A guest column by the American College of Physicians, exclusive to KevinMD.com.
One of the American College of Physicians’ priority areas for the current fiscal year is to “Help ACP members experience more joy in their professional lives.” This includes decreasing what is known as the “hassle factor” that distracts and demoralizes practicing internists. Bob Doherty, ACP’s Senior Vice President for Governmental Affairs and Public Policy, described this initiative, dubbed “Putting Patients before Paperwork,” in a recent ACP Internist article.
It would be great if these hassles simply went away, but that is not likely to happen anytime soon, if ever. The next best thing is to make them less of a hassle. Over the past few years, my practice introduced ways to reduce the administrative burdens on our physicians. You can implement much of what I will share using your existing staff and practice resources. Many high-performing and efficient practices have been doing some of these things for years. Looking back, I’m struck by how much of this I could have started doing a long time ago, before the push towards team-based care.
Many of these methods to reduce the impact of physician hassle involve smarter use of medical assistants (MAs). Nurses can perform these tasks as well, though not all offices have nurses.
Forms and paperwork
Nothing epitomizes the hassle factor more than the many forms that we are asked to complete. Forms for durable medical equipment, work, college, prior authorization of medications or imaging procedures, and disability are just some of the types of forms that end up on our desks. Most of the forms ask for information that is documented in the medical record. It does not require someone with a medical degree to answer many of the questions. Do you really need to fill out your name, practice address, and NPI number when your medical assistant can do it for you? For that matter, why can’t your MA use your medical record to complete as many of the other questions on the forms as they can before turning them over to you?
I can’t remember the last time that I completely filled out a prior authorization (PA) form. Many of these are predictable, such as PAs for advanced imaging. If I anticipate needing a PA, I make sure that I have the rationale for the test clearly spelled out in the electronic health record (EHR) so that it can easily be entered on the form by staff. While I still review the form for accuracy, it takes much less time than filling the whole thing out myself.
A recent phenomenon in the world of paperwork is the flood of forms from employers and insurers asking for verification that a patient had a preventive exam, BMI, lipid profile, and/or diabetic screening. Again, your MA can complete these forms so that all you have to do is review and sign.
Some forms ask for information that can be provided by printing parts of the medical record. Why fill in an immunization record or exam findings when your MA can print it out from the EHR and attach it to the original form? I have yet to have a form returned because the information provided was not written in their boxes (and I know what I will do if that ever happens).
Protocols and standing orders
It’s not all about diverting forms from the physician. Other routine processes that can be written into a protocol or standing order are fair game for other members of your team. For example, prescription refills for chronic medications such as antihypertensives can be addressed by developing protocols that specify which drugs can be refilled and the number of refills, provided that the patient has been seen within a specified period and is up to date with monitoring labs.
Programs such as meaningful use and “pay for performance” introduce requirements that add to the administrative burden. Here, too, your staff can help. For example, in my office, my MA administers the depression screen using the Patient Health Questionnaire (PHQ-9) as she is “rooming” the patient. We have a laminated card with the questions that the patient answers using erasable marker while waiting for me to enter the room. By the time that I enter the exam room, the PHQ-9 is scored and entered in the record and I address any positive screens. My MA administers a fall risk assessment using a standardized instrument and performs medication reconciliation based on protocols developed by the practice. I review the results and address any outstanding findings.
You may ask whether giving the MAs these additional tasks is feasible, given that they are already busy doing other things. We found that other staff such as medical secretaries and clerical staff could perform many of the tasks historically performed by the MAs. In other cases, using technology freed up additional time.
These and other workflow changes, make it possible for me to “work to the top of my license.” They do not substitute for eliminating the burdens that add little or no value to patient care, but they make it possible for me to spend more time doing what I trained to do, help to decompress my day, and sometimes even allow me to go home earlier.
Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.
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