Planning a new office is a good time to re-examine what I do and how I do it. This will be my third office (and my first paperless office). I have learned something new with each planning exercise, and worked on the current drawings with a space planner. There is a very useful podcast on the subject at Canadian EMR.
This office is being built for three family physicians, and is about 2,000 square feet. We teach, and have two residents in the practice. All of us are members of a Family Health Team; we have a nurse, a social worker and a dietitian seeing patients at various times.
One of the biggest differences between this office and my current office is that there is no space for filing cabinets. Instead of paper storage, I have exam rooms; there are eight of those. I work best with two available rooms; while I am seeing one patient, the next patient is put in the exam room, and a third patient is in the lab area getting their vitals done. Each physician will have two dedicated exam rooms; all three physicians are rarely in the office at the same time, so I expect to have four extra rooms available most of the time for the use of our Allied Health Professionals and students. The residents are encouraged to take extra time at the beginning for their patient encounters; the additional exam rooms ensure that this does not impede patient flow for the attending physician.
The exam rooms are mostly 8 x 10 feet. This is enough for an exam bed, a sink, a bit of counter space, and a small desk to put the Tablet on. I will also be putting a printer in each room, and have low stands for those, with space underneath to store extra printer paper and magazines for patients to read while they are waiting. I use transparent file sleeves attached to the wall for the very few paper forms that are still needed, and for my clipboards (I use clipboards to sign forms and to go over handouts with patients).
We decided to have a common consultation room; this is a major departure from my current office, where each physician has their own consult room. The shared room is far more space efficient, but does entail some loss of privacy. There is also minimal space for paper storage; paper tends to spread and fill all areas allocated to it. I designed the room for 5 people: 3 physicians with allocated desk and storage space, and two shared areas for residents, Allied Health Professionals, and the RN (with the ability to use the allocated areas when a physician is not present). In my current office, I share space in my consultation room with our RN when she is in, and with our resident (I added an extra desk for them); I find that this leads to much improved communication. I expect an increase in “corridor consultations” if all health professionals sit in the same room, and I consider this to be an important aspect of Team building.
If one of us does need privacy, for example, for a personal phone call, we can use one of the exam rooms and a cell phone. One of the things we will look into is having small wireless phones as part of our system for physicians to carry around while in the office, or having telephone jacks in exam rooms.
There is also a staff room. I find that we have an increasing amount of “back room” office work (billing, managing our preventive services, following up on OHIP numbers etc). This is often better handled away from the front desk, so that the staff person at the front can attend to patient flow in the office: checking patients in, getting vitals done(the vitals area—scale, stadiometer for height, BP machine—is right beside the front desk), putting patients in rooms. The staff room is also a good area for lunch away from the front desk or consult room, and can also be used for staff meetings.
I have not allocated space to drug samples in the lab "nurse" area. Sample storage is very space consuming, as the packaging can be wasteful. As well, we have to manage the samples: periodically, a staff member has to review expiry dates, and discard expired samples in our contaminated waste (which is very expensive). We have been asking drug reps to check and refill our cupboards, as this is not something that my staff should be doing; however, samples still expire. I also find that samples tend to spread to the space in adjacent cupboards where we still store some paper handouts. In my new lab area, there is no space for paper handouts (the best ones are all scanned in); the cupboards are for storage of clinical materials (urine dipsticks, pregnancy tests, gauze etc). We will have shelves for overflow clinical materials in the Staff room, so that only the most useful things are stored in the lab, where they are most accessible. I’m not quite sure where samples should go, but probably not in prime space.
In terms of the IT, I have a small closet for the routers, firewall, and other boxes that I want kept out of the way. My telephone system will also go in there. My wireless access point will be installed centrally in the ceiling, and tested before I use it. I plan to have network drops (RJ45 plugs) in every exam room, at the front, in the staff area, in the lab area and at each workstation in the shared consult room. These are easy and inexpensive to install when building a new office, and I prefer to have redundancy. The printers in each exam room will be plugged into the network access points. If there is only one RJ45 plug, and two devices need to be plugged in, I can use an Ethernet switch (costs $25).
You can see how I have tried to plan this office with workflow, team work, communication, and appropriate storage in mind. I have tried to think of who does what, and what the best place and flow for each member of our practice team is. I have also deliberately minimized the amount of paper-based storage; I find that if there is no place to store paper, you just naturally decrease the amount that you keep around. The basic principles for designing an EMR-based office are the same as those for a paper-chart office; the major difference is in the opportunity to decrease the wasted space allocated to paper.