The electronic health record (EHR) continues to be a tool for both evil and good. One of my roles in my healthcare organization is helping fellow physicians with workflow and efficiency. Observing other physicians’ struggles and having challenges of my own with the EHR compels me to consider ways to incorporate the computer into the patient-physician encounter in a manner that supports rather than detracts from the work that I love to do.
The following strategies and considerations can help any physician better navigate the use of EHRs for patient care and efficiency.
Beware the illusion of anonymity
We’ve all made the fatal error of sending a poorly-worded, emotionally-laced email. It’s a terrible feeling but the behavior is so quick and easy to replicate.
The EHR offers the same illusion of protected communication. But be cautious with how you word communications to your nursing staff or what you choose to immortalize forever in an electronic record.
While many of us are careful with the office visit notes we write or dictate, we may be less careful in how we word comments in the patient’s chart or in electronic communication with our staff members.
Educate your staff
One of the best things I ever did was take ten minutes and educate my medical assistant about the new cervical cancer screening guidelines.
Armed with the information and my preferences, she is now able to determine if a patient needs a pap smear 90% percent of the time. This allows her to educate my patient before I enter the room and to enter the correct orders electronically for me.
The more you can share with your medical assistant or nursing staff about your preferences and processes, the more they can do to help you with the growing pile of electronic work.
Find opportunities to standardize
Do you tell your patients with bronchitis or low back pain or toenail fungus the same thing every time? If you have (as most of us do) patient information that you use routinely, standardize that by using the tools available in your EHR to build custom text.
Look for these opportunities wherever you can find them. It will improve your documentation because the information will be complete and well thought out.
It will also save time because you will be able to short-cut the typing. Any time you can do a better job in less time is a win.
One-piece flow
Our organization models lean manufacturing principles. Therefore, one piece flow figures high on our list of model behaviors.
Like many physicians, I tend to batch work. I look at all my results over lunch or finish up all my charts at the end of the day. This is a definite no-no in the manufacturing world and, for the sake of safety, quality, and sanity, should become a no-no in medicine as well. Think about how hard it is to remember which of your six patients with pharyngitis had tonsillar exudate at the end of the day or which of your patient’s ears was infected.
Attending a recent professional practice seminar, I vowed to incorporate one piece flow into my clinic day. This meant that the note and orders were completed by the time
I left the exam room.
When I started this process, I had the strangest feeling as I stepped out of the exam room into the hall at the end of a visit. It was the feeling of a clear and unburdened mind. Instead of mentally filing away pieces of information for later about the patient I just saw, I reminded myself I was done and moved on to the next patient with improved focus.
Rule of 3s
Despite my admonition to avoid batching work, inevitably it will happen.
So when work does pile up, think of the rule of threes. It is daunting to sort through 50 results, but you could sort through three. Do the work in little chunks throughout your day and the job becomes more manageable.
Set small goals
Sometimes I run into the note that I really don’t want to finish. Usually it involves a complex patient with multiple social and medical issues that ran over by a good 20 minutes. Sometimes I haven’t been able to type anything in the exam room because my attention needed to be fully on the patient for the entire visit.
Trying to reconstruct a complicated 45-minute office visit in your notes can be painful. This might be a situation you need to break into chunks and tackle just one part of the note throughout the day. Avoid the temptation to put this off because the task will become more onerous as the day (or days) pass.
Touch it once
If you’re like me, you probably look at certain lab results and can instantly and easily address them with a couple of clicks. Other lab results require you to review the chart, calculate the 10 year cardiovascular risk score, or consult a reference.
While our natural inclination is to put aside the more complicated work, don’t do it. When you see the result, address it and finish it. Otherwise it will take up electronic space, space in your brain, and will probably be a result (or refill request or patient call) that you click on repeatedly, waiting hours or days to finally reach a conclusion.
Use your own templates
Previously I used the standard templates provided by our organization, especially for acute complaints. This gave the illusion of efficiency, except that I didn’t necessarily conduct my visit according to the template, nor did I ask all of the same questions.
This translated into formulaic notes that failed to convey the story of the patient and which required a lot of editing.
So, I moved to my own templates and narrowed it down significantly. For certain conditions (like new-onset headache), I have a lengthy list of questions I want to remember to ask every time. For other visits, I have the skeleton of a chronic disease or problem-focused visit and fill it in as we go along.
Conclusion
EHRs afford us many advantages compared with the days of a paper chart. However, as with all technology, unforeseen consequences can result even from useful technology.
Thinking through your own processes and adopting rigor can tip the balance of your EHR from aggravating to helpful.