Curbside Consult with Dr. Jayne 11/25/13

I’ve seen a lot of articles lately about physicians who are unhappy with their EHRs because they feel they’re being forced to collect too much meaningless data and to do “too many clicks.” I read most of them to see if I can pick up any pearls that will help my physicians and also to prepare counter-arguments for when my colleagues email me links to those articles.

I’ve used quite a few different systems and each has its own little annoyances. Physicians always seem to think the grass is going to be greener on the other side of the fence. If I had a dollar for every time I’ve heard someone say, “It would be so much better if we just had System X,” I could retire much sooner than currently planned.

I know I have a fair number readers who are CMIOs, medical directors, CMOs, or EHR champions. There are quite a few physician leaders I know who are new to the EHR game and haven’t quite figured out all their responses yet, so I wanted to share some of mine. These should also be helpful to anyone who has to work with physicians, train them, or manage physician practices. Vendors might want to take note as well and incorporate some of these elements into their implementation and optimization strategies.

When physicians complain about entry of discrete data, I like to ask them specifically what data fields they are referencing. Our organization has a pretty liberal policy about using free text or voice recognition to enter data in certain parts of the chart. For example, users can enter the patient’s History of Present Illness (why they are seeking care and how their condition has progressed) in a non-discrete way. No drop downs, no picklists, no checkboxes, if that’s how they want it. When you dig deeper, many of the fields they are complaining about are those that are required for Meaningful Use, quality initiatives, or important things like drug-allergy checking. They are often fields that do not specifically require physician entry.

We created a matrix of required data and documented which staff members could be authorized to enter the data after appropriate training. It also includes directions on where and when it should be done in the flow of the patient visit. For example, the patient’s pharmacy and HIPAA contact preferences can be entered by the front desk check-in staff. Neither data element requires clinical training or expertise, just access to the right screens. If a physician has to enter the pharmacy name (and it’s not because the patient changed his or her mind at the last minute regarding where the prescription should be sent) this is a systems and workflow failure, not a “terrible EHR.”

The matrix also explains specifically why each data element must be collected, what our organization plans to do with it, and how it benefits patient care. This has been a helpful reminder for many of our physicians as well as new information for those who tried to skip out on training. It doesn’t make the data gathering less from a volume standpoint, but often understanding why these might be “good clicks” can make them feel less burdensome.

For those physicians who do choose to enter non-required data discretely, the most common mistake I see is feeling the need to ask about something just because there is a field for it. For example, in the social history section under pets, our EHR has a specific checkbox for “reptiles in the home.” This makes sense if you’re a gastroenterologist or infectious disease specialist treating certain symptoms, or if you’re a pediatrician who needs to counsel against risks, but if it’s not pertinent to the user’s specialty it doesn’t need to be asked.

It’s OK to ignore fields. That’s a hard thing to teach people – if you don’t like it or don’t need it, don’t use it. And if you didn’t ask it before EHR ,don’t feel obligated to ask it now just because there’s a box (unless it’s flagged as required).

One of the other things I hear a lot of complaints about is refill management, especially in the primary care setting. Some EHRs are better than others at being able to streamline refills, but the key is to eliminate the existence of the refill request in the first place. This is not really an EHR strategy. Primary care literature has been talking about this for years, but it’s been slow to catch on. The concept of writing for enough medication to see the patient through the next scheduled appointment (or for up to a year for stable patients with controlled conditions) seems hard for some physicians to accept. Of course there are some controlled substances that aren’t inherently refillable and may require paper prescriptions between visits, so practices need systems and rules to handle these so they don’t cause chaos.

In my practice, I took a lot of time to educate our patients that we don’t do refills. If they are out of medication, they need to be seen. Everyone in the office was schooled on the same message so that it could be delivered consistently. Patients were encouraged to schedule their next appointment before they left. We had same-day and next-day appointments available for people who missed the point and ran low on their medications. Worst case scenario, we could get patients in to be seen within a week and at that time they got new refills for a maximum time period based on their status (as well as re-education.)

Another huge time suck is allowing the patients to call a refill phone line at the office and leave messages for the staff requesting refills, or even worse, to speak directly to a staff member. Those conversations were never brief. Patients often brought up other medical issues or wanted to chit-chat. Given the status of electronic refill requests in most systems, it’s much more efficient for patients to request their refills through the pharmacy and let the staff process them electronically in the EHR. The worst case of this I’ve seen is staff who were transcribing the voice mail messages onto little pink phone message slips, then later transcribing them into the EHR. Not only was it double work, but it delayed the refill process for the patient. Again, there are exceptions (controlled substances being one of them) that may merit a call to the office, but these should not be the rule.

Physicians usually push back here and tell me they don’t want to receive requests from the pharmacy because X pharmacy always sends erroneous requests or something similar. I’ve seen this in practice and have found that a quick phone call to the pharmacy supervisor recommending that they get their staff in gear or you might start recommending all your patients have their scripts filled at Competitor Pharmacy Y is very helpful in producing high-quality refill requests with few errors. It may take 10 minutes to make the call, but it will save countless minutes in the future.

For practices that refuse to write medications through the next scheduled appointment, I often recommend a protocol-driven refill policy that allows nurses to refill based on a signed standing order and written algorithm. The key words here are signed standing order and written algorithm. You can’t just let your staff issue refills “because they know what you would want” because in most states that’s considered practicing without a license. On the flip side, you can’t have standing orders in every state and may only be able to do them with a certain level of staff (RN), but it’s worth considering. If a patient who has controlled high blood pressure and high cholesterol is current on labs and has an appointment scheduled, I as a physician don’t need to see that request because my protocol allows the staff to issue scripts through the scheduled appointment.

These concepts stray a little from our healthcare IT focus, but I’m tired of the EHR taking the blame for clunky and duplicative office processes. In what situations do you find physicians and staff using the EHR as a scapegoat? Email me.

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