Curbside Consult with Dr. Jayne 3/9/15

I mentioned last week that I’ve been gearing up to start a new urgent care position. Unless you have been on the provider side of things, it may be difficult to understand all the moving pieces that go with a physician starting a new job.

It’s not just about adding them to the EHR and making sure they have logins. There are countless steps before you can even consider that. In addition to passing the normal steps in the hiring process (interview, reference checks, background check, drug test, pre-employment physical, etc.) there are applications for medical liability insurance and credentialing applications for all the different insurance payers. We also have to update our licenses and DEA registrations, not to mention state narcotics board certificates, hospital privileges, and more.

Since I’ve done a fair amount of locum tenens work, I was lucky to have all the required documentation already organized and scanned. The practice’s onboarding coordinator was excited about that, as was the medical liability carrier. Rumor has it that my onboarding process was one of the most streamlined they’ve had. I suppose that’s the benefit of having been on the employer side – I’ve seen what happens when a new physician stalls in filling out the paperwork and I didn’t want to be “that doctor.” It can literally take months to get everything ready to go if there’s a lot of back and forth with the documentation.

Based on the initial progress, they were convinced things would come together quickly and scheduled me for some shifts. They use staff management software that not only proactively asks me for my schedule requests, but also makes sure recipients acknowledge their receipt of the final schedules.

I started my EHR training last week while waiting for the above dominoes to fall into place. The online training was engaging, but I didn’t get very far due to the length of the modules and competing priorities on my schedule. Luckily I had completed the EHR overview, so I crossed my fingers and headed to my first day of work.

With as long as EHRs have been around, practices expect new physicians to be able to hit the ground running. Even if physicians haven’t had an EHR in the office, most of us have used electronic records in the hospital to at least some degree. Even if we’re not writing our notes on a computer, we may be doing CPOE or reviewing nursing documentation.

The practice arranged for one of their in-house trainers to stay with me during my shift. I was fortunate that she is not only a trainer, but also one of the most skilled medical assistants in the practice. She was able to teach me about office workflow and how the staff handles various situations in addition to making sure I wasn’t missing key EHR documentation.

I was honest and told her that I hadn’t completed all the training. Apparently getting through any at all was a big plus compared to other physicians she had trained. She said that most physicians don’t bother to do the self-directed learning until they work their first shift and realize they’re unprepared.

I guess that’s one way to figure out whether an EHR is truly intuitive or not, but I’m glad I didn’t take any chances. The EHR wasn’t as smooth as it had looked during the training, which was no surprise because trainers by design are skilled at making things look easy.

Most systems perform differently in the heat of battle than they do in the rarified air of the training room. This wasn’t the first time I’ve been trained on the job in an ER or urgent care – most of the time when you are a fill-in physician, that’s how things happen. Physicians who are paid hourly aren’t willing to donate their time for training and employers aren’t likely to want to pay for training time.

This system wasn’t any different from others I had used in that the first four or five patient notes were acutely painful as I tried to develop muscle memory and a feel for the different variations in the layout for the different patient complaints. Although there was another physician in the office, he was there only to back me up if I got too far behind. The organization prides itself on short wait times and immediate care and he was there to maintain standards while I got my feet wet.

By the end of the shift, I was feeling pretty good, but I’m nowhere close to the productivity I know I’ll have after two or three days in the office. Since I’ve spent the last year documenting most of my work using a paper-based template system, I was happy to be back in the EHR world. I’ll take some extra clicking any day in exchange for allergy and interaction checking, medication refill history, and clinical decision support. The e-prescribing system acted a little quirky, but I’m guessing it’s due to the fact that I’m enrolled on multiple vendor systems. Hopefully a couple of phone calls will sort that out.

At the busiest part of the day, I had 8-10 incomplete charts with a full count of patients in the exam rooms. Things slowly got easier, but I still had a pile of half-finished charts when we accepted our last patient for the night. While she received some IV medication, I was able to complete the rest of my documentation so that I could walk out the door right behind the patient. That’s always a good feeling and I know the staff appreciated the effort so they could get home as well.

Although the practice allows me to complete my charts from home, I’ve never liked that approach. I had to do that during my first EHR implementation and it was too easy to forget patient details and miss documentation. Processing refill requests and reviewing lab results is one thing, but trying to do visit note hours after the fact has never worked for me. I’m taking the immersion approach and working three shifts this week, so hopefully by the weekend I’ll be where I need to be to feel like I’m pulling my weight. It’s a heck of a way to spend a week of vacation, that’s for sure.

How long does it take your new physicians to get up to speed? Email me.

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