JMIR MEDICAL INFORMATICS Jabour

Original Paper

The Impact of Electronic Health Records on the Duration of

Patients’ Visits: Time and Motion Study

Abdulrahman Mohammed Jabour, PhD

Department of Health Informatics, Faculty of Public Health and Tropical Medicine, Jazan University, Jazan, Saudi Arabia

Corresponding Author:
Abdulrahman Mohammed Jabour, PhD
Department of Health Informatics
Faculty of Public Health and Tropical Medicine
Jazan University
Almarifa Road
Jazan, 82822
Saudi Arabia
Phone: 966 17329500 ext 5545
Email: ajabour@jazanu.edu.sa

Abstract
Background: Despite the many benefits of electronic health records (EHRs), studies have reported that EHR implementation
could create unintended changes in the workflow if not studied and designed properly. These changes may impact the time patients
spend on the various steps of their visits, such as the time spent in the waiting area and with a physician. The amount of time
patients spend in the waiting area before consultation is often a strong predictor of patient satisfaction, willingness to come back
for a return visit, and overall experience. The majority of prior studies that examined the impact of EHR systems on time focused
on single aspects of patient visits or user (physicians or nurses) activities. The impact of EHR use on patients’ time spent during
the different aspects of the visit is rarely investigated.
Objective: This study aimed to evaluate the impact of EHR systems on the amount of time spent by patients on different tasks
during their visit to primary health care (PHC) centers.
Methods: A time and motion observational study was conducted at 4 PHC centers. The PHC centers were selected using
stratified randomized sampling. Of the 4 PHC centers, 2 used an EHR system and 2 used a paper-based system. Each group had
1 center in a metropolitan area and another in a rural area. In addition, a longitudinal observation was conducted at one of the
PHC centers after 1 year and again after 2 years of implementation. The analysis included descriptive statistics and group
comparisons.
Results: The results showed no significant difference in the amount of time spent by patients in the reception area (P=.26), in
the waiting area (P=.57), consultation time (P=.08), and at the pharmacy (P=.28) between the EHR and paper based groups.
However, there was a significant difference (P<.001) in the amount of time spent on all tasks between the PHC centers located
in metropolitan and rural areas. The longitudinal observation also showed reduction in the registration time (from 5.5 [SD 3.5]
min to 0.9 [SD 0.5] min), which could be attributed to the introduction of a Web-based booking system.
Conclusions: The variation in the time patients spend at PHC centers is more likely to be attributed to the facility location than
EHR use. The changes in the introduction of new tools and functions, however, such as the Web-based booking system, can
impact the duration of patients’ visits.

(JMIR Med Inform 2020;8(2):e16502) doi: 10.2196/16502

KEYWORDS
patients experience; time and motion; waiting time; electronic health records

reducing drug expenditures, improving the utilization of

Introduction radiology tests, allowing for better documentation of charges,
Many studies have shown the benefits of electronic health and decreasing billing errors [1-6]. On the other hand, some
records (EHRs) in reducing duplicate tests and procedures, studies have reported that the new systems can disturb the
current workflows and result in unintended consequences. The
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Agency for Healthcare Research and Quality defined workflow explained by an EHR system having more functions and being
as “a sequence of physical and mental tasks performed by more complicated than a comparable paper-based system [14].
various people within and between work environments. It can The additional functions and features could result in a longer
occur at several levels (one person, between people, across amount of time needed to complete tasks.
organizations) and can occur sequentially or simultaneously”
The aim of this study was to investigate the time patients spend
[1].
at the various departments in PHC centers. The study focused
The patients’ waiting time and the consultation time are very on the following: time at registration, time spent in the waiting
important parts of patients’ experience that could be impacted room, consultation time, and the time spent at the pharmacy.
by the introduction of EHR systems. Many studies have shown We hypothesized that the time patients spend at EHR-based
that physicians are concerned about the amount of time needed and paper-based PHC centers is different. Furthermore, we
for data entry, and the physicians have stated that the data entry hypothesized that the time patients spend at the EHR-based
time could be better used to provide direct patient care [2-7]. PHC centers will decrease with time after implementation.
The distribution of patients’ time during visits to primary health
care (PHC) centers is a strong predictor of patient satisfaction Methods
and, thus, utilization. Studies have found that patients prefer to
spend less time waiting for doctors, registering, or at the Sites, Context, and Sampling
pharmacy and would prefer to have more time with physicians The Research Ethical Committee at Jazan University approved
[8-10]. the study (approval number REC-39/4S005). We selected 4
The vast majority of prior studies that investigated the impact PHC centers within Jazan area, Saudi Arabia, using a stratified
of EHR on time can be categorized into two general classes of randomized sampling. Of the 4 PHC centers, 2 used an
studies: efficiency studies and time and motion studies. EHR-based and 2 used a paper-based system. One of the 2 PHC
Efficiency studies tend to focus on the number of patients who centers using an her-based system was located in a metropolitan
can be seen in a given period, whereas the majority of the area and the other was located in a rural area. Similarly, 1 of
EHR-related time and motion studies investigate the duration the 2 PHC centers using a paper-based system was located in
of a single task performed by health care providers [2-4,11-16]. a metropolitan area and the other was located in a rural area.
Most patient-centered studies focused on the patient-physician Only public PHC centers operating under the Ministry of Health
interaction and the amount of time physicians allocate to (MOH) were included in the study. These centers used the same
patients. These studies examined the consultation time by policies and regulations related to funding, patient eligibility
comparing the time physicians allocate to EHR or electronic and coverage, and resources and were subject to the same laws.
data entry with the amount of time physicians need for The MOH PHC centers provide public-free services to national
completing conventional paper-based documentation. Studies citizens who make over 94% of the visitors, and the remaining
reported conflicting results regarding EHR’s effects on noncitizens were covered through a private insurance or
consultation time [11,15,17]. In addition, one study also reported out-of-pocket [21]. Health care providers at the PHC centers
that more variation was attributed to the facility location than included were general practitioners; some of the PHC centers
the system being implemented [11]. provide basic dental services, which we excluded from this
The results of these studies provided details about patients’ study.
experience and the amount of time spent at the doctor’s office As all PHC centers operate under the MOH, the 2 EHR-based
but did not provide information about the time spent before or PHC centers included were using the same EHR system, and
after a physician visit. Examples of time spent before and after the 2 paper-based PHC centers were using the same forms and
a physician visit include the time spent in the waiting room documentation guidelines. Private and semipublic centers were
before seeing a physician. To determine the impact of EHR on excluded from the study to maintain homogeneity of sampling
patients, it is important to investigate the impact of EHR from and to control for other confounding variables. More details
a patient’s perspective. The amount of time spent in a waiting about the PHC government solution strategy can be found on
area is strongly associated with patients’ satisfaction and the Ministry of Health website [22].
willingness to revisit [8-10,18-20]. Similarly, other tasks that
do not involve interactions with a physician impact patients’ Observation and Data Collection
satisfaction. These tasks could include registration and pharmacy The data collected included both cross-sectional and longitudinal
services, which can add to the total duration of patients’ visit. observations. To investigate the impact of familiarity and facility
experience with EHR on the time patients spend at each phase
The duration of users’ experience with EHR can contribute to
of the visit, longitudinal data were collected. The longitudinal
the duration of tasks at EHR-based facilities. Studies have
observation was carried out at 1 of the EHR-based PHC centers,
indicated that user familiarity with a system is related to the
first at baseline during January 2018 and then at follow-up
amount of time per task. Some studies have highlighted reduced
during December 2018. The remaining 3 PHC centers were
productivity in hospitals shortly after EHR implementation. The
observed cross-sectionally during the same period of the
reduced productivity often improves as users become more
longitudinal follow-up observation (during November 2018 and
familiar with the new system and develop the necessary skills
December 2018).
to use the system efficiently. In some cases, the longer amount
of time needed to perform tasks may continue, which can be

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The observation was conducted by 8 undergraduate health who end up going to the laboratory or x-ray department were
informatics interns. To ensure the consistency of data collection, excluded from the analysis. The reason for this is that patients
observers were trained for 2 weeks on the workflow concepts, who revisit the physician after an x-ray may have a different
observation, and the data collection techniques of the study. waiting time and consultation time from those visiting for an
Before data collection, they also spent 3 days at each site to initial consultation.
familiarize themselves with the workflow processes. On the
fourth day, they began the collection of data via direct
Analysis
observation. The duration of each task was documented using Data were analyzed using the Statistical Package for the Social
a stopwatch and papers. The observers were also sharing their Sciences version 21 (IBM Corp). The analysis performed
findings and experiences with the research team on a weekly included descriptive statistics to show the time per task for the
basis during the observation period. different groups.
The study focused on the time spent on each task from a For the group comparison, we performed the Mann-Whitney
patient’s perspective and not the health provider’s perspective. test, a nonparametric test. The comparison included the time
For example, a patient’s waiting time is not a task that is based patients spent at each phase of their visit at the PHC centers.
on the provider’s activity time. Moreover, because the emphasis The factors evaluated were EHR system versus paper-based
was on the time spent from a patient’s perspective, the details system and metropolitan area versus rural area.
of tasks or subtasks from a health care provider’s perspective The Mann-Whitney test was also used to examine the impact
were not differentiated. For example, from a health care of PHC familiarity with the EHR system and the time patients
provider’s perspective, patient registration involves the subtask spent on each task during visits. This included comparing the
of checking patient identities, entering patient information, and time per task during the baseline and follow-up.
searching for the patient file. In this study, these tasks were
considered as a single step—patient registration. In addition, if Results
health care providers were performing parallel tasks, the duration
of the tasks was measured as the time spent by the patient. The results included comparing the time per task at the PHC
The definition of the beginning and end of each task was also centers using the EHR-based system with the PHC centers using
defined from the patient’s perspective. The reception time was the paper-based system and comparing the metropolitan PHC
defined as the time from the beginning of patient-clerk encounter centers with the rural PHC centers. The results also included
to the end of the registration process. The waiting time was comparing the changes in the duration of tasks at 1 of the PHC
defined as the time from the end of the reception time to the centers after 1 year and after 2 years of using EHR.
time patients entered the physician’s office. The consultation Electronic Health Record Versus Paper-Based Primary
time was defined as the time from entering the physician’s office Health Care Centers
to the time exiting the office. The pharmacy time was defined
as the time from the beginning of patient-pharmacist encounter First, we observed the time spent performing basic tasks such
to the time patients receive the medication and instruction. An as the registration time at the reception, time waiting for the
important point to highlight is that all waiting (before physicians, consultation time, and time spent at the pharmacy.
consultation) takes place in the waiting room. Some studies These observations were made at the 4 PHC centers. Other tasks
showed that a physician may serve multiple rooms sequentially such as getting x-rays and laboratory tests were excluded as
by inviting patients to one of the rooms, getting their vital signs these services were not available at all PHC centers. After the
taken by the nurse, and then having them wait for the physician exclusion, the remaining number of events were 118 and 106
in the same room. We found that each physician has a single at the PHC centers using the EHR-based system and the PHC
room and patients were instructed to enter the main physician’s centers using the paper-based system, respectively. No
room when it was time to be seen. significant differences were found between PHC centers that
used an EHR-based system and those that used a paper-based
For comparability, we also excluded the tasks that were not system (P=.26, P=.57, P=.08, and P=.28 for the reception time,
applicable to all PHC centers, such as the dental clinic or waiting time, consultation time, and time spent at the pharmacy,
laboratory and x-ray. Patients who came for a dental visit or respectively; Table 1 and Figure 1).

Table 1. The time per task for primary health care centers using the electronic health record (EHR)–based system versus the paper-based system.
Task EHR Paper P value
Events, n Time (min), mean (SD) Events, n Time (min), mean (SD)
Reception 31 1.52 (1.02) 31 1.89 (1.36) .26
Waiting for doctor 30 6.33 (7.37) 21 5.47 (6.11) .57
Consultation time 28 3.30 (1.86) 26 6.39 (6.79) .08
Pharmacy 29 1.61 (1.20) 28 1.95 (1.33) .28

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Figure 1. The time spent performing tasks at primary health care centers that use the electronic health record system and the paper-based system. EHR:
electronic health record.

(Figure 2). There were 2 metropolitan PHC centers and 2 rural

Rural Versus Metropolitan Primary Health Care PHC centers with 109 and 115 events, respectively. Our results
Centers showed statistically significant difference between the PHC
The time spent performing tasks at each of the 4 PHC centers centers located in metropolitan areas and the PHC centers
was also compared based on the location of the PHC centers located in rural areas for all 4 tasks, with P<.001 (Table 2).
Figure 2. The time spent performing tasks at primary health care centers in metropolitan and rural areas.

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Table 2. The time per task for primary health care centers located in metropolitan areas versus primary health care centers located in rural areas.
Task Metropolitan Rural P value
Number of events, n Time (min), mean (SD) Number of events, n Time (min), mean (SD)
Reception 30 2.36 (1.299) 32 1.09(0.710) <.001
Waiting for doctor 26 9.73 (6.20) 25 2.07 (5.10) <.001
Consultation time 23 7.43 (6.79) 31 2.83 (1.64) <.001
Pharmacy 30 2.60 (1.22) 27 0.86 (0.42) <.001

12-month follow-up. When comparing the time patients spent

Longitudinal Observation for Electronic Health at each phase during their visits at baseline and follow-up, there
Record–Based Primary Health Care Center was a significant difference in the time spent at the reception
Finally, we examined the effect of familiarity with the EHR on (P<.001) and at the pharmacy (P=.01). The difference in time
the duration of tasks. At one of the EHR-based PHC centers, patients spent waiting for the doctor and the consultation time
the observation was conducted longitudinally (Figure 3). There was insignificant, with P=.22 and P=.36, respectively (Table
were 72 events at the baseline observation and 63 events at the 3).
Figure 3. The time spent performing tasks at 1 electronic health record–based primary health care center after 1 year.

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Table 3. The time spent per task at baseline and 12-month follow-up at 1 electronic health record–based primary health care center.
Task Before After P value
Number of events, n Time (min), mean (SD) Number of events, n Time (min), mean (SD)
Reception 15 5.5 (3.5) 16 0.9 (0.5) <.001
Waiting for doctor 15 1.87 (3.5) 15 3.79 (7.89) .22
Consultation time 20 3.1 (0.8) 18 3.05 (2.08) .36
Pharmacy 22 1.49 (0.94) 14 0.75 (0.33) .01

Consultation time was an important factor as it impacts the

Discussion quality of care, patient satisfaction, and level of utilization
Overview [18,27-29]. Although consultation time varies based on the
country, studies showed that patients, in general, prefer a longer
The vast majority of prior research examined the impact of EHR consultation time [18]. Studies based in the United States
on the duration of tasks from the user’s perspective (such as reported an average consultation time of 10 to 15 min, whereas
examining the time taken by doctors and other hospital staff to a local study reported that 80% to 85% of patients spent less
perform tasks). They often focus on a particular task or subtask than 5 min with the doctor and 10% to 16% of patients spent 5
that was aided by a new tool such as the computerized provider to 10 min with the doctor [24].
order entry or personal digital assistant. The impact of these
tools on a patient’s time was rarely examined from the patient’s Comparing consultation times in this study with consultation
perspective [14]. In this study, we examined the difference in times in prior studies must be done cautiously, as the local
time taken per task for patients at PHC centers that used an studies are outdated, and those that were conducted in the United
EHR-based system compared with those that used a paper-based States follow different workflow practices. In the United States,
system. We also compared the time taken per task at PHC patients typically see a nurse who will take basic vital signs,
centers in the metropolitan and rural areas. Then, we examined collect medical history, and obtain general signs and symptoms
the differences in task duration in 1 year and 2 years of EHR [25]. Following this interaction with a nurse, patients will then
implementation. wait at the doctor’s office to be seen [25]. This waiting time is
sometimes counted as part of the consultation time, which will
One advantage of our study is that it controlled for many of the result in a longer patient-doctor interaction. In the PHC centers
confounding variables that could vary based on the PHC centers. where our study was conducted, patients are called directly into
Some of these variables were the facility rules and regulations, the room to see the doctor, and the visit with the doctor begins
funding, the type of system used (either EHR or paper form), at this point with no waiting time in between [25].
and patient eligibility. We also applied the same data collection
techniques using time and motion observations for both groups Consistent with prior studies, no significant difference was
instead of using artifacts or a timestamp analysis. found in the duration of tasks between the PHC centers that use
EHR-based systems and the PHC centers that use paper-based
Compared with prior studies, the average waiting time was systems [12,17]. A significant difference was found in the
relatively short. In a study conducted in the United States for duration of tasks between PHC centers based on location.
instance, the average waiting time for a family physician was
13.5 min [23]. In our study, the average waiting time was 6.33, Our results did not show any significant difference in patients’
5.47, 9.73, and 2.07 min for the PHC centers using an waiting time or consultation time after 2 years of EHR adoption.
EHR-based system, using a paper-based system, in the There was a significant difference in the time spent registering
metropolitan areas, and in the rural areas, respectively. and at the pharmacy. The time spent at the reception decreased
Consistent with our result, a study conducted in Saudi reported from an average of 5.5 min (SD 3.5) in January 2018 to an
that 83% of patients had a waiting time of less than 5 min [24]. average of 0.9 min (SD 0.5) in December 2018. The decrease
in time could be attributed to the MOH Web-based booking
Consistent with our findings, prior studies showed variations system, which was adopted between January 2018 and
in the waiting time based on the geographical area [25]. Studies December 2018. The MOH Web-based booking system called
also reported that the distribution of PHC centers in the country Mawid was implemented to allow patients to book, cancel, or
was consistent with population distribution. This distribution reschedule appointments while also allowing individuals to
resulted in overutilization of some PHC centers and manage referral appointments [30]. This booking service was
underutilization of others [26]. The overutilization or provided by the government as part of a larger initiative, which
underutilization of certain PHC centers could help explain why was intended to help to verify patient identities by linking
certain patients were unsatisfied with the waiting time at patients to a national ID. The Web-based booking system
particular locations [8,20]. The concept of satisfaction was required patients to enter the information needed by the
based on a self-administered survey, and the survey did not registration office online before visiting the PHC center.
inquire about the exact waiting time and also did not provide Although this service was provided initially as an optional
documentation of the waiting time based on direct observations service, many PHC centers have made the service mandatory
or EHR audit files [20]. for accepting nonurgent patients.

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Limitations and Future Work investigated in future studies by including more PHC centers
Although we tried to control for confounding variables such as and examining the potential factors such as reason for visits,
the type of EHR system being used, facility rules and staffing, and variation in workflow and clinical practice.
regulations, funding, and patient eligibility, we did not account Moreover, we recommend examining the waiting time and
for some factors that could impact the generalizability of our consultation time in the different cities within the country. In
study. One of the factors was patients’ conditions and addition, more studies are needed to examine the impact of EHR
demographics. Patients with more complex diseases may require on the way patients spend their time when visiting the doctor
more time for consultation and data entry. In addition, the type in more busy environments.
of EHR system being used can impact the outcome. Although Conclusions
the system being used at PHC centers is provided and approved
Our study showed that the time spent by patients on the various
by MOH [22], the generalizability of our finding to PHC centers
tasks during PHC center visits is the same at both EHR- and
that use a different EHR system is unknown. Moreover, we
paper-based PHC centers. We also found that patients’ waiting
were unable to determine the effect of system familiarity on the
time and consultation time were the same after 1 year and 2
reception time for the longitudinal part of the study because of
years of EHR implementation. The registration time, however,
the introduction of the Web-based booking system after the
decreased when comparing the time after 1 year with the time
baseline period. Another limitation is that we did not measure
after 2 years of EHR implementation. We expect that the change
the interobserver reliability. However, all observers were similar
was attributed to the Web-based booking systems rather than
in their academic qualification, experience, and training received
EHR itself. Apart from the training and skills related to
before data collection. For future studies, we recommend
short-term impact after EHR implementation, we believe that
controlling for patients’ conditions and reasons for visits because
changes in time after EHR use are often attributed to the addition
of their expected impact on the duration of visits. This will not
or elimination of tasks and functions rather than EHR itself.
only help in explaining the source of variation in time but also
Therefore, focusing on the EHR function that minimizes the
improve the generalizability of the results.
tasks performed by patients can shorten the duration of their
Our result shows a significant difference in the duration of tasks visits and enhance their satisfaction. Some of these tasks include
between metropolitan and rural PHC centers; however, the cause Web-based tools for booking, entry of patients’ history, and
of these differences is yet unknown. This could be further medication refill.

Acknowledgments
The author would like to thank the research assistants for their time and effort during the data collection. The author also wants
to acknowledge Jazan University for their funding support. This research was supported by the Deanship of Scientific Research
at Jazan University. The deanship has no role in the design, analysis, or interpretation of the results.

Conflicts of Interest
None declared.

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 JMIR MEDICAL INFORMATICS Jabour

Abbreviations
EHR: electronic health record
MOH: Ministry of Health
PHC: primary health care

Edited by C Lovis; submitted 04.10.19; peer-reviewed by A Ekeland, L Rusu; comments to author 10.11.19; revised version received
29.11.19; accepted 01.12.19; published 07.02.20
Please cite as:
Jabour AM
The Impact of Electronic Health Records on the Duration of Patients’ Visits: Time and Motion Study
JMIR Med Inform 2020;8(2):e16502
URL: http://medinform.jmir.org/2020/2/e16502/
doi: 10.2196/16502
PMID:

©Abdulrahman Mohammed M Jabour. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 07.02.2020.
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(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work, first published in JMIR Medical Informatics, is properly cited. The complete bibliographic information,
a link to the original publication on http://medinform.jmir.org/, as well as this copyright and license information must be included.

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