Friday, August 10, 2007

of Time and EMRs

After almost a year and a half of using an EMR, I think it saves me time. There is no question that it saves a lot of administrative time for my staff: there is no pulling of charts, things don’t get misfiled, and accessing data is a lot faster when patients call for results. That is partially counter-balanced by the need to scan and file non-electronic data, but still accounts for net time-savings.

However, saving physician time is less obvious; I think the EMR can help to save time, but you have to organize yourself to do this. I was away for two weeks, with essentially no Internet access. When I returned, there were 52 labs, 26 Diagnostic Imaging reports, and 58 correspondence reports waiting for me. There were also 10 staff messages. I had budgeted time on the day before I came back to go through everything; it took about four hours to review all the reports, and to send appropriate messages for my staff. The time savings here happened because I was able to review the data by logging in from home instead of having to go to the office. Prior to EMR, I sometimes tried to do this while booking a full complement of patients on my first day back, which was inevitably a disaster.

I do not routinely finish recording patient encounters during or right after I see patients. Much of the numerical data (vital signs) is now entered by my staff before I see the patient. Some of the data, such as a note that a patient is in for a routine diabetic visit or a routine BP visit, is quickly entered using a drop down list as I start the encounter; the reason for that is that it takes only two clicks and does not interfere with the interview. I usually will not load a template, such as an Upper Respirator Infection, when I see the patient, because I don’t want to fill in this data instead of attending to my patient's needs; instead, I’ll use free text to write “URI x 2 days”. The free text reminds me to load and fill the template later. If there are significant abnormal findings, I’ll note those in free text. The templates are especially useful for noting normal findings. I’m not sure I save time; however, my records are more complete.

When I am finished seeing a patient, I’ll often go on to the next patient instead of completing the encounter. I don’t like to make my patients wait, so the visit takes precedence over record completion; I note the abnormal/significant results during or right after the encounter, and the rest waits. The alternative is booking fewer patients so I can finish recording encounters.

Because of this, I have routinely have uncompleted visits at the end of the day. I allot one hour to complete my records, return phone calls, review and file reports, and finish insurance or other forms. The difference with EMR is that I can leave for home if I’m tired and not finished by then, and I don’t lug charts home. I find that it is not as painful to finish completing charts after I have supper with my family. Prior to EMR, I had some charts left for completion for a couple of days (which I know is less than ideal); this no longer occurs. It is unusual for me to have a practice summary showing more than one or two tasks undone at the end of the day; most often, there are none; everything has been done.

The difference here with EMR is the ability to complete tasks more quickly, and to have fewer pending reports. My patients have commented on how fast we get forms back to them.

Electronic lab reports seem to come in overnight, mid-morning and mid afternoon. I’ll review them before I start my office, so that I can send a message to my staff if needed. I’ll review them again at lunch, and before I leave the office in the afternoon. Non-electronic reports get scanned in the afternoon, so I’ll review those at the end of the day. If it is a bit quieter, I’ll do that between patients. Time savings for me stem from the fact that lab results go automatically into flow sheets (no duplication), and from having the ability to look at trends easily. Actually reviewing reports takes the same amount of time; there are no EMR savings there.

Inter-office messaging is much more efficient. For non-urgent message, my staff writes an e-note which is automatically attached to the patient’s chart. A little “M” appears at the bottom of my screen to let me know I have pending messages. I check those periodically, and will often send a note back for my staff to call the patient. We also have pop-up messaging for instant communication, and my secretary can always knock on the exam room door if needed. This has led to quicker turn-around to return messages, and fewer phone calls in the evening for me, as the majority of messages can now be handled by my staff. In order to save time here, you and your staff have to use e-messaging consistently, and you have to work with and trust your staff to return messages appropriately.

I think the conclusion is that we have to work with our EMRs and figure out where they will save us time; this won’t happen by itself. One of the best ways to do this is to find out what our colleagues are doing; I am starting to see some forums for exchanging ideas, such as the new EMR Advisor on our provincial website, OntarioMD.

I can see that if I didn't work on my office procedures when the EMR came in, I was just in for endless frustration. Investing time up front to figure out how to do things better and faster with EMR is definitely worthwhile.


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