Vol.3, No.11, 703-707 (2011)
doi:10.4236/health.2011.311118
C
opyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Health
The impact of a computerized care records service
(CRS) on doctors’ work patterns in urological
outpatient clinics
Stefanos Kachrilas, Christian Bach, Pryia Kumar, Faruqz Zaman, Nicola Dickens,
Junaid Masood, Noor Buchholz*
Endourology & Stone Services, Department of Urology, Barts and The London NHS Trust, London, United Kingdom;
*Corresponding Author:
Received 18 August 2011; revised 13 October 2011; accepted 21 October 2011.
ABSTRACT
Objective: Government targets to reduce wait-
ing times are putting enormous pressures on
outpatient services. The implementation of an
electronic care records service (CRS) at our
hospital in 2008 has led to widespread press
coverage of ensuing chaos in clinical admini-
stration. We wanted to know how this new elec-
tronic system impacted on our working patterns
in outpatient clinics and—more specifically—on
the time actually spent with the patients. Mate-
rial & methods: This study was performed 4 and
12 months after implementation of CRS to as-
sess its impact on the time distribution in clinic.
Senior doctors were monitored with a stop
clock during consultations. T imings for pre- and
post-consultation administration, and the actual
consultation with the patient were recorded. A
total of 170 consultations were evaluated in this
way. Results: The key findings were that the
total time needed to spend on a urological out-
patient of 16 minutes remains unchanged from
the pre-CRS era, but a majority (57%) of this
time is spent in administration on the computer
without the patient involved. Conclusion: No
more than 15 patients should be seen in a 4
hour outpatient clinic per doctor. This recom-
mendation drawn up by BAUS before CRS re-
mains still valid. Patient administration related
to the consultation that has previously been
done by administrative aides is now to be done
by the doctors on the computer in the same
consultation session. Intended to streamline
patient pathways, this does reduce the quality
interaction-time between doctor and patients
significantly.
Keywords: Working Pattern; Consultation Time;
care records service; Outpatient Clinic; N ational
Health System NHS
1. INTRODUCTION
Just before the end of the 20th century, an outlook on
the future of British Urology concluded that the urologi-
cal workload was set to increase. This was thought to be
mainly due to an increase in screening, investigations,
counselling and non-surgical treatments [1]. All these
activities concern the work in outpatient clinics. More
recently, government initiatives to improve patient care
and reduce waiting times have added even more pres-
sures on the effective use of outpatient resources [2].
Indeed, only around 20% of urologists are able to follow
recommendations of the British Association of Urologi-
cal Surgeons (BAUS) for outpatient workload “A Qual-
ity Urological Service for Patients in the new Mille-
nium” published in 2000 [3,4]. The average urology
consultant team in the United Kingdom (UK) “overper-
foms” in outpatient clinics by a factor of 1.4 [4]. Con-
sultants do spend more time with patients than in the
past. The list of medical investigations and surgical
treatments has increased dramatically, and patients are
better informed, more demanding and expect more ex-
planation, with doctors increasingly offering to share
their knowledge [1,5]. Therefore, it was thought that
perhaps an electronic system to access and record patient
information may be the best approach to ease these
pressures [6].
As one of a handful of sites, the Care Record Service
(CRS) by Cerner was implemented at Barts and The
London NHS Trust in April 2008 as part of a £ 12.7 bil-
lion National Program for Information Technology (IT)
in the National Health Service (NHS). Although initial
problems at implementation were and must be expected,

S. Kachrilas et al. / Health 3 (2011) 703-707
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
704
they went beyond what was anticipated [7-12]. As ex-
pected, clinicians were struggling with the new system.
Whereas the system held the promise of streamlining
patient pathways, administrative tasks that had been pre-
viously performed by clerks were now to be performed
by the doctor on the computer in the same patient ses-
sion (i.e. printing of results, ordering of investigations,
booking of surgeries etc.). In consequence, paper notes
holding pre-CRS information were left incomplete and
often in disorder. Finding information in these became
an additional time factor.
After we had waited four months thinking this to be
enough time to overcome teething problems, we wanted
to know how this new electronic system impacted on our
working patterns in outpatient clinics and—more spe-
cifically—on the time actually spent with the patients.
2. MATERIAL AND METHODS
Before April 2008, a senior urologist in our hospital
would see 20 patients in a typical clinic. As outlined
above, this was in line with a national average of “over-
performance” of a factor 1.4 [4] as compared to guide-
lines. This corresponds to 12 minutes consultation time
per patient which at that time was a mixture of conversa-
tion, viewing referral letters and results, and dictation.
Results were printed previously and readily sorted on top
of the file. Bookings of diagnostic tests and procedures
would be done by clerical staff. Because of the latter,
times were deemed appropriate although an average of
12 minutes per patient could be challenging depending
on the patient population. Therefore, BAUS issued its
guidelines recommending no more than 15 patients per
doctor per clinic [3,4] in 2003.
CRS was implemented at Barts and The London NHS
Trust in April 2008. Four months later, well after im-
plementation, urological outpatient clinics were moni-
tored as to time usage of the consulting doctors. During
August 2008, medical students shadowed three senior
urologists during outpatient clinics on a one-to-one basis.
New referrals and follow-up patients were booked and
seen at a ratio of 1:2 which corresponds to national
standards [3,4]. Consultations were broken up and sepa-
rately measured in seconds for:
1) pre-consultation computer and notes research dur-
ing which the patient was kept in the waiting area (re-
ferral letters and previous correspondence from different
departments for new patients, previously requested re-
sults for follow-up patients, and in case of patients suf-
fering from urinary stone disease also booking time for
an X-ray on arrival),
2) the actual consultation with the patient during
which no forms or computerized requests were filled in
or processed,
3) post-consultation computer and written administra-
tion (computerized bookings of investigations, admis-
sion forms etc.),
4) dictation of consultation letters.
Whenever there was a disturbance to the consultation
flow (i.e. phone calls), the clock was stopped. Booking
of follow-up appointments was done by the receptionists
and was not considered in this study.
To avoid bias through an initial learning curve in han-
dling CRS, the study was repeated one year after imple-
mentation of CRS in April 2009 in the same clinic, with
the same personnel, using identical methodology.
The timings measured were converted into minutes
(with seconds converted onto a decimal scale) and aver-
ages calculated. Results between the two study periods
were compared using a student’s t-test. A P-value ≤ 0.05
was considered statistically significant.
The timings measured were then extrapolated accord-
ing to a typical urologist’s working pattern of 2 outpa-
tient clinics a week [3,4] and 40 working weeks per year.
3. RESULTS
Before April 2008, a typical outpatient clinic would
see 20 patients per doctor per clinic. This meant 12 min-
utes total session time with each patient. The official
recommendation at the time [3,4] was 16 patients result-
ing in 15 minutes per patient. Usually, the patient would
be present and interactively involved in conversation
during most of this time.
In August 2008, four months after implementation of
CRS, a total of 83 consultations were monitored and
timed according to the criteria mentioned above. The
total average consultation time for a single patient was
12.97 ± 6.04 minutes (range 3.13 - 28.73 minutes). Time
spent with the patient was on average 5.11 ± 2.84 min-
utes (range 0.25 - 12.8 minutes) which corresponds to
39% of the total time. Consequently, 61% were spent by
the senior doctors on administrative work. 29% of pa-
tients needed an X-ray booked before seeing the doctor
adding to the pre-consultation administrative time.
Computer start-up with various log-in steps at the begin-
ning of each clinic counted for 8 (!) minutes pre-con-
sultation time for the first patient of the day.
In April 2009, one year after implementation of CRS,
the study was repeated in exactly the same fashion
measuring the same parameters in the same clinic. The
number of consultations was comparable (n = 87). 31%
of patients needed booking for a pre-consultation X-ray.
The total consultation time was 15.13 ± 8.52 minutes
(range 4 - 48.93 minutes). Of this, on average 6.94 ±
5.73 minutes (range 0.71 - 29 minutes) were actually
spent with the patient which corresponds to 45% of the
total time. In turn, 55% of senior doctors’ time was spent

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Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
705705
on various administrative tasks. Computer start-up times
were unchanged.
When comparing the two groups, the average total
time needed per patient was 14.05 minutes (range 3.13 -
48.93 minutes). This overall time is not much different
from the 12 (actual) to 15 (recommended) minutes pre-
CRS. Pre-consultation administrative time was stable at
4.49 ± 3.62 minutes (range 0 - 25.56 minutes). The con-
sultation time spent interacting with the patient had
slightly but significantly increased from ~ 5.11 to ~ 6.94
minutes (p < 0.05). For the whole group of 170 patients
it was 6.05 minutes equalling 43% of time spend on a
single patient. The average time for requesting investi-
gations had slightly but significantly decreased from ~
2.26 to ~ 1.48 minutes (p < 0.05). Dictation time had
remained stable and was for all patients ~ 1.66 minutes.
The total time spent on administration for a single pa-
tient seen in outpatients per senior urologist was ~ 8.03
minutes (range 0.88 - 26.27 minutes). Therewith, 57% of
time was spent on administration alone.
With the average time needed per patient of 14 min-
utes, a typical outpatient clinic of one programmed ac-
tivity (PA) of 4 hours can accommodate consequently no
more than 16 patient per senior doctor. This corresponds
with the recommendations of the British Association of
Urological Surgeons BAUS [3] issued well before the
arrival of any Computerized Record System.
Also, with an average of 8 minutes spent on admini-
stration, a typical senior urologist would spend 128 min-
utes per clinic on administration, that is 2 hours and 8
minutes, or more than half of the PA.
With on average 2 clinics per week [3] over 40 work-
ing weeks per year and 8 hours work per day, our typical
urologist spends 3.79 weeks = 21.3 working days =
170.66 working hours per year on administration of out-
patients in clinic.
4. DISCUSSION
To ease outpatient clinic pressures it was thought at
the start of this millennium that an electronic patient data
system might be the answer [6]. The Veteran Health
Administration (VHA) in the USA had successfully in-
troduced their Computerised Patient Record System
(CPRS) and introduced it as a patient-centred approach
to clinical computing rather than a department-centred
approach [13].
CRS was introduced at Barts and The London NHS
Trust in April 2008 as one of four sites in London, and
one in 12 in Southern England. British Telecom (BT)
had taken over the contract with Cerner who developed
the product and is due to implement 29 more sites until
2015 in England [14]. CRS means that all patient records
will exist within one central database, which can be ac-
cessed by the different medical bodies within the UK
[15]. After implementation, there were a lot of problems
in all places affected. The initial problems which would
be normally expected from a project of that magnitude
went well over the teething phase. Patients were lost in
the system [9], and government targets were not reached
[7,9], which led to a snowball effect onto the referring
primary care trusts [8]. Six months after implementation,
Barts and The London NHS Trust still faced significant
problems with data access, data recording and technical
issues, leading to a £3 million revenue shortfall [9]. An
independent external audit commission in another trust
using CRS reported that despite 2 years of extensive
remedial works since implementation they had little
confidence in the data generated, found the system
overly difficult and complicated and posing a significant
risk to the trust’s services, both in the ability to treat pa-
tients and in general administration [10].
In consequence, in February 2009 it was announced
that all further CRS implementations in England were
put on hold until the problems at Barts and The London
NHS Trust and one other major London Hospital are
fixed [11]. Following this and on the background of the
worldwide credit crunch, in May 2009 Cerner an-
nounced redundancies due to a sharply reduced expected
implementation rate which had been cut down from 70
to now 41 hospitals in total [14].
Whilst all this was making headlines, healthcare
workers were struggling as the end-users. Generally,
physicians seem to find electronic software more diffi-
cult than usual care with paperwork [16]. A one-to-one-
two-day learning curve was postulated for new users of
CRS [13]. Being based on the assumption of a glitch-
free system working user-friendly, this did not corre-
spond to reality. In particular doctors were expected to
research and find information that has been previously
presented to them in a ready-to-use manner (referral let-
ters, notes, printed results, X-rays), and they were also
given the additional tasks of booking many investiga-
tions and other things that previously had been in the
hands of nurses and clerks. They had to work with a
combination of both, paper records and CRS. Paper re-
cords were left incomplete as it was assumed that new
information is on CRS which could in many cases not or
only with difficulty be accessed.
It turned out that some administrative processes took
even longer with CRS and doctors found it impossible to
use CRS to its full potential due to time restrictions and
the untimely response of the system [12].
In the light of all this, we decided to look at the im-
pact CRS had on our working pattern and, in particular,
the time spent with the patients. In 1988, the time spent
with the patient in a urological outpatient clinic was 7.6

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minutes on average. This decreased to 4.6 minutes in
2002 in spite of introducing time saving measures such
as nurse-led clinics and one-stop clinics 40% was spent
on administrative tasks [6]. In our own clinics before
CRS, an average of 12 minutes total time per patient was
scheduled. This on the background that most booking
and researching tasks were done by administrative aides.
This time was a mixture of administrative time and pa-
tient inter-action very much along the lines previously
described [6]. However, the patient was involved during
the whole time. We are glad to see that our study showed
that the patient’s time has not further reduced as com-
pared to 2002 [6] at ~ 6.05 minutes as might have been
expected with the additional administrative burden on
the doctors. However, whereas in 2002 40% of doctor’s
time in outpatient clinics was spent in administration [6],
this has now risen in our study to 57%.
Out of a total of 14 minutes spent per patient, 8 min-
utes are spent on administration. Apart from dictation of
letters, 45% of the urologist’s time is nowadays spent on
the computer and, more precisely, on CRS. In a similar
study in the pre-CRS era, an additional 15% disturbance
time rate was calculated [6] which has not been consid-
ered in our study. This was mainly due to interruptions
by phone, nurses, junior doctors and others. It also
means that the expected average consultation time per
patient as shown in our study would rise further by 15%
from 14 to 16 minutes, and the patient number to be seen
in clinic by a single doctor must therefore not exceed 15
(instead of 16). This is in accordance with the BAUS
guidelines mentioned earlier [3,4] drawn up for paper-
administered urological outpatient clinics in the pre-CRS
era. It is of note that these baselines have not changed
despite the introduction of CRS.
The time actually spend with the patient had a little
but significantly risen between the two study periods
from ~ 5.11 to ~ 6.94 minutes (p = 0.0097). Nevertheless,
the total administration time had not significantly
changed with ~ 8.03 minutes (p > 0.05) after 4 and 12
months post-CRS. The post-consultation administration
which mainly consists of booking of follow-up investi-
gations had significantly decreased from August 2008 to
April 2009 from ~2.26 to ~ 1.48 minutes, allowing for
the additional time spent with the patient. This may in-
dicate an increased familiarity of the doctors with CRS
in bookings, however it did not have a significant impact
on overall administrative time which remained increased
as compared to pre-CRS assessments in comparable
clinics [6].
Looking at the overall data 4 and 12 months post CRS
implementation, it appears that despite extensive reme-
dial works and increased familiarity of the users with the
system not much difference has been made to the doc-
tors although patients benefitted from a small increase in
time spent with them.
A key message of this study lies in the average time
required per patient. Data comparison with the pre-CRS
era shows that CRS is not the solution to outpatient
clinic overload. The BAUS recommendations from 2003
are still valid and, the clinic profile should not exceed 15
patients per doctor per clinic in urology whether working
with CRS or not. We believe however, that with CRS the
researching of referral data on new patients outweighs
the looking up of results in follow-up patients. Therefore,
at least in our clinic equal slots have been given to both
groups of patients of 15 minutes each.
Another key message of this study is that an addi-
tional administrative burden has been put on the shoul-
ders of the doctors in clinic. This does not mean admin-
istrative sessions in the office, reports, meetings and
academic activities. It means simple day-to-day tasks
without which an outpatient clinic and with it the doctor
cannot function. It is password protected, privileged and,
therefore, cannot be delegated. Extrapolating our data, a
senior medical doctor consequently spends 170.66 hours
or 3.7 weeks of his working life per year on administra-
tion within the outpatient clinic alone. With this price to
pay, it remains to hope that CRS will fulfil its promise of
a streamlined patient pathway in the long run.
5. ACKNOWLEDGEMENTS
We like to thank Ms. S Pararajasingam and Mr. A Ahmed for their
invaluable help with collecting the data from outpatient clinics.
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