Adding 5 minutes to patient charting is a big deal

“I estimate these changes to your charting work flow will take only five minutes.”

Five minutes is fine if it happens for only one patient. But when it is multiplied by as many as forty patients in a day, the multiples get impressive. Five minutes x forty patients = 200 minutes (more than 1.5 hours a day).

Minor five-minute changes to administrative charting requirements aren’t so minor, especially when you add more time for quality assurance reporting or pay-for-performance initiatives. Suddenly huge swaths of time from a doctor’s opportunity to take care of their patients. We need more care time and less data entry time. Doctors must insist that we not become data entry clerks.

Increasingly, I see the data entry burdens of regulatory health care documentation requirements falling on doctors. On first blush, this seems logical because only doctors (or very capable, highly trained surrogates) understand the nuances required to make potentially life-altering adjustments to the electronic medical record. But when new administrative documentation requirements are added to doctors and other care providers, it compromises our time with patients where we explain the mechanisms of their disease and its management nuances. Discussions of medications, therapies, and required follow-up get get short shrift to mandated governmental documentation burdens. If we want to maintain patient volumes to improve access for new patients, we must get creative. After all, time is not expandable.

And there could be a better way.

I believe we need to get patients more involved in their own care before they see their doctor. Imagine a patient entering proposed changes to their list of health problems, surgeries performed, medications and doses being taken and allergies before they are seen on their cell phone or local waiting-room computer terminal or iPad. These proposed changes could then be reviewed, validated, a approved (or not) by their doctor leaving the majority of the patient visit for what matters: actual patient care.

Then maybe, just maybe, I could salvage four of those five precious minutes for both of us.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • http://twitter.com/DrUKDO DrUKDO

    As a medical student, most of the outpatient physician’s offices I have rotated through do not have an EMR system in place yet. However, the point is still valid about data entry whether it is filling out a history sheet by hand or with mouse clicks: it takes time. Some offices give the patient an actual sheet of paper while they are out in the waiting room, asking questions about their medical history for them to fill in. I have found a couple issues with this. First, very few patients actually fully complete the form in the first place. Second, they are filled with inaccuracies which must be decoded in the exam room, taking up extra time. Third, some patients are so thorough in filling out the form that they take lots of extra time in the waiting room and end up going past their appointment time. Having an EMR present would solve some of these issues, especially if patients have online access to their medical record while at home. That way they could add things over a longer period of time when they have access to their med lists, make a trip to the pharmacy, or randomly remember something while watching T.V. I have also had a hard time coming up with every nuance of my medical history while not feeling well, and being nervous waiting to see the doctor.

    internalizemedicine.com

  • http://twitter.com/fancyscrubs Fancy Scrubs

    We have seen this at a local orthodontist where the young patients fill out all the necessary info on the computer in the waiting room upon arrival. It also saves time for patients waiting for their appointments.

  • Anonymous

    We soo often get “you know” written on our annual  paper H&P forms, for both medications, surgeries, and  other doctors.
    When I have patients bring in the actual bottles, there are often meds from other MD’s I don’t know about .
    Getting patients to hand over their lists, before I walk into the room- so I have a chance to see what I’m walking into- 30%.
    This 5 minutes is a really big deal with an elderly patient with social,  cognitive, issues and multiple meds. 
    And it feels  even worse with the looming Medicare cuts.

  • Ileana Balcu

    BINGO!

  • http://www.facebook.com/profile.php?id=655523194 Jeanine Satriano-Pisciotta

    The charting is killing us nurses too. In LTC, all part A and B skilled need a complete note and why. Any change in condition, antibotic therapy, med changes, then if there is an incident your making out reports, documenting on a braden, pain sheet, calling the dr. and the family, updating the care plan. I am also giving out meds throughout the day. And I have 27 patients daily. You get it. We would love to spend more time with our patients, but the CYA and requirements, make it extremely difficult. It’s getting worse too.

  • Anonymous

    ABSOLUTELY RIGHT!  Paperwork and charting adds 3-4 hours to my day.  Almost all of that to keep the attorneys away.  It’s a shame and a crime.

  • http://makethislookawesome.blogspot.com/ PamC

    Maybe my math is off here, but how much time are you spending with each patient if you’re seeing 40 of them a day? 12 minutes? Would 1.5 hours of lost time translated into 5 lost patients?

    How is charting and doing the appropriate documentation not taking care of the patient?

    • http://www.facebook.com/susan.d.dooley Susan D. Dooley

      Here’s the deal.  Doctors have always documented. It’s just that back in the day, they didn’t have to point and click through some silly user-unfriendly, poorly designed interface to do that.  They would scribble some abbreviations on a paper chart or, more likely, dictate their findings in detail in fewer than 30 seconds. Then a medical transcriptionist would render that hurried mumbled speech into an intelligible paragraph that would be applied to the chart. 

      In an effort to find the funds to afford the massively expensive EMR, some practices have eliminated their transcription staffs–after all, they’re invisible since almost all of them work from home, so it’s easy to lay them off–and now they find their financial engines, the doctors, laden with mind-numbing clerical work. And worse yet, quality of documentation is suffering because physicians have  lost the second pair of eyes that the transcriptionist offered, silently double-checking whether the doctor meant right or left leg amputation, hip replacement or knee replacement. 

      There’s an interesting discussion of transcriptionist/speech rec editor-corrected errors at the MT Inner Circle, where an informal 6-month survey revealed some heinous errors that MTs silently correct, then move on. Physicians aren’t even aware that we are fixing these things.  Check it out:  http://mtinnercircle.com/2011/10/07/medical-transcription-identifying-errors-protecting-patients/

    • Gil Holmes

      Old note:
      Date 6/14/78
      T98.8 P78 R 16 BP 124/78
      C/O runny nose                              

      ***Up to here was written by nurse***

      dx: URI     

      ***written by doc, if unusual finding would be documented, past medical history and whether they smoke and other relevant history is noted on front flap of paper chart***

      SAME VISIT THESE DAYS
      5/6/2011
      CC: runny nose
      HPI: 4 days or rhinorrhea and cough. Taking OTC Mucinex with minimal relief.  No fever.
      ROS:denies  fever, chest pain, shortness of breath, headache, otalgia, rash.    
      PMH: no asthma, no CAD, no COPD, no allergies, no chronic sinusitis
      SH: no tobacco
      PE: T 98.8 P 78 R 16 BP 124/78 BMI 26.8
      Gen: NAD
      HEENT: NC/AT, OC/OP with some drainage, no tonsillar enlargement or errythema, TMs pearly grey, + nasal congestion, no sinus tenderness, eyes without injection or discharge
      Lung: CTAB, no distress or wheezing
      CV: RRR, no M/G, 2+ pulses, no edema
      Psych: CAOx3
      Lymph: no cervical or auricular LAD
      Skin: no rash 

      A/P 1) URI-viral nature discussed. Rationale for not starting antibiotics discussed. Recommend OTC decongestants, antihistamines and nasal saline spray/rinses. Reasons to return including fever, worsening of symptoms, no not getting better over 10 days are discussed.
      2) overwight-discussed diet and exercise. Rec BMI of 20-25.

      Same care provided. One note took 5 seconds of the doctors time. The other took much more.                               

      • http://makethislookawesome.blogspot.com/ PamC

        But not the same care provided if you’re trying to track symptoms over time. There simply isn’t the same information there. How are slowly progressive diseases discovered if there aren’t snapshots taken over time?

        • Gil Holmes

          I argue no relevent info is missing in the first note.
          If they return for a 23rd cold in a year, it needs to be explored deeper.
          If they return in 5 days for same symptoms, I probably remember anything relevant anyway. And truthfully, there is nothing likely relevant from the first visit. What matters at the 2nd visit is how long they’ve been sick and current symptoms. All the other stuff asked is mostly customer service.

          • Anonymous

            Or the “other stuff” tries to keep the attorneys at bay.

            I remember back in 1989 when I took over the practice of a retiring rural 80′ish year old MD. His records were mostly on 3×5 index cards–sometimes 30 years on one card.

  • http://twitter.com/dvoran David Voran, MD

    One of Dr. Fisher’s point is that we need to alter our workflows and have the patient begin shouldering much of this documentation as they are the ultimate source of the data anyway.  Many other industries (Airlines, Banking, Investment, Retail Purchasing) have pushed a large amount of administrative duties to the consumer in order to reduce costs, increase data collection and service.  I have long argued that we’ll never get a return on our investment until the patient is the primary user of our EHRs and have experimented around with this with internal patients (other physicians, nurses, therapists) and have found those self-managed and maintained charts are the most accurate, thorough and complete charts and when they document over half of the note on any visit it’s a joy to take care of them.  
    If they can do it I’m convinced the majority of my other non-professional patients could also do this. This would bring a whole new level of transparency to the chart that’s actually required by HIPAA and would dramatically improve the communication between providers and patients.
    None of us really believes we’re going to need less information in the future and that applies to every part of the healthcare industry.  It thrives on data and the data needs are only going to increase.  What doesn’t need to increase is the amount put in by front line providers of care.  The main obstacles are internal access restrictions and our persistance on keeping the patient out of the charts … again, an archaic notion in this digital age and one that is, as mentioned before, not tenable with the HIPAA regulations.
    Technology can help us greatly but we have to change who’s doing what in order to take advantage of this

  • Anonymous

    As usual, the Primary Care physician gets screwed the most. The more patients you have to see each day to meet overhead, the more the nickel and dime administrative burden drives your practice into the ground.  

  • Anonymous

    It is hard to explain to someone how much communication and documentation has deteriorated with the advent of EMR. Of course, no one wants to hear that. 

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