Our most scarce health resources are asked to carry the largest load

It happened, of all times, when I was in the car driving the kids to violin practice.  My pager buzzed with a message from one of the medical floors.  I waited till the car was parked, and dutifully pecked the numbers on my cell phone.

Hello doctor, we have your patient, can you please put admitting orders into EPIC?

I, of course, like most doctors, wasn’t sitting by my phone waiting at a computer terminal.  I explained that I would have to give orders over the phone.  There was a pause.

I’m sorry doctor, new hospital policy, all orders must be placed by a physician.

I already knew that there was no use fighting it.  This was just another onerous policy piling the work on the primary care physician’s back.  The last time I faced this situation the nursing supervisor couldn’t have been more clear.

If you don’t like it, use the hospitalists!

I explained that I wouldn’t be able to sign on to EPIC for a couple of hours, and told her I would call back.  When violin practice was over and the kids were tucked sleepily in bed, I signed on to the EMR to admit the patient.  Browsing the med list in the computer, I quickly realized that the ER staff hadn’t reconciled the medicines correctly.  The list on record was outdated by years, a remnant from the last admission.  But since that time the patient had stayed at a nursing home and had several changes.  Sitting in my office at the house, I had no way of knowing the right doses.

So now I had to call back to the medical floor, have the nurse rustle through the paper chart and find the medicine list from the nursing home.  Then, because she was not allowed to enter the orders herself, she had to read off all twenty medications and wait while I entered them one by one into the computer.  It took forty five minutes in all.  Forty five minutes in which neither the floor nurse nor I were actually taking care of patients.

Now it’s safe to say, we wouldn’t have had this problem if the nurse or physician had reconciled the meds correctly in the ER (like they were supposed to).  I could have just pointed and clicked. But they don’t have enough time either!  They can barely appropriately accomplish their jobs.

As the parade of health care reform travels on and the electronic revolution continues, our most valuable and scarce resources are asked to carry the largest load.  And we all know that there isn’t going to be a physician uprising.  This is my new reality.

How can I, a physician responsible for twenty five hundred people, spend an extra hour on nonclinical administrative work for each admission?  Maybe I could handle that kind of workload if I was taking care of a patient population a tenth of the size.

Hey, wait.

There’s an idea. 

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion.

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  • http://www.facebook.com/shirie.leng Shirie Leng

    Yah. I feel your pain.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    How can a physician give admitting orders at all if they have not examined the patient or taken a history? I am sorry but I am an old school medical dinosaur who still believes in seeing my patients in the emergency department first and writing my own orders. My Electronic Health Record system is set up so I can access it remotely and check on medications from locations other than my office. I never trust the Emergency Department staff to get the medication reconciliation correct because usually between the paramedics trip sheet and the patients carrying around a medication list in their wallets older than the Dead Sea Scrolls it is inaccurate. Unfortunately , if it is my turn to cover my patients hospital admissions I have to do it. I agree it is inconvenient but nobody really gets a choice when to become acutely ill and be taken to the ER. The hospital nursing staff and floor nursing staff are definitely overworked. There are so many non health care delivery people running around with clip boards to make sure we achieve all the core measures goals that patient care suffers.The computers allowed administration to terminate the ward clerks who previously did that work and now the docs and nurses have become the administrative ward clerks at the hospital. The threat of the hospital using their hospitalists instead of you used to be called ” racketerring and was the method used by La Cosa Nostra. Now it is the preferred treatment of Hospital Administrations and Medical Staff Executive committess comprised primarily of doctors controlled by and under salary to the hospital
    Yes limiting your practice size and choosing a membership fee type practice or direct pay practice makes it easier to deal with this. It is still illogical to make doctors and nurses into ward clerks.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Quick question: Do you have remote access to the hospital EMR as well? In a situation like the one described here, would you have to manually copy the meds from your EMR to the hospital one?

      • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

        I have remote access to the hospital EMR and can go on line and use the CPOE system to place orders on hospitalized patients.. Its tough to know what to order if you have not seen the patient, taken a history and performed an examination. The Smartphone accesses are available as well but it is difficult to concentrate and give mulitple orders while engaged in some other process. or activity. It requires your full attention. We can still give emergency verbal orders at our hospital which you confirm when you have access to a computer

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          That’s nice. Thank you.

  • http://twitter.com/FerkhamPasha Ferkham pasha

    Examining the patient is the best way

  • logical_thinker

    “And we all know that there isn’t going to be a physician uprising.”
    You sure about that? ;)

    I agree that EHR is far from optimal… in fact it is largely oriented towards benefitting the administrative side at any cost to the physician… which is probably because physicians by and large are completely un-savvy with tech and have let others make decisions for them.

  • militarymedical

    So which is it to be – let RNs (not LPNs or below) take verbal orders for later verification by the MD/DO, as has been done for decades, or further restrict their “intrusion” into medical practice? We can’t have it both ways. The state nursing licensure boards, with a scope of practice defined by state legislatures (largely orchestrated by physician ghost-writers), have had taking verbal orders on the books forever. What’s next: no verbal orders during a code? to pre-hospital emergency providers? I swear, some days I think some administrators ought to be shot.

  • Ben W

    I am biased, but wouldn’t it help if you could use transcription again to supplement the EMR?