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The New York Times1 and USA Today2 recently reported on a study3 that highlighted the amount of "nonproductive" time a group of internists reported during their average workday. The lead researcher, Richard Baron, MD, sought to understand how physicians spend their time in the delivery of primary care. In the study, he described the daily work of the physicians in his practice and concluded that much of their time was spent in nonbillable activities, which in our current reimbursement system equates to nonproductive time.
"... It is urgent that we understand the actual work of primary care and find ways to support it," Baron wrote. In addition to expressing dissatisfaction with the reimbursement practices of the current system, Baron provided a narrow definition of primary care providers (PCPs) as either "internists" or "physicians." His exclusive focus on physicians seemed to ignore the expanded role nurse practitioners and physician assistants can play in meeting future societal healthcare needs.
As the face of healthcare changes, NPs and PAs have the opportunity to affect healthcare by clearly defining their roles and demonstrating their value in light of a looming shortage of primary care physicians.
Background Literature
Productivity, often expressed as patient visits per day or income generated, is an important concept for all healthcare providers. However, this article focuses only on nurse practitioner productivity.
 Rhoads et al 4 defined productivity as "a measure of output per unit of input." A landmark randomized trial by Mundinger et al,5 which controlled for productivity, authority, responsibility and administrative requirements, found that NPs had patient outcomes similar to those of physicians in primary care clinics. Compared to physicians, NPs achieved similar or better outcomes in patients with common conditions seen in primary care, including diabetes, asthma and hypertension.
A search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL) revealed limited literature related to the nonbillable work of NPs. In a relevant foreign study,6 a group of Australian nurse researchers examined the direct care, indirect care and service-related activities of 30 NPs in that country. Indirect care, defined as "activities performed away from the patient but on a specific patient's behalf, including coordination of care, collaboration with other healthcare professionals and documentation," most closely resembled nonbillable activities in the Baron study. Indirect care activities accounted for 32% of the Australian nurse practitioners' time. Coordination of care was the most time consuming element, accounting for 10.8% of NPs' time.
Caution should be used when applying these results to NPs in the United States. Australia has a national public health insurance program that provides free or subsidized health services to the country's citizens.
U.S.-based literature on the nonbillable activities of primary care providers is limited to physicians. Baron,3 using descriptive methodology, examined the nonbillable activities of his internal medicine practice, including phone calls and emails to patients or families, reviewing laboratory and imaging results and consultant reports, and refilling prescriptions. In Baron's study, primary care internists typically worked 50- to 60-hour weeks and saw 18 patients per day. The most frequent nonbillable activity documented was telephone calls for acute problems, administrative needs and other purposes (23.7 per day). This was followed by reviewing laboratory reports (19.5 per day), emailing patients and other physicians (16.8 per day), reviewing consultant reports (13.9 per day), refilling prescriptions (12.1 per day), and reviewing imaging reports (11.1 per day).
Our Investigation
We sought to describe the typical practice day of the primary care NP with a focus on frequency and duration of time spent on nonbillable activities.
We used a nonexperimental concurrent tracking of office visits and personal logs to capture the nonbillable activities. The setting consisted of two primary care clinics owned and operated by a nonprofit health system in the mid-South region. One clinic primarily focused on family practice and was staffed by one NP and five physicians. The other setting primarily focused on adult patients and was staffed by one NP and three physicians. Providers in both clinics saw an average of 21.6 patients per day. The University of Arkansas Institutional Review Board granted approval for our research.
Both NPs providing data for this study held MSN degrees and were certified by the American Nurses Credentialing Center. One NP, certified in family practice, had 14 years of experience in this role. The second NP, certified in adult practice, had 11 years of experience as an NP.
 Data Collection and Analysis
We recorded the frequency of NPs' office visits and nonbillable activities (frequency and duration of time) for 1 month. The NPs kept personal logs to track telephone calls, prescription refills, emails to patients or guardians, laboratory reports, imaging reports, and consultations. Table 1 provides operational definitions and examples of each type of nonbillable activity. All data were entered and stored on Excel spread sheets. Data analysis included descriptive statistics (frequencies, means and percentages).
Results
During the month studied, one NP collected data for 19 practice days and the other NP collected data for 21 practice days. The two NPs saw a total of 336 patients during this period, for an average of 12.7 visits per day. The NPs reported working 40 hours a week.
Six nonbillable activities were identified and studied. Reviewing and interpreting lab results occurred most often (13.7 per day), followed by prescription refills (10.1 per day). However, the NPs spent the most time consulting (17.4 minutes per day), followed by interpreting lab results (10.2 minutes per day).
Table 2 shows the frequency and duration of time for each nonbillable activity studied. Overall, NPs spent 79% of their time in billable activities and 21% in nonbillable activities.
 Discussion
The NPs averaged 12.7 patient visits per day. This is consistent with data contained in a focused report from the 2010 National Salary Survey of NPs & PAs,7 which found that NPs see an average of 64.95 patients per week, equaling 12.9 patients per day. This is a lower productivity rate compared to physicians; however, NPs are educated to provide more holistic, nursing-based care, often involving more time in face-to-face interactions with patients. The personal interaction may translate into more patient satisfaction, less patient confusion and hence fewer post-visit communications.
An important supposition, not studied here but certainly reported in other research, is that increased face-to-face interactions leads to high patient satisfaction. Many studies have concluded that patients report a high level of satisfaction with care provided by NPs.8-10 These findings might substantiate an economic interest for NPs to continue providing rich face-to-face encounters with their patients.
Image results and consultations are other factors to consider in the analysis of NPs' low percentage of nonbillable time. A possible explanation is that the NPs may have been less involved in imaging results and consultations because they were more likely to refer medically complex patients to specialists. The NPs had 1.8 consults per day, which took an average of 17.4 minutes per day. Based on the examples in the definition of consultation (Table 1), the length of time required for consultations seems reasonable.
Nurse practitioners share a primary concern for prevention, health maintenance and common disease management. Their education is holistic, with a strong focus on patient-centered care in which the patient is an equal partner in medical decision making. Spending more time with patients and knowing their needs may translate into less diagnostic testing, extraneous communications and other nonbillable activities that take time away from face-to-face encounters.
Implications
Primary care physicians are accustomed to providing medically focused examinations, perhaps allowing the opportunity to see more patients in less time compared to NPs. As a result, physicians are often viewed as more productive than NPs. In this study, NPs spent most of their time providing care in billable office visits (79%). This finding prompts an interesting question in the new era of healthcare reform: How might the duration and holistic nature of primary care office visits impact patient participation in primary prevention activities and overall healthcare costs?
Future studies should investigate the outcomes of nonbillable activities in clinics employing both physicians and NPs. And to control for confounding variables, future practice settings should be matched based on number of patient visits and methods of provider reimbursement (e.g., salary vs. productivity bonuses and other incentive arrangements).
The data from our pilot study indicate discrepancies in the type and amount of activities between the two NPs. For example, one NP did not use email as a means of communicating with patients or family members, while the other NP did not review imaging reports as a part of her typical practice day. This may be due to differences in the types of practice setting (internal medicine versus family practice), but it would certainly warrant further study using a larger sample of NPs from a variety of settings and specialties.
In addition, future studies should have larger sample sizes, be conducted in multiple and varied primary care settings, and be controlled for patient income, race and diversity. Expanding the sample size, institutional settings and patient diversity would increase our knowledge of current NP practice and provide valuable information about billable and nonbillable activities. Understanding the productivity of typical NPs and associated outcomes could identify future opportunities for the cost-conscious expansion of NP practice. For example, in light of possible future Medicare funding cuts, it may be more cost effective for community settings such as schools, nursing homes and prisons to hire NPs to directly manage primary care with a greater, more orchestrated focus on prevention.
Limitations
Limitations of our study include the limited sample size of two NPs and that data were gathered in only one healthcare system. Also, the categories of nonbillable activities were selected based on the desire to replicate Baron's work. Considering the holistic nature of NP practice, other categories may have provided data more pertinent to the breadth of NP practice.
Conclusions
As our federal government seriously considers an expanded NP role in primary care, it is important to understand how NPs spend their time in practice and how cost-effective they are in comparison to primary care physicians. If other studies validate our findings that NPs may be involved in fewer nonbillable hours than physicians, future studies should investigate the implications of this on patient care.
Future researchers also should consider cost/benefit analyses of the two types of PCP. For example, how might future care be impacted by creative models that use NPs? As the trend of physician specialization continues, creative ideas for the expanded utilization of NPs in primary care should be given serious consideration. Only then may the best quality care provided in the most economical manner finally be realized.
Ellen M. Odell is a clinical nurse specialist who is an assistant professor of nursing at the University of Arkansas in Fayettville. Bill M. Buron is a gerontologic and family nurse practitioner who is an instructor in the College of Education and Health Professions at the University of Arkansas. Thomas A. Kippenbrock is a professor of nursing at the University of Arkansas. Candy Auler is an adult nurse practitioner who practices at Mercy Health System in Rogers, Ark. Kim Carney is a family nurse practitioner who practices at Mercy Health System in Rogers, Ark.
References
1. Lohr S. Study shows 'invisible' burden of family doctors. The New York Times. April 28, 2010:B3.
2. Rubin R. Primary care internists inundated with phone calls, e-mail. USA Today. April 29, 2010:7D.
3. Baron RJ. What's keeping us so busy in primary care? A snapshot from one practice. N Engl J Med. 2010;362(17):1632-1636.
4. Rhoads J, et al. Measuring nurse practitioner productivity. Dermatol Nurs. 2006;18(1):32-38.
5. Mundinger MO, et al. Primary care outcomes in patients treated by nurse practitioners or physicians. A randomized trial. JAMA. 2000;283(1):59-68.
6. Gardner G, et al. The work of nurse practitioners. J Adv Nurs. 2010;66(10):2160-2169.
7. Pronsati MP, Gerchufsky M. Focused report from the 2010 National Salary Survey of NPs & PAs, available online. The 2010 National Nurse Practitioner Salary Questionnaire. www.advanceweb.com/NPPA. Accessed Sept. 30, 2011.
8. Benkert R, et al. Trust, mistrust, racial identity and patient satisfaction in urban African American primary care patients of nurse practitioners. J Nurs Scholarsh. 2009;41(2):211-219.
9. Green A, Davis S. Toward a predictive model of patient satisfaction with nurse practitioner care. J Am Acad Nurs Pract. 2005;17(4):139-148.
10. Knudtson N. Patient satisfaction with nurse practitioner service in a rural setting. J Am Acad Nurs Pract. 2000:12(10):405-412.
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