Just-in-Time Healthcare Information

flying cadeuciiOne of the things that can cause physician burnout is the arcane way information flows in medical offices. In essence, due to EMRs we are the recipients of increasing amounts of unfiltered data without context.

Pre-EMR, team members sorted incoming data, which allowed us to deal with it more efficiently. We would have piles of things that needed a signature just as a formality, other piles for normal reports, smaller piles for abnormal reports, or whatever system worked best for us and our practices.

Because EMRs were created by people who never imagined that doctors themselves knew anything about how to maximize their own efficiency, results and reports now fill our inboxes in random order and demand our attention and our electronic signatures more or less immediately.

There is a better way. It is standard practice in manufacturing. They call it “Just in Time”.

First, let me describe the way it works now:

I saw Mrs. Keller three months ago for her diabetes. Next week, she will be back for her three month followup appointment. In the next few days, I will get her blood test results, each requiring my electronic signature. This time that might be her HbA1c and her annual urine microalbumin and a chemistry profile. I might also have received an eye doctor report from last week and a progress report from her podiatrist, neither one of which requires any action on my part. That means I must “steal” time from this week’s patients to peruse and electronically sign off five items, which I will have to review again when I see her next week. I also have to remember to flag the eye doctor report for my medical assistant to enter in the flowsheet so we can keep up our quality reports.

In my mind, I multiply Mrs. Keller’s five sign-offs by the number of followup visits I have every week. Even CT scans, MRIs and other imaging could be reviewed and signed off at the time of the followup visit; the radiology departments at all my area hospitals have routines in place to flag critical results.

Why should I look at everything twice? Why are physicians, the highest paid members of the health care team, essentially opening and sorting the mail?

I imagine how my day would flow if none of those five items cluttered my inbox, but popped up when I sat down with Mrs. Keller to talk about her diabetes or with Bill Watterson to talk about his partially torn meniscus.

In the lean, “Just in Time” manufacturing paradigm, factories don’t store parts and raw materials needed for production. They save space, time and money by planning for what they will need and having these supplies arrive just before they are needed.

In medicine, information like test results and outside reports are the parts we need in order to produce treatment plans, which is the output in our “industry “.

Most of the time today, we get paid only for face-to-face visits, and not for “managing” patients’ care. Even in the future, when Medicare starts paying us for outcomes, efficient information flow is essential. Imagine getting important information in random order versus delivered in context, when it is time to assess a patient’s or an entire population’s health status.

Between the skill and experience of our team members and the vast untapped potential of the expensive information systems we have, we could get to where we touch most incoming information only once, just when we need it. Imagine how much time, energy, frustration and money that could save us all.

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7 replies »

  1. I am currently reviewing and assessing the National Academies’ “Improving Diagnosis in Health Care.” A long read. Full of references to EHRs (e.g., search “electronic health record”). Also, a ton on the workflow-cognition nexus.

    Free PDF copy for your convenience at http://www.bgladd.com/PDF/ImprovingHCdx.pdf

  2. Forcing a person to use a bad methodology that takes both time and money leads to a lot of damning. Let the EMR be voluntary and in the marketplace. Soon enough what is desired will be accomplished unless the desire is impossible. At one time physicians didn’t use faxes. Eventually the price was right and the service satisfactory.

  3. Thanks. I don’t think non physicians can begin to imagine how awkward and cumbersome today’s EMRs are. We need EMRs. They just need to work better. See
    THCB – “All I want for Christmas. Seven things I wish my EMR could do” (https://thehealthcareblog.com/blog/2015/12/19/all-i-want-for-christmas-seven-things-i-wish-my-emr-could-do/)
    A Country Doctor Writes – “The Red Blues” (http://acountrydoctorwrites.wordpress.com/2014/06/04/the-red-blues/).

  4. Hans…I’ve been critical in the past of physicians who damn EMRs. We plainly need fully interoperable EMRs. Of course, easy for me to be critical when I’ve never had to use one and not being an MD. You here make two very important points: 1) Improve the flow, and you give ways to do so; and 2) someone other than the MD should be doing most of this stuff. Good article.