifts. Workflow visualisations showed frequent task switching and marked variation in how fragmented individual shifts became.
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Computer Work Extends Beyond the Clinical Shift
Continuous in-person observation was combined with electronic health record event logs to capture both on-shift activity and computer use after scheduled work. Each physician was observed during an eight- or nine-hour shift, producing 150 hours of time-motion data. A trained observer used a validated application to assign the physician’s activity continuously to a dominant task category, including computer use, patient interaction, verbal communication with staff, phone use, procedures, personal time and miscellaneous tasks.
During observed shifts, physicians spent a median 34.1% of their time on computers and 26.9% with patients. Verbal communication with clinical staff accounted for 15.9% of shift time, while phone use accounted for 9.5%. Smaller proportions were allocated to miscellaneous activities, personal time, electrocardiogram review and other clinical procedures. The longest period away from the computer during a shift was 20 minutes.
Electronic health record logs were then used to estimate active computer use after observation ended, up to 48 hours later or until the physician’s next clinical shift. Across 19 included physicians, median after-shift computer use was 1.3 hours. The measure counted active electronic health record use and excluded longer periods without recorded actions. One physician’s log was excluded because administrative responsibilities made attribution to clinical care uncertain. Combining observed and after-shift activity, physicians spent a median 29.8 minutes on computers for every scheduled hour of clinical work.
Task Switching Shows a Fragmented Work Environment
Emergency care involved frequent movement between activity categories rather than long uninterrupted periods focused on a single type of work. Workflow visualisations mapped the timing, sequence and duration of individual tasks across each observed shift. They showed frequent alternation between activities and substantial variation in task density and fragmentation from one physician and shift to another. Some shifts contained many high-intensity activity intervals, while others included longer uninterrupted periods.
Multitasking was not recorded as a separate category. When physicians performed more than one activity at the same time, the observer identified the dominant focus and switched categories as attention changed. Rapid alternation between categories therefore provided an indirect indication of multitasking and contributed to the high number of recorded task transitions. The application captured these transitions as physicians moved between dominant tasks.
Workflow changes should be evaluated through more than overall computer time alone. Potential targets for improvement include excessive task switching, low-yield documentation and cumbersome electronic health record workflows. Usability priorities include reducing unnecessary clicks and screen changes for common activities, improving access to time-sensitive information, limiting redundant documentation and supporting team communication and coordination. At the same time, interruptions and workflow variability can also support timely information transfer and team-based emergency care, making it important that efforts to reduce fragmentation do not compromise clinical coordination.
Workflow Redesign Requires Careful Measurement
Combined observation and electronic log measures provide baseline data for assessing changes in electronic health record design, documentation processes and other workflow interventions. Direct observation captures non-computer activity but cannot measure work completed after physicians leave the emergency department. Event logs capture electronic health record activity beyond the shift but cannot describe the full range of clinical tasks. Combining both methods therefore gives a broader view of how scheduled and after-shift work are distributed.
User-centred electronic health record design, improved documentation processes and human factors approaches are areas for further work. Training that improves physicians’ understanding of electronic health record functions may also reduce burden. Emerging tools intended to decrease documentation, including ambient artificial intelligence scribes, have shown early promise in reducing after-shift work, but possible technical difficulties, workflow disruption and unintended consequences remain concerns. Any technology should therefore be assessed against measures such as on-shift activity distribution, total computer time and after-shift electronic health record use. Proposed improvements should be tested to determine whether they reduce burden rather than merely redistribute it.
Interpretation is limited by the single emergency department setting and a convenience sample of attending physicians working daytime shifts. One trained observer collected the data, patient-room time was assumed to be direct patient care and electronic activity thresholds may have overestimated or underestimated actual computer use. After-shift logs could also include documentation relating to earlier shifts.
Emergency physicians in this single-site assessment spent more observed shift time on computers than with patients and continued electronic health record work after scheduled hours. Their workflow also showed frequent switching between activities and substantial variation in fragmentation across shifts. The findings support efforts to reduce low-yield computer work and unnecessary workflow burden while preserving communication and care coordination. Future evaluations can use combined observation and electronic event-log measures to determine whether changes in technology, documentation or workflow improve efficiency without simply moving work to another part of the shift.
Source: JMIR Medical Informatics
Image Credit: iStock
References:
Henreid AJ, Ioannides KLH, Pevnick JM et al. (2026) Quantifying and Visualizing Emergency Physician Workflow: Observational Time-Motion Study. JMIR Med Inform;14:e85983.
