Curbside Consult with Dr. Jayne 6/9/14

I mentioned that I was planning to start working in an urgent care that documents patient visits on paper. I fell into an opportunity with an independent facility and worked my first shifts this week. A reader asked if I had mentioned during the job interview that I would be blogging about my work and whether I’ve been able to remain anonymous in my various work roles.

The answer to the blogging question is “no.” I enjoy my day jobs and wouldn’t want to jeopardize them. Although I share many stories about my work, there are a great many stories that don’t get told because they might result in specific people or organizations being identified. Some of the best tales will go with me to the grave.

A reader once said that as a CMIO, I’m still a doctor, but my patients are sick hospitals and physician offices. That’s true to a degree and I guard their information as I do with patient information. Often my material reflects events that are so common they could apply to many organizations across the country, so camouflaging the events and players isn’t necessary.

As far as my clinical duties, I do think I’ve been able to remain anonymous. Frankly most clinicians in the trenches are too busy keeping their heads above water to even know that there’s an entire health care IT community out there. They may not know who their own CMIO is or what he or she does, let alone that there are scores of us who know and talk to each other. The idea that there would be blogs talking about EHRs and the people who use them to torment physicians isn’t even remotely something that would cross their minds.

If I use photos from work, it’s often months after they were originally taken or in a slightly different context than where I obtained them. I have a veritable treasure trove of photos I’ll never be able to use because they would be easily identifiable or involve people that I know read HIStalk. I also use photos that have been sent to me by readers when they can help embellish something I’m writing about. Hopefully if anyone recognizes those, the story is different enough from their reality that they don’t make the connection.

Back to the world of paper records. I arrived at the office ready to go. It’s a little different vibe from working the ER. The lack of a metal detector and security guard was refreshing, although I admit after my first procedure, I missed wearing scrubs.

The physician I worked with was quick to show me the processes and systems. Staff does the intake interview, gathers the history, and performs any needed pre-testing based on a written standing order. The clipboard goes in the door with a magnet to indicate which patient should be seen next. Simple and elegant, although low tech.

The physician sees the patient, documents on a paper template (they have a dozen or so templates for their top conditions plus some more generic versions), then comes out and order whatever additional tests are indicated. If there aren’t any, we prepare the discharge instructions and prescriptions, which are done via computer. The prescription ordering system isn’t sophisticated, but it does have hard-coded selections for the most common drugs, sortable by body system and diagnosis. If you can’t find them, there’s a search dialog, and if you get in a real bind, there’s a paper script pad in the drawer.

I have to reiterate that this is obviously not a practice that is trying to achieve Meaningful Use. As an opt-out site, we’re not asking super-detailed questions about smoking history or the types of tobacco used. We’re not asking race and ethnicity. We’re not codifying problems in SNOMED. Since we’re not part of a hospital system or accredited by The Joint Commission, we’re also not spending time assessing suicide risk, nutritional status, or any number of possibly irrelevant scenarios on all our patients. This leaves us time to actually see our patients at a reasonable pace.

Even though the first part of the shift was fairly busy (5-6 patients per physician per hour), the pace didn’t seem extreme. I think mostly it felt like I was able to focus on the patient’s current needs and not feel expected to address unrelated issues just because someone made a regulation that said I needed to.

Once the provider is finished, the nursing staff then takes the discharge instructions and scripts, goes back in the exam room, counsels the patient, and addresses follow-up needs. Then the patient gets to go home. Their plan may not have all their medications printed on it nor their list of historical diagnoses, recent vitals, or a host of other things, but it does have the information they need to care for today’s problem and to follow up with their primary care physician.

Up to this point, I’ve focused on the things that made today easy. Let’s talk about what made it difficult.

The first thing that jumped out at me was the fact that there is no drug or allergy checking when we write prescriptions. Although physicians have used paper scripts for years and there are plenty of people who argue that we were better on paper, I can’t help but think that I’m going to harm someone because I don’t have technology backing me up.

I calculated most of my weight-based pediatric prescriptions two or three times because I didn’t trust myself. I had one pharmacy call-back for prescribing a drug that might have had a mild to moderate interaction with a patient’s current medication. I know it would have flagged in an electronic prescribing system, but I’m wondering if there is a chicken vs. egg phenomenon going on. Did I miss the interaction because my vigilance was weakened by my reliance on technology? Or would I have missed it anyway?

I ended up customizing 80 percent of the patient education materials to include additional precautions or information that I like to provide for my patients. Most EHR systems would allow some level of saved customization. but our discharge system doesn’t. I’ll likely create a text document of common phrases that I can use to populate them in the future and just keep it open on my desktop.

Unlike some chain or pharmacy-related urgent cares, we don’t have an easy way to send information back to the primary care physician. It’s something that definitely merits discussion with my new employer.

Looking at the workflow with a critical eye, there were other inefficiencies. Staff had to transcribe lab data to the chart that might have been interfaced with an EHR. Patient education topics had to be searched manually rather than linked from diagnoses. These inefficiencies were virtually unnoticed, though.

Having done more than one stint as a science fair judge, I can’t say this was a valid experiment of any kind. Comparing this practice (regardless of whether it uses paper or EHR) to any other place I’ve practiced in the last several years would be like comparing apples to unicorns.

One major difference is the ability to focus on the patient’s presenting problem rather than extraneous but required information. Another is the encouragement to rely on support staff for tasks like order entry and diagnosis code lookup. It’s been so long since I was just able to articulate a diagnosis without codifying it that I didn’t know what to do with myself.

Whether it was due to the workflow process, the patient acuity mix, or other factors, I noticed one thing. Even after 12 hours of non-stop work, I felt like I had spent more of my day being an actual physician than in doing other tasks. We’ll have to see if I still feel this way in six months, but right now I’m cautiously optimistic. I’m still going to lobby for e-prescribing, though.

Have a story about going back to the basics? Email me.

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