The New England Journal of Medicine has conducted a sort of time-and-motion study on a small family practice in Philadelphia (above), showing how much of an internist's work day is spent on activities that do not generate income. Each physician at Greenhouse Internists saw 18 patients a day, at $70 per visit. But they also made 24 phone calls to patients, specialists and others, read 20 lab reports, examined 14 consultation reports, reviewed 11 imaging reports, and sent 17 email messages. Each day. They didn't make money from any of the extra work, leading to a comment from NCHIT David Blumenthal that electronic records plus "changes in workflow and payment" can solve the problem. But even a casual look at the study sees a bigger problem for Dr. Blumenthal. The Greenhouse clinic is already automated. Their Web site has health advice and email links to the doctors. Most practices don't have electronic health records (EHRs), let alone email access or other automated tools. My own internist doesn't have a Web site, although she has a competitor, just a few miles away, who has one, along with a similar-sounding practice name. Last time I saw my doctor, a few months ago, she was still using paper records. I have never been able to email her, or her partner, who was my primary until she came in after he had a health scare. If Greenhouse is barely keeping itself afloat, what about my doctor? And how can she find the time to install, train on and make meaningful use out of EHR software while continuing to practice, no matter how much sweet, sweet stimulus cash might be coming her way as a result? The larger question is, how can doctors be paid for essential work that isn't part of an appointment. That's where concepts like the medical home come in -- per-patient fees, teams of care including nurses, all tied together with technology. But the term is over 40 years old, and as I have noted before it is a huge change, not just in terms of the business model but in the nature of the practice, a change many doctors may fear more than an EHR. The bottom line is that family doctors have bigger problems than EHRs, they don't have the time or mental bandwidth with which to work on their businesses (as opposed to in their businesses), and they need a business model stat that will let them do their thing, make more money, and retain as much autonomy as possible. Ideas? I'm thinking franchising myself.