I did a Peer to Peer visit to some colleagues working in two large group practices, in another city. The visit really highlighted the value of reviewing and updating current workflows. The physicians and staff at this site did a very substantial amount of preparation, which greatly enhanced the value of the visit.
I can certainly give quick tips to my colleagues on how to use the EMR more productively. Much of this comes under the guise of “task analysis”, which relates to the speed and efficiency of data entry. For example, keeping hands on the keyboard (instead of switching back and forth to the mouse) and reducing the number of clicks and travel between clicks needed to achieve a task (especially a repetitive one) can make a large difference. For example, double clicking on the “Invoice” tab to bring up a bill is much faster than clicking “Invoice”, then “New Invoice” in a different part of the screen. I use the Tab button to go to the next cell, instead of the mouse, and I use the spacebar to fill in a checkbox, not the mouse. However, there is much more to workflow than individual data entry.
My colleagues had structured the visit over two days. The first part was a large group session, with the EMR being projected on a screen (using dummy data). They had prepared questions ahead of time, and asked me to demonstrate different areas of the chart. The benefit of having a clinician do this (instead of an EMR company representative) is that I have had the chance to think through all the various issues in actual practice and with patients, because I am familiar with both practice and EMR. As well, I am not financially tied to the company, so I have the freedom to show where the bugs are, and how to get around them.
There was a lot of interaction and many questions during that initial 1.5 hour session; I spent most of the session demonstrating the “quick tips” above. Once that was done, we went to see the scanning area, and the front area, and I spoke with a nurse and an administrator. This group had clearly decided that EMR implementation was done as a team, and wanted to make sure that I saw how different areas of the clinic functioned; this is the right approach to take. We went through what happens when a patient checks in at the waiting room, then gets their initial work up (done by a Practical Nurse), and then gets put in a room. What was really interesting was that the lead physician identified bottlenecks in flow as we were going through the clinic; the first step in solving a problem is to actually see what the problem is. At lunch, we went over the bottlenecks as a group, and brainstormed several possible changes.
For example, I saw the front secretary taking calls, checking patients in, and being handed a couple of papers by another staff member. There was a small queue of patients waiting to give her their health cards, and the phone was constantly ringing. The problems here are that incoming calls can’t always be answered and patients can’t get through on the phone; this leads to call backs and telephone tag (extra work, less patient satisfaction); as well, multitasking can make it challenging to do work well. One of the things we came up with was the concept of the “front and back”: the front secretary could direct traffic (greet patients and check them in), but not answer phones, and the back secretary could answer the incoming calls and do outgoing calls as needed. Any papers or tasks that do not have a direct impact on the front need to be given to the back secretary. We also talked about management of notes that are paid for privately; in my office, these are printed at the front (not in the physician’s office), and payment is received at the front. Payment, in other words, is directly linked to work produced (the form). What that will mean at that site is networking the front printer to all of the clinic’s PCs, and having agreement on a common workflow for the notes and payment from all clinic members. The front secretary can handle payments, unless the clinic prefers to direct patients to the back secretary for this.
For the second day, I went to the other site, and again observed different areas of the clinic. We then had several small group sessions with a projector, to go over particular problems that had been identified. For example, one of the administrators was having difficulty with large group scheduling. We sat around the table with her; there was a lot of discussion and input, ideas were flying back and forth, and we kept trying different scenarios on the projector. Within a half hour, the issue that had caused her a large amount of stress was substantially resolved. She still has the work of implementing the suggestions, but we could all see that the problem was solvable.
We then had an additional large group session. Several physicians had already tried some of the “quick tips”, and were happy with them. We discussed further improvements in charting, such as using coded entries for chronic conditions. I showed how to rapidly enter data in the CPP, as this had been a common query. This session gave everyone a chance to solidify the gains that they had made in the previous day, and to think about additional changes.
The last part of the day was a “debriefing” session with the key physicians, staff and the unit administrator. The administrator ably helped the group to decide which changes in process they were going to implement first and how, and which changes were going part of the next phase.
We have planned a return visit to my office in several months; I think a very worthwhile thing to do is for one or two of their key admin staff to spend time with our FHN administrator. We did this following another P2P meeting, and it worked well; you can’t change processes if you don’t involve all staff, and I wish the program allowed non-physician members as P2P consultants--in other words, a Team consultation.
What was done at this visit shows how to maximize the value of a consultation; the more you put in, the more you get out; have good processes in place for the consultation itself. The value to this group was largely due to the fact that they were well prepared, had clear questions and goals, and were ready to consider how to implement changes at the end. It also helps to have a cohesive group, were there is mutual respect and good communication between team members. I was very impressed with this group.
I am starting to wonder if one of the outcomes of this Peer to Peer program may well be the formation of a group of physicians familiar with both EMR and workflow analysis in primary care practices. This was not the intent of the program, but EMR implementation is so intimately tied with workflow re-design that an effective P2P physician must address both. There are already practice management consultants (through organizations such as MD Management), there are physician leadership training programs (PMI), and there are “EMR experts”; what I don’t know is whether there are “cross-overs” familiar with primary care practices—and those are the ones who may be the most useful as we transfer from paper to EMR. Perhaps Infoway should discuss this with the Practice Management people.