{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T16:21:44Z","timestamp":1775838104364,"version":"3.50.1"},"reference-count":59,"publisher":"Oxford University Press (OUP)","issue":"1","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2016,1,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:p>Objective Primary care efficiency and quality are essential for the nation\u2019s 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.<\/jats:p>\n               <jats:p>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\u2019s progression, and the presence of an electronic health record (EHR) at the clinic.<\/jats:p>\n               <jats:p>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.<\/jats:p>\n               <jats:p>Discussion PCP workflows were unpredictable during face-to-face patient visits. Workflow emerges as the result of a \u201cdance\u201d between physician and patient as their separate agendas are addressed, a side effect of patient-centered practice.<\/jats:p>\n               <jats:p>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\u2019s mental and physical work, resulting in effective, safe, and efficient primary care.<\/jats:p>","DOI":"10.1093\/jamia\/ocv107","type":"journal-article","created":{"date-parts":[[2015,9,3]],"date-time":"2015-09-03T01:04:19Z","timestamp":1441242259000},"page":"29-37","source":"Crossref","is-referenced-by-count":44,"title":["The myth of standardized workflow in primary care"],"prefix":"10.1093","volume":"23","author":[{"given":"G Talley","family":"Holman","sequence":"first","affiliation":[{"name":"American Academy of Family Physicians, Leawood, KS, USA Department of Industrial Engineering, University of Louisville, Louisville, KY, USA, Email: gtholman@gmail.com"}]},{"given":"John W","family":"Beasley","sequence":"additional","affiliation":[{"name":"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"}]},{"given":"Ben-Tzion","family":"Karsh","sequence":"additional","affiliation":[{"name":"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"}]},{"given":"Jamie A","family":"Stone","sequence":"additional","affiliation":[{"name":"School of Pharmacy and the Center for Quality and Productivity Improvement, UW- Madison, Madison, WI, USA, Email: jamie.stone@wisc.edu"}]},{"given":"Paul D","family":"Smith","sequence":"additional","affiliation":[{"name":"Department of Family Medicine, School of Medicine and Public Health, UW-Madison, Madison, WI, USA, Email: paul.smith@fammed.wisc.edu"}]},{"given":"Tosha B","family":"Wetterneck","sequence":"additional","affiliation":[{"name":"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"}]}],"member":"286","published-online":{"date-parts":[[2015,9,2]]},"reference":[{"issue":"8930","key":"2020110613021578700_ocv107-B1","doi-asserted-by":"crossref","first-page":"1129","DOI":"10.1016\/S0140-6736(94)90634-3","article-title":"Is primary care essential?","volume":"344","author":"Starfield","year":"1994","journal-title":"The Lancet."},{"issue":"3","key":"2020110613021578700_ocv107-B2","first-page":"457","article-title":"Contribution of primary care to health systems and health","volume":"83","author":"Starfield","year":"2005","journal-title":"Q."},{"issue":"3","key":"2020110613021578700_ocv107-B3","doi-asserted-by":"crossref","first-page":"831","DOI":"10.1111\/1475-6773.00149","article-title":"The contribution of primary care systems to health outcomes within Organisation for Economic Co-operation and Development (OECD) countries 1970-1998","volume":"38","author":"Macinko","year":"2003","journal-title":"Health Serv Res."},{"key":"2020110613021578700_ocv107-B4","doi-asserted-by":"crossref","first-page":"h904","DOI":"10.1136\/bmj.h904","article-title":"Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study","volume":"350","author":"Kontopantelis","year":"2015","journal-title":"BMJ."},{"issue":"10","key":"2020110613021578700_ocv107-B5","first-page":"872","article-title":"Practice jazz: understanding variation in family practices using complexity science","volume":"50","author":"Miller","year":"2001","journal-title":"J Fam Pract."},{"key":"2020110613021578700_ocv107-B6","first-page":"921","article-title":"Human factors in primary care","volume-title":"Handbook of Human Factors and Ergonomics in Patient Safety","author":"Beasley","year":"2006"},{"issue":"591","key":"2020110613021578700_ocv107-B7","doi-asserted-by":"crossref","first-page":"604","DOI":"10.3399\/bjgp11X601244","article-title":"Electronic health records: research into design and implementation","volume":"61","author":"Beasley","year":"2011","journal-title":"Br J Gen Pract."},{"issue":"1","key":"2020110613021578700_ocv107-B8","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1136\/bmjqs-2011-000067","article-title":"Development of a primary care physician task list to evaluate workflow","volume":"21","author":"Wetterneck","year":"2012","journal-title":"BMJ Qual Saf."},{"issue":"2","key":"2020110613021578700_ocv107-B9","first-page":"113","article-title":"Care of the secondary patient in family practice. A report from the Ambulatory Sentinel Practice Network","volume":"50","author":"Orzano","year":"2001","journal-title":"J Fam Pract."},{"issue":"5","key":"2020110613021578700_ocv107-B10","first-page":"397","article-title":"Trade-offs in high-volume primary care practice.[see comment]","volume":"46","author":"Zyzanski","year":"1998","journal-title":"J Fam Pract."},{"key":"2020110613021578700_ocv107-B11","doi-asserted-by":"crossref","first-page":"236","DOI":"10.7326\/0003-4819-150-4-200902170-00004","article-title":"Primary care physician's links to other physicians through Medicare patients: the scope of care coordination","volume":"150","author":"Pham","year":"2009","journal-title":"Ann Intern Med."},{"issue":"1","key":"2020110613021578700_ocv107-B12","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1016\/j.apergo.2013.04.023","article-title":"Human factors systems approach to healthcare quality and patient safety","volume":"45","author":"Carayon","year":"2014","journal-title":"Appl Ergon."},{"key":"2020110613021578700_ocv107-B13","doi-asserted-by":"crossref","first-page":"227","DOI":"10.3109\/02813439409029245","article-title":"Features of good consultation in general practice: is time important?","volume":"12","author":"Anderson","year":"1994","journal-title":"Scand J Prim Health Care"},{"key":"2020110613021578700_ocv107-B14","first-page":"119","article-title":"Consultation length in general practice: a review","volume":"41","author":"Wilson","year":"1991","journal-title":"Br J Gen Pract."},{"issue":"6","key":"2020110613021578700_ocv107-B15","doi-asserted-by":"crossref","first-page":"494","DOI":"10.1370\/afm.391","article-title":"Physician activities during time out of the examination room","volume":"3","author":"Gilchrist","year":"2005","journal-title":"Ann Fam Med."},{"issue":"5","key":"2020110613021578700_ocv107-B16","doi-asserted-by":"crossref","first-page":"1871","DOI":"10.1111\/j.1475-6773.2006.00689.x","article-title":"Time allocation in primary care office visits","volume":"42","author":"Tai-Seale","year":"2007","journal-title":"Health Serv Res."},{"issue":"1","key":"2020110613021578700_ocv107-B17","first-page":"65","article-title":"A cognitive task analysis of information management strategies in a computerized provider order entry environment","volume":"14","author":"Weir","year":"2007","journal-title":"JAMIA."},{"issue":"1","key":"2020110613021578700_ocv107-B18","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1177\/0272989X10394462","article-title":"Factors relating to patient visit time with a physician","volume":"32","author":"Migongo","year":"2012","journal-title":"Med Decis Mkg."},{"issue":"12","key":"2020110613021578700_ocv107-B19","doi-asserted-by":"crossref","first-page":"1289","DOI":"10.1007\/s11606-010-1470-2","article-title":"Between-visit workload in primary care","volume":"25","author":"Doerr","year":"2010","journal-title":"J Gen Intern Med."},{"issue":"6","key":"2020110613021578700_ocv107-B20","doi-asserted-by":"crossref","first-page":"488","DOI":"10.1370\/afm.404","article-title":"Time spent in face-to-face patient care and work outside the examination room","volume":"3","author":"Gottschalk","year":"2005","journal-title":"Ann Fam Med."},{"issue":"1","key":"2020110613021578700_ocv107-B21","doi-asserted-by":"crossref","first-page":"58","DOI":"10.1007\/s11606-010-1494-7","article-title":"Patient care outside of office visits: a primary care physician time study","volume":"26","author":"Chen","year":"2011","journal-title":"J Gen Intern Med."},{"issue":"10","key":"2020110613021578700_ocv107-B22","doi-asserted-by":"crossref","first-page":"693","DOI":"10.7326\/0003-4819-147-10-200711200-00005","article-title":"How much time do physicians spend providing care outside of office visits?","volume":"147","author":"Farber","year":"2007","journal-title":"Ann Intern Med."},{"issue":"3","key":"2020110613021578700_ocv107-B23","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1370\/afm.310","article-title":"Is there time for management of patients with chronic diseases in primary care?","volume":"3","author":"Ostbye","year":"2005","journal-title":"Ann Fam Med."},{"issue":"4","key":"2020110613021578700_ocv107-B24","first-page":"635","article-title":"Primary care: is there enough time for prevention? \n              Am J Public Health","volume":"93","author":"Yarnall","journal-title":"2003"},{"issue":"5","key":"2020110613021578700_ocv107-B25","doi-asserted-by":"crossref","first-page":"405","DOI":"10.1370\/afm.94","article-title":"How many problems do family physicians manage at each encounter? A WReN study","volume":"2","author":"Beasley","year":"2004","journal-title":"Ann Fam Med."},{"issue":"17","key":"2020110613021578700_ocv107-B26","doi-asserted-by":"crossref","first-page":"1632","DOI":"10.1056\/NEJMon0910793","article-title":"What's keeping us so busy in primary care? A snapshot from one practice","volume":"362","author":"Baron","year":"2010","journal-title":"New Engl J Med."},{"issue":"12","key":"2020110613021578700_ocv107-B27","doi-asserted-by":"crossref","first-page":"2058","DOI":"10.1007\/s11606-008-0805-8","article-title":"The increasing number of clinical items addressed during the time of adult primary care visits","volume":"23","author":"Abbo","year":"2008","journal-title":"J Gen Intern Med."},{"issue":"10 Spec No","key":"2020110613021578700_ocv107-B28","first-page":"SP345","article-title":"The impact of electronic health record use on physician productivity","volume":"19","author":"Adler-Milstein","year":"2013","journal-title":"Am J Manag Care."},{"issue":"5","key":"2020110613021578700_ocv107-B29","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1046\/j.1525-1497.2003.10735.x","article-title":"Communication patterns of primary care physicians in the United States and the Netherlands","volume":"18","author":"Bensing","year":"2003","journal-title":"J Gen Intern Med."},{"issue":"5","key":"2020110613021578700_ocv107-B30","doi-asserted-by":"crossref","first-page":"430","DOI":"10.1370\/afm.345","article-title":"Delivery of clinical preventive services in family medicine offices","volume":"3","author":"Crabtree","year":"2005","journal-title":"Ann Fam Med."},{"issue":"2","key":"2020110613021578700_ocv107-B31","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1370\/afm.624","article-title":"Jazz and the \u201cart\u201d of medicine: improvisation in the medical encounter","volume":"5","author":"Haidet","year":"2007","journal-title":"Ann Fam Med."},{"key":"2020110613021578700_ocv107-B32","first-page":"166","article-title":"Competing demands of primary care: a model for the delivery of clinical preventive services","volume":"38","author":"Jaen","year":"1994","journal-title":"J Fam Pract."},{"issue":"4","key":"2020110613021578700_ocv107-B33","doi-asserted-by":"crossref","first-page":"350","DOI":"10.1001\/jama.1997.03540280088045","article-title":"Communication patterns of primary care physicians","volume":"227","author":"Roter","year":"1997","journal-title":"JAMA."},{"issue":"6","key":"2020110613021578700_ocv107-B34","first-page":"425","article-title":"Clinical jazz: harmonizing clinical experience and evidence-based medicine","volume":"47","author":"Shaughnessy","year":"1998","journal-title":"J Fam Pract."},{"issue":"1","key":"2020110613021578700_ocv107-B35","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1177\/1460458213476968","article-title":"Sources of variation in primary care clinical workflow: implications for the design of cognitive support","volume":"20","author":"Militello","year":"2014","journal-title":"Health Inform J."},{"issue":"3","key":"2020110613021578700_ocv107-B36","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1370\/afm.1002","article-title":"Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home","volume":"7","author":"Nutting","year":"2009","journal-title":"Ann Fam Med."},{"issue":"2","key":"2020110613021578700_ocv107-B37","first-page":"e48","article-title":"EHRs in primary care practices: benefits, challenges, and successful strategies","volume":"18","author":"Goetz Goldberg","year":"2012","journal-title":"Am J Managed Care."},{"key":"2020110613021578700_ocv107-B38","author":"Cain"},{"issue":"4","key":"2020110613021578700_ocv107-B39","first-page":"539","article-title":"The impact of computerized provider order entry systems on inpatient clinical workflow: a literature review","volume":"16","author":"Niazkhani","year":"2009","journal-title":"JAMIA."},{"key":"2020110613021578700_ocv107-B40","doi-asserted-by":"crossref","first-page":"552","DOI":"10.1057\/ejis.2012.2","article-title":"Mediating the intersections of organizational routines during the introduction of a health IT system","volume":"21","author":"Novak","year":"2012","journal-title":"Eur J Inform Syst."},{"issue":"2","key":"2020110613021578700_ocv107-B41","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1016\/j.jbi.2004.04.001","article-title":"Incorporating ideas from computer-supported cooperative work","volume":"37","author":"Pratt","year":"2004","journal-title":"J Biomed Inform."},{"key":"2020110613021578700_ocv107-B42","author":"Carayon"},{"issue":"10","key":"2020110613021578700_ocv107-B43","doi-asserted-by":"crossref","first-page":"1261","DOI":"10.1001\/jama.293.10.1261","article-title":"Computer technology and clinical work: still waiting for Godot","volume":"293","author":"Wears","year":"2005","journal-title":"JAMA."},{"key":"2020110613021578700_ocv107-B44","first-page":"454","article-title":"Quantifying the impact of health IT implementations on clinical workflow: a new methodological perspective","volume":"17","author":"Zheng","year":"2010","journal-title":"JAMIA."},{"key":"2020110613021578700_ocv107-B45","author":"Friedberg","year":"2013","journal-title":"Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Rand Corporation, 2013"},{"issue":"e1","key":"2020110613021578700_ocv107-B46","first-page":"e100","article-title":"Electronic medical records and physician stress in primary care: results from the MEMO Study","volume":"21","author":"Babbott","year":"2014","journal-title":"JAMIA."},{"key":"2020110613021578700_ocv107-B47","doi-asserted-by":"crossref","first-page":"i50","DOI":"10.1136\/qshc.2005.015842","article-title":"Work system design for patient safety: the SEIPS model","volume":"15","author":"Carayon","year":"2006","journal-title":"Qual Saf Health Care."},{"key":"2020110613021578700_ocv107-B48","author":"Conover"},{"issue":"5","key":"2020110613021578700_ocv107-B49","first-page":"542","article-title":"Unintended consequences of information technologies in health care \u2013 an interactive sociotechnical analysis","volume":"14(","author":"Harrison","year":"2007","journal-title":"JAMIA."},{"issue":"19","key":"2020110613021578700_ocv107-B50","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1097\/01.NT.0000421892.82755.93","article-title":"In practice: the worst features of EHRs and how to fix them","volume":"12","author":"Avitzur","year":"2012","journal-title":"Neurology Today."},{"key":"2020110613021578700_ocv107-B51","author":"Quality AfHRa"},{"issue":"11","key":"2020110613021578700_ocv107-B52","doi-asserted-by":"crossref","first-page":"782","DOI":"10.7326\/0003-4819-159-11-201312030-00012","article-title":"Texting while doctoring: a patient safety hazard","volume":"159","author":"Sinsky","year":"2013","journal-title":"Ann Intern Med."},{"issue":"8","key":"2020110613021578700_ocv107-B53","doi-asserted-by":"crossref","first-page":"962","DOI":"10.1007\/s11606-012-2001-0","article-title":"Electronic medical record availability and primary care depression treatment","volume":"27","author":"Harman","year":"2012","journal-title":"J Gen Intern Med."},{"issue":"1","key":"2020110613021578700_ocv107-B54","doi-asserted-by":"crossref","first-page":"134","DOI":"10.1016\/j.pec.2005.03.004","article-title":"Electronic medical record use and physician-patient communication: an observational study of Israeli primary care encounters","volume":"61","author":"Margalit","year":"2006","journal-title":"Patient Educ Couns."},{"issue":"5","key":"2020110613021578700_ocv107-B55","doi-asserted-by":"crossref","first-page":"502","DOI":"10.1177\/0018720811405986","article-title":"Modeling eye gaze patterns in clinician-patient interaction with lag sequential analysis","volume":"53","author":"Montague","year":"2011","journal-title":"Hum Factors."},{"key":"2020110613021578700_ocv107-B56","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1186\/1471-2296-7-62","article-title":"Shifts in doctor-patient communication between 1986 and 2002: a study of videotaped general practice consultations with hypertension patients","volume":"7","author":"Bensing","year":"2006","journal-title":"BMC Fam Pract."},{"issue":"4","key":"2020110613021578700_ocv107-B57","first-page":"454","article-title":"Quantifying the impact of health IT implementations on clinical workflow: a new methodological perspective","volume":"17","author":"Zheng","year":"2010","journal-title":"JAMIA."},{"issue":"3","key":"2020110613021578700_ocv107-B58","doi-asserted-by":"crossref","first-page":"272","DOI":"10.1370\/afm.1531","article-title":"In search of joy in practice: a report of 23 high-functioning primary care practices","volume":"11","author":"Sinsky","year":"2013","journal-title":"Ann Fam Med."},{"key":"2020110613021578700_ocv107-B59","author":"Wetterneck"}],"container-title":["Journal of the American Medical Informatics Association"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/jamia\/article-pdf\/23\/1\/29\/34146868\/ocv107.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/jamia\/article-pdf\/23\/1\/29\/34146868\/ocv107.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2020,11,6]],"date-time":"2020-11-06T18:53:47Z","timestamp":1604688827000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/jamia\/article\/23\/1\/29\/2380110"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2015,9,2]]},"references-count":59,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2015,9,2]]},"published-print":{"date-parts":[[2016,1,1]]}},"URL":"https:\/\/doi.org\/10.1093\/jamia\/ocv107","relation":{},"ISSN":["1527-974X","1067-5027"],"issn-type":[{"value":"1527-974X","type":"electronic"},{"value":"1067-5027","type":"print"}],"subject":[],"published-other":{"date-parts":[[2016,1]]},"published":{"date-parts":[[2015,9,2]]}}}