Physicians

Restoring Office Workflows to the EMR: Or How I Restored Patient Face Time and Got Back the Joy in Medicine

A report from The Blog That Ate Manhattan:

The Problem : Lost Face Time = Lost Joy

One day, about 5 years into using the electronic medical record in my practice, I came to the realization that I wasn’t having fun anymore. I was sitting throughout most of every office encounter facing a computer screen, my back to the patient on the exam table across the room. The joy of face to face interaction with people, the real reason I went into medicine in the first place, had been replaced with the more pressing urgency of data entry.

My revisit routine went something like this – I’d enter the room, briefly greet the patient (undressed and sitting on the exam table) and then, apologetically saying “Let me just open your chart”, I’d log on and begin interacting with the more immediately demanding presence in the room – the EMR. I’d turn around as often as I could to look at my patient, but mostly I listened but kept my back to her and I typed. After which I’d rush over to her side, do the exam, then head back over to the computer to make sure I got all her orders, refills and charges in as required.  A brief goodbye, and I was on to my next patient.

As more and more mandatory clicks were demanded from the EMR to prove I was a good doctor – smoking history reviewed (click), medication reconciliation  (click, click, click,click), problem list review (erase duplicates from ENT , remove resolved problems, add today’s, then click that I had reviewed what I just did) – the actual moments of face time with my patients had became smaller and smaller, till they were almost an annoying distraction from the real task at hand – finishing my charts.

I found myself spending office hours longing for them to be over, and even more sadly, wondering just how many more years I needed to do this before I could retire.

Something had to change. Since the EMR wasn’t going anywhere, it was going to be up to me to make it work.

Renovating the Exam Room was not the anwser

My internist has a patient chair next to the desk in the exam room – I talk with her there, then she leaves the room while I change, then she comes back and does the exam, finally wrapping things up at the desk while I wait in my gown. Then I dress after she leaves.

I thought about pushing for our exams rooms to be renovated, but realized that I probably wouldn’t adopt my internist’s workflow. It just ties up an exam room for too long.

Advance chart prep was not the answer

I tried doing what some of my colleagues do – reviewing the charts of my patients the night before, creating a presumptive note based on her history and the scheduled reason for her visit (when I knew it) , even entering charges and orders for mammograms and birth control pill refills, all of which I could quickly edit and sign tomorrow when I saw the patient, freeing up the encounter itself for more personal interaction.

That idea lasted about a day. While it may work for surgical sub-specialists who hold office hours twice a week to prep charts the night before, it’s impossible for a doc like myself who sees between 15-24 patients a day, 4 days a week.  I had to find a way to get today’s work done today (and not at 4:30 am today, which is when another colleague does his chart prep).

Changing office workflow was the answer

I realized that my private office, which sits between my two exam rooms, is arranged so that I can type and look at my patient at the same time. So I decided to reserve all my electronic charting to my office, and leave the exam room to do what it does best – exams.

My patients now come to see me in my office before and sometimes after they’ve been examined – a workflow previously reserved for new patients. It’s a little more complicated for the office staff, but it’s working really well for me and for my patients. We’re both more relaxed and can both look one another in the eye while we talk and I type.

Its not just the office staff who’ve had to get used to the new workflow. Long-time patients can get thrown, despite my staff explaining that this is the new routine. One patient told me she felt like she was being called to the principal’s office. Another was convinced I had bad news for her. Once I explain my rationale, however, my patients are more than pleased with the new arrangement. Some have remarked on how much they like my office, and how its decor and wall art has allowed them to get a better sense of who I am.

Other pluses –  I’m no longer wasting precious time logging in and out of the EMR, since my office computer isn’t used by anyone but me. I’m physically more comfortable, and so is my patient. Our wrap up after the exam is that much more personal because I am able to enter her mammogram and refills and even her charges while she changes instead of in the exam room. I remember more of the visit later because I’m more fully present with the patient in the exam room. Finally, there’s less down time for me, since I’ve effectively added a third room to office hours and can see a patient in my office while the other two patients are either dressing or undressing in the exam rooms.

But the biggest upside to my new workflow? I’m having fun!  It’s like falling in love with medicine (and my wonderful patients) all over again.

The down side

The down side to my new workflow is that I’ve got to hold everything in memory between the time my patient leaves my office and when she is ready in the exam room, during which I may have seen another patient or two.  It can take me a second or two to ascertain who’s behind door number two, and sometimes I get it wrong. Which has led to an embarrassing moment or two when I opened the door with a comment related to a prior conversation in my office and realize the person behind it is not who I was expecting to see. I’ve since learned to keep my mouth shut until I’m entirely in the exam room.

The good old days

In the good old days, I could pick up a chart from the rack outside the door, and in what seems life a few seconds, familiarize myself with with my patient’s history (because I kept a great paper chart if I do say so myself…) before opening the door to greet her. During the visit, I could sit with the chart in my lap, jotting down notes as we spoke, my focus on my patient and my thoughts rather than a user interface. Once the visit was over, a few brief jotted notes and some well-placed check marks on the encounter form summarized the visit, a few scribbles on a prescription pad or radiology order form clipped to the chart finished the orders (the rest taken verbally by my tech), a check off or two on the superbill and I was done. The entire work of a patient’s encounter took place in one room (or just outside its door), and in one allotted space of time, during which I was hers and hers alone. My chart was there, sure, but it was not the dominant presence in the encounter the way the EMR is now.

Is the IPad the answer?

I find myself thinking a lot about the Ipad these days. While initially skeptical about it’s place in healthcare, I’m beginning to think that it may ultimately provide the best workflow solution for me. However, I’m worried about my ability to type into it – something that’s not easy to do standing up.  And its compelling interface could be even more of a distraction than the desktop. But its portability could allow me to review a patient’s chart outside the room just like the old days, and things like favorite lists and drop downs in the EMR could minimize typing.

Our EMR vendor at this point only offers a limited version for the Ipad, something that may be useful on call but not robust enough for office hours. So nothing new anytime soon.

That’s okay. I’m happy again. I can wait.

Margaret Polaneczky is a board certified obstetrician-gynecologist and Associate Professor of Clinical Obstetrics and Gynecology at Weill Medical College of Cornell University. You can follow her at The Blog That Ate Manhattan where this post first appeared.

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JR
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JR

Who will instruct patients in EMR-speak so that they know words will fit into the fields that are offered? Surely this should be Step 2, at least, in this process, for why fill the air with descriptives and medical conditions that do not exist – in the applications, anyway? Cut through it all. Narrow it down to 4 or 5 options. Only see patients electronically. (There is one article that states that 80 to 90% of patients know what’s wrong with them). This all is entirely driven by the lack of jobs. $20 billion or so was issued through the… Read more »

KRWilliams
Guest

You get the “e-Doctor award” for engaging patients in ways that enforce mutual respect. http://bit.ly/z2FiCM

Dr. Mike
Guest
Dr. Mike

And to all you EHR designers/programmers who might be listening in – you need to understand that the note needs to evolve both forward (history => exam => diagnosis => treatment) and backwards (diagnosis => history). Much of a “proper” note (both for medicolegal and coding purposes) depends on the diagnosis. The ROS has to be pertinent to the diagnosis and so any prompts for ROS information needs to diagnosis driven, not only symptom driven, i.e. the ROS for “chest pain” is not as relevant as the ROS for “angina.” Likewise “Acute Abdomen” should prompt different questions than “abdominal pain.”… Read more »

BobbyG
Guest

Agree. BTW, “Physicians are right to condemn forms of control that involve exclusion of information and power over decision making. But physicians are in denial about the extent to which they themselves impose these forms of control on patients. Physicians are right to reject impoverished, cookbook medicine, but they are in denial of how impoverished is their own know-how. So too are they in denial when they view themselves as “highly skillful,” because their levels of skill would be far greater within a disciplined system of care. Physicians are right that “one cannot separate the decision from its context,” and… Read more »

Margaret Polaneczky, MD
Guest

Agree! We docs are under constant barrage of change in workflow. It becomes impossible to ever find one’s groove in such a rapidly evolving system of documentation. And distracts from the task at hand, which is patient care.

Am going to have to read that book.

Peggy

Margaret Polaneczky, MD
Guest

Dr Mike I still rely on my patient to complete family and social history and a brief review of systems on a paper intake form, and then I use the form as a jump off to my history, so I can focus on the rpoblem areas and not just spend all my time transcribing. I then scan that form into the chart. I’ve been using that intake form for decades, and giving it up was impossible if I was ever to keep up the volume of patients I see on a daily basis. I envision a day when patients can… Read more »

Dr. Mike
Guest
Dr. Mike

I too envision the day when the patient is handed the tablet in the waiting room, interacts with it in a meaningful way, and then hands it to me in the exam room and I complete the note on the same device.

Thanks for starting an interesting discussion

Mike

Margalit Gur-Arie
Guest

It’s better than that. You don’t need to have the same device. You can see what they do in real time on your device and take it from there.
Try Google documents sharing. It’s pretty nifty.

azzasapana
Guest

Great re-cap!In rpeosnse to the first Q&A – The cost of moving to ICD-10 for small practices may seem minimal as compared to the government or large healthcare agencies. However, I’m not sure I would call purchasing new servers, software upgrades, and the cost of training minimal for small practices. They need to plan for these expenses and they are incurring them now as most of this money is being spent with the 5010 transition. Taking providers and staff out of productivity to do training is an expensive proposition even if its done in-house.

Dr. Mike
Guest
Dr. Mike

Ah, a victory for EHR proponents – a real life example of a doctor enjoying life with their EHR. Except that’s not the take home message here – the disruptive technology has forced a compromise that leaves the doctor less productive and still less engaged with the patient than previously. These are unacceptable compromises that physicians all across this country are making because they are otherwise made to feel guilty for not embracing the “quality” and “savings” of a modern EHR. These products are clearly inferior to the technology that preceeded them – inferior in so many ways that outweigh… Read more »

BobbyG
Guest

See the works of Lawrence Weed, MD

http://xnet.kp.org/permanentejournal/sum09/Lawrence_Weed.pdf

I have his new book “Medicine in Denial” — and have actually read it, cover to cover. Just starting to review it in detail on my REC blog.

Not to dismiss your criticisms out of hand — unlike the way you reflexively dismiss all things HIT a priori.

“…pretty front ends on a database that requires the doctor to become a date entry clerk.”

It doesn’t have to be that way. Read the works of the Weeds.

Dr. Mike
Guest
Dr. Mike

Why would someone who dismisses all things HIT use an EHR? HIT includes more things than just the EHR. The ability to access the community database of labs and imaging results has been nearly revolutionary. “It doesn’t have to be that way” but it is. Why are there so many apologists for the EHR in its current state? Dr. Weed’s work may very well lead to something very useful, but will have to be tested extensively in the real world. I don’t think we want a medical world in which every diagnosis suggested in the algorithm has be excluded –… Read more »

Margaret Polaneczky, MD
Guest

Thanks for pointing out this book.

Margalit Gur-Arie
Guest

This is a case of micro-regulation. Companies that build EMRs must comply with regulatory requirements because otherwise nobody would buy their product. Would you have signed up for your free EMR if it was not “certified”? It is almost impossible, and contradictory, to build an EMR that pleases you and pleases the regulators, just like it was impossible to build an EMR that was fit for clinical duty and also supported billing regulations. I do agree that EMR vendors are profiting from the EMR mandate, but I’m pretty sure that most would much prefer to please their users than the… Read more »

Dr. Mike
Guest
Dr. Mike

Yes, I would have signed up for my EHR even if it were not certified. At the time, meaningful use was not in play and I could have cared less about CCHIT. I must disagree that the Vendors are in an impossible situation. I admit that they have had to divert resources to MU instead of making their products more useable, and this will be an ongoing challenge, but the two are not mutually exclusive. Without even trying very hard I can think of dozens of ways that would make the user interface better. I will be very interested in… Read more »

Margalit Gur-Arie
Guest

You do understand that if it cannot be made to work on a PC 90% of the market will not buy it, right? I have had the opportunity to conduct these types of conversations with countless numbers of physicians, and I can tell you that within the first 30 minutes, you usually have at least 3 diverging opinions on what it should do and how it should do it. There is no such thing as a perfect EMR. Unlike common mythology, EHR vendors consult heavily with doctors, but they cannot consult with the plurality of doctors, therefore any one product… Read more »

southern doc
Guest
southern doc

I suspect the author’s re-found joy in practicing medicine may be short-lived. As you point out, even sitting across a desk from the patient, she has to look at the screen to do all those clicks, and the EHR is still the primary focus of her attention.

The basic problem seems to be that, rightly, she deeply resents being forced to concentrate on clerical work that should be secondary to evaluating and treating the real, live patient sitting in front of her. Not a recipe for a happy doctor.

Dr. Mike
Guest
Dr. Mike

The comment about 90% not buying it if not available on PC may not be as true as you think – the cost of tablets/iPADs is dropping – if the interface was compelling I would have no problem plunking down $2000 for 4 tablets. When I am seeing patients I need nothing else from my computer other than to enter my notes and access the internet based resouces or text documents that I need for direct patient care, and tablets can do all of this. There are physicians who successfully used paper templates for years without experiencing any decrease in… Read more »

Margaret Polaneczky, MD
Guest

“Paper will accept whatever goes through your mind at that moment. Computers have preset needs and you have to fit to your thought to the form.Paper will instantaneously adapt to changes in the situation in the room. Computers will require that you add/change/modify templates.” You’ve nailed the difference right there. Margalit – The other big difference is that writing on paper generates personal individualized memories – how that page looked, your handwriting vs the patient’s when you’ve scribbled a few comments onto the intake form, the tactile sensation of a heavy chart vs a thin one, the flipping of a… Read more »

Margaret Polaneczky, MD
Guest

Dr Mike –
Agree. And the fact that we have yet to show that EMR improves outcomes means that we may be embracing technology for technology’s sake alone. I sometimes wonder if all the money we are spending on IT wouldn’t have been better spent to improve nursing staffing ratios.

Thanks for your thoughtful comments.

Peggy

southern doc
Guest
southern doc

Why is it considered acceptable when using an EMR to take time away from the patient’s visit (which they are paying for) to do chart work? With paper, it was assumed that this would be done after the end of the visit.

Margalit Gur-Arie
Guest

The paper was solely there to support your work on behalf of the patient. EMR has “secondary” goals….

Margaret Polaneczky, MD
Guest

southern doc. – more and more, we are being demanded to complete our charting earlier and earlier. The need to print an AVS at exit means that most of the fields need to be completed while the patient is still there, or the AVS won’t be current.

So more and more of the patients face time is lost to the computer. I see no end to it.

Peggy

Bill
Guest
Bill

Dr Polaneczky, I like your perspective on how the way in which you “interact” with your EMR has impacted your patient exams and discussions. Too many IT professionals including those with clinical backgrounds have sold EMR’s while downplaying the upheaval it causes in this important element of patient care. The EMR folks need to do a better job of helping manage this change!

Margaret Polaneczky, MD
Guest

BIll – thanks! I agree on all counts. I think we need to start identifying best practices among EMR using md’s, have more end user groups, continued training on systems as they evolve. Usually once the go live is done, support for ongoing use falls off as IT staff are diverted to putting out fires. MD’s who have gotten some experience with and EMR need advanced training to learn to maximize it’s power. Instead we continue with our early use habits and miss the chance to find ways to use the system better.

Thanks for your comment.
Peggy