The Cost of a Click

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click-90If time is money, emergency medicine needs to take another look at electronic medical records which introduce inefficiencies into the medical system. A recent study brought this issue of ED efficiency – and its impact on revenue – into sharp focus. The study asks the question, “Just how long are physicians actually spending on the computer?”

New research quantifies the costliness of inefficient EMRs and begs the question, “What is the value of gaining an extra hour per shift?”


If time is money, emergency medicine needs to take another look at electronic medical records which introduce inefficiencies into the medical system. A recent study brought this issue of ED efficiency – and its impact on revenue – into sharp focus. The study asks the question, “Just how long are physicians actually spending on the computer?” as well as the necessary follow-up: “What if physicians used that time to interact with patients?” The answer speaks to the very core of the healthcare crisis. 

The study, by Hill, Sears and Melanson,1 analyzed physician computer usage at a community hospital ED. They noted that “total mouse clicks approach 4,000 during a busy 10-hour shift” – and that was per provider. Quantified another way, the average percentage of time spent on data entry was 43% compared with 28% spent in direct contact with patients.

Let’s examine this more closely to see the true impact of these clicks. What could be gained if they were eliminated? We’ll start by looking at these findings from a purely revenue perspective, using as an example an ED with an annual volume of 50,000 patients and a LWOT rate of 2%.           


  • 4,000 mouse clicks at 1 click/second equates to 66 minutes per shift.
  • Two EPs working double coverage for only one shift will each gain effectively one extra hour if the mouse clicks are eliminated.
  • Two EPs each with one extra hour per day for 365 days equates to 730 extra hours.
  • Using very conservative ACEP2 criteria of 2.1/patients per hour and 730 hours equates to 1,533 additional patients seen (1,686 if the full 66 minutes of clicking are accounted for).   
  • LWOT rate for this ED with an annual volume of 50,000 patients at 2% or 1,000 patients.
  • Cash per visit collections for this sample ED practice is $100/patient.

click-sidebarThe reallocation of the EP’s time away from computer clicks on the electronic medical record results in two positive outcomes. First, it eliminates the LWOT problem. Second, an additional $153,300 is generated in practice revenue. Even if these same parameters were applied to two mid-level providers the additional practice revenue would be $130,305. And this impact is multiplied as staffing is increased.

Of course, there are other positive ways that an EP could use an extra hour each shift. Patel and Vinson3 report higher patient satisfaction when patients are contacted briefly after their visit either by e-mail or by telephone. Similarly, Scaletta4 reports “Contacting patients the day after an ED visit has helped the hospital consistently achieve 95-99 percent Press Ganey satisfaction scores, reduce the risk of negative outcomes following discharge, and collect timely and statistically significant patient data.” In a purely revenue-neutral allocation of EP time, patient follow-up holds significant potential for enhancing a critical quality index of patient care.

Rick Bukata has been beating this drum for years – in this publication and elsewhere.5 “…The goal should be to have physicians unencumbered and their work facilitated. Ideally the physician would be a free-floating intellect, not required to write, not required to sit in front of a computer, not required to do anything but interact with patients and staff…. The key is to have the right people working at the right tasks – and that means empowering scribes and getting physicians off the computer!” While hiring scribes to assist in data entry can bring its own challenges – and can be an uphill process with the hospital C-Suite – 
the data would seem to strongly support the concept.

As if the internal barriers to emergency department efficiency weren’t high enough, emergency physicians have to also be wary of the maneuvers being made by other specialties and organizations. The continuing development of ACOs evidences movement principally by the payer community. CMS in the 2013 Final Rule is beginning to spread reimbursement coverage to primary care physicians outside their office visit settings. Payers are getting more and more creative in their approaches and plans. Asplin6 states “…Every smart ACO should try to partner with EDs to coordinate care and create alternatives to admissions/readmissions.” These developing changes require the utmost in efficiency in patient care; put simply there is no room for physician time to be hi-jacked for non-patient care activities.


Emergency physicians have two potential paths to pursue here. First, this information justifies a request for simply more efficient technology that is already adapted to the ED space and nuances of emergency care. Second, emergency physicians have leverage from a hospital revenue perspective to push for scribe coverage and staffing. Augustine7 documents that the ED is now accounting for a staggering 68% of hospital admissions. This number is higher than previously reported last year in the RAND report. EPs need to take these studies and make a strong case to administrators to get the additional coverage they need. 

The time to address these issues is now because the problems created by EMRs are only growing. The recently-released OIG report8 will likely trigger a new level of EHR scrutiny at a time when ED volumes continue to rise. On the flip side, this challenge creates an opportunity for real change. Emergency physicians have the ability to position themselves more appropriately as diagnosticians, leaving computer work to non-physicians, resulting in more patients being seen, higher satisfaction and better overall patient care.

Dr. Augustine is the vice president of the Emergency Department Benchmarking Alliance and is the Director of Clinical Operations for Emergency Medicine Physicians (EMP) in Canton, Ohio.

John G. Holstein is a Director at Zotec Partners.


  1. Hill, Robert G., Sears, Lynn Marie, Melanson, Scott W. “4,000 Clicks: A Productivity Analysis of Electronic Medical Records in a Community Hospital.”  The American Journal of Emergency Medicine.  September 23, 2013.
  2. “Staffing an ED Appropriately and Efficiently. ” ACEP Clinical and Practice Management.  August 2009.
  3. Patel, Panicaj B, Vinson, David R. “Physician E-Mail and Telephone Contact After Emergency Department Visit Improves Patient Satisfaction: A Crosssover Trial.” Annals of Emergency Medicine. Volume 61, Issue 6. June 2013.
  4. Scaletta, Tom, MD. “Post-Visit Patient Contact Improves Patient Satisfaction.” Robert Wood Johnson Foundation. April 8, 2013.
  5. Bukata, Rick, MD. “Scribes Hold the Key to ED Efficiency.”Emergency Physicians Monthly. September 16, 2009.
  6. Asplin, Brent., MD. Emergency Medicine and Value-Driven Healthcare Reform.” EDPMA presentation. April, 2013.
  7. Augustine, James J. “The Front Door to the Inpatient Unit of the Hospital: The Emergency Department Admits at least 68% of Inpatient Volume. EDBA.
  8. HHS; Office of the Inspector General. “Not All Recommended Fraud Safeguards Have Been Implemented in Hospital HER Technology.” December 2013. 


Editor’s Note

Need better data on EHR efficiency

We need data that quantifies what a lot of ED doctors suspect – that EHRs are chaining us to desktops, keeping us typing and clicking instead of spending time with patients. And while the “4000 clicks” study is certainly provocative, it’s not the solid, well-conducted study we need to advance the dialog. First, the study authors evaluated one of the worst-reviewed ED information systems, one with a small and declining market share. Second, they don’t tell us much about the ED they studied or the providers they followed. Finally, the “4000 clicks” is a big extrapolation, with unwieldy error bars. This is a question that needs more scholarship if we’re to take meaningful strides forward.


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