Curbside Consult with Dr. Jayne 10/2/17

I saw patients this weekend and was dismayed to find a mini-release from my EHR vendor that disrupted my muscle memory. Apparently they’ve decided to create a workflow to allow documents to be uploaded to a health information exchange. However, instead of putting that feature in place to automatically send when I sign my charts, they’ve broken the signing process.

Previously, upon hitting the “signature” icon, I received a nice little pop-up where the cursor defaulted into the field where I could enter my PIN, then the pop-up closed after PIN entry. Now I get the pop-up, to which has been added a pre-populated “send to HIE” field with the cursor defaulting nowhere. Since we are not connected with a health information exchange, I have to unclick the HIE field, put my cursor in the PIN field, then key my number to sign the chart. Although technically it’s two clicks, it’s a whole lot of annoyance. I was surprised by how long it took to attempt to correct the muscle memory issues as I continued to try to go directly to PIN entry for signature. Even after 50-plus patients, I still wasn’t handling the transition smoothly all the time.

I’m often the proverbial canary in the coal mine since I work mostly weekends and our vendor likes to roll updates on Saturday nights. I talked to our EHR champion and she wasn’t aware of any way to turn off the auto-populated checkbox or to get the cursor to default to the PIN field.

By way of calculation, we can take my 50 patients, multiply it out to the 750+ patients seen daily in our practice, then times all the practices serviced by our vendor. It’s a significant amount of waste. It’s definitely enough to make one wonder whether the EHR vendor does any focus group work or user acceptance testing at all when they ship these changes to the masses. Since we’re on a Web-based product, the updates are automatic, meaning it’s impossible to pick and choose. If there were any actual improvements in the release, I’m not sure what they were since I wasn’t able to tease them out during 12 hours of patient care.

It was a rough shift overall, especially since I was working at one of our expansion locations that is still under construction. We purchased an independent urgent care facility whose owner wanted to retire, where they were seeing roughly 8-10 patients per day. Our owners figured that the low volume would allow us to do some renovation and expansion while staying open. The ongoing shortage of primary care physicians in our area has fueled a boom in our business, which we sometimes aren’t staffed to handle. Couple that with an office being in disarray due to construction and you have a recipe for a chaotic workplace.

I arrived today to find two of three bathrooms out of commission for construction, which made it tricky to handle patient needs at times. One exam room was doubling as a staff break room, with a refrigerator crammed in the corner and the microwave propped on the exam table. The dedicated laboratory area had been relocated onto one of the nursing station counters, throwing a wrench into some of the workspace efficiency.

Sometimes you forget how well your practice runs until something pushes it off kilter. Although we’ll benefit from swapping the business office and oversized lab for four new exam rooms and a right-sized lab, growing pains aren’t much fun. I was having flashbacks to the last emergency department I staffed, which completely renovated the department over an 18-month period while we continued to see steady volumes of patients and also deployed a new EHR. It was fairly traumatic for the staff, as we struggled to enter orders when we couldn’t even find supplies and were pressed into smaller quarters during the build-out. The construction chaos was bad enough, but adding in the frustration of the extra clicks in the EHR didn’t help.

The shortage of primary physicians is also causing more patients to come to the urgent care who don’t have urgent care problems. I’m glad that we’re less expensive than the emergency department and fill a vital after-hours need, but we’re not equipped to handle complex medical situations or social issues.

About 15 minutes prior to closing, a patient arrived who was seriously ill. She was in the middle oncology treatment and was afraid she had pneumonia. We made a quick decision that she needed to be transferred to the hospital, but we had the complicating factor of the minor children who were with her. We were reluctant to call for an ambulance transfer without someone to care for the children, knowing they couldn’t ride with her, but her condition was worsening. We also can’t have children in the office without a parent or guardian, especially after closing.

As we worked with her to quickly try to find someone to pick up the children, the rest of the story unfolded, revealing an even more tragic explanation for why she was caring for her grandchildren. At least if we could get her to the hospital, social workers could assist. We finally found a solution when one of our patient care techs called the ambulance district and convinced a dispatch supervisor to head over with the ambulance so he could transport the children to the hospital.

These are the situations that can’t be captured well with discrete data, and when you’re trying to problem-solve well outside the box and get the patient ready for transfer, every click counts. We have to complete our H&P documentation so it is printable for transfer and finally I gave up and just free-texted most of it. By the time our patient was stabilized and loaded, the staff was mentally and physically exhausted.

It’s important for team members who work on the IT or billing side of the house to understand the kind of situations we’re facing in patient care. I’m pretty sure I didn’t code the visit as accurately as I could have or gather as many quality measure data points as I should, which would count against a lot of physicians. I won’t take too much heat for it, but it will definitely skew my treatment cycle time metrics. As I reflected on the day overall, I started to question myself on continuing to practice clinically. Although it’s important to see patients to keep me grounded, it’s significantly more stressful than just being on the IT or consulting side and I completely understand why we can’t keep physicians in primary care practices in my community.

Hopefully my next shift will be more in the box than out, but you never know any more in healthcare.

If you’re a CMIO and don’t see patients, how do you stay grounded? Email me.

Email Dr. Jayne.