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Curbside Consult with Dr. Jayne 4/22/19

I’ve been working with a large provider group and recently spent some time with them in a retreat format. Although the group bills itself as a topnotch organization from a clinical quality perspective, there is a great deal of physician dissatisfaction. The EHR is a major target of complaints, so I was brought in to do some workflow mapping and to help facilitate the sections of the retreat where workflow topics were discussed.

It no longer surprises me, but I’m still baffled by physicians who refuse to delegate or to use their support teams to actually support them. My workflow mapping revealed the usual operational failures: 

These are all paper problems that I suspect existed before the EHR, yet providers insist that the EHR is the reason they are working on charts at home. One physician I shadowed has his schedule blocked for 15-minute appointments, yet he consistently spends 20 to 25 minutes seeing each patient. He has a highly capable scribe and they work well together. However, he is always behind. Just doing the math, there is no way he is ever going to be able to get out of the office on time (nor will his staff) and he’s always going to have to do some work after hours. It wouldn’t matter what system he has. Until he can either figure out a way to see patients faster or is willing to adjust his schedule to match his actual cycle times, he’s always going to feel like he is under the gun.

(I suggested reducing the sports-related small talk that he engages in with every patient whether they seem interested or not, but that was met with a frosty stare from the physician, although the scribe seemed grateful for the suggestion.)

Physicians were frustrated by “missing results in the EHR” but failed to realize that it wasn’t that the results were misfiled, it was that the patient never had the tests performed. This is an issue that can be caught prior to the visit, either through pre-visit planning or an orders management process. Most of this frustration occurred when physicians were processing medication refills, which I would argue they shouldn’t be processing in the first place. They would be looking for cholesterol or diabetes labs so they could decide on whether to grant a refill or not, and were unwilling to task staff to do the hunting for them.

One physician is handling refills on his patients constantly since he won’t give them more than 90 days’ worth of refills at a time. That might be a necessary strategy for a patient whose conditions are not well controlled or who has issues with follow up, but the majority of patients can receive refills for a year without risk.

I discussed the number of organizations that successfully use refill protocols and the tools available to assist with ensuring patients are at goal before granting refills, but they felt that allowing anyone to approve refills other than the physicians themselves was “negligent.” We arrived at this conclusion halfway through the first day of the retreat, and it was all I could do to keep a straight face while I tried to figure out how I was going to get through another 12 hours with people that are not living in the real world.

We did identify a number of true EHR issues, mostly around lack of use of shortcut techniques and provider-level configurations. More than 50% of the providers I had shadowed didn’t even have favorites lists in their prescribing profiles, so they were manually searching for every single medication rather than selecting from a short list of medications that they commonly prescribe. Although providers agreed it would be beneficial to have such a favorites list, most of them said they were unwilling to create them on the fly, but instead wanted someone to build them for them either after a chart audit or through shadowing. We discussed how that could be a self-defeating strategy, because as they begin prescribing new agents or if their prescribing habits change, they wouldn’t be able to add those drugs without spending the time to explain them to a staff member or spending the time to log a help desk ticket.

We also found some issues with their CPOE system, including some confusing test names, and they were willing to come to a consensus to streamline that feature.

There were a number of issues on which we never reached resolution, but I did get to sit in on some of the sessions on non-operational topics so I could get a better feel for the culture of the group. There was an extensive review of their clinical quality metrics. Providers had previously received their reports only twice a year, but with the addition of the EHR, they began to receive them quarterly. At a previous retreat, they had asked for monthly reporting and were quite happy with it. However, it didn’t seem like anyone was willing to admit that it was only because of the “soul-sucking” EHR that they could ever have that level of transparency into their practice without spending a considerable amount of money on chart audits.

I also sat in on a financial workshop where expenses and provider compensation were reviewed. The providers weren’t terribly receptive to the CFO’s explanation that they had higher-than-market physician salaries with lower-than-average staffing costs as a possible explanation for why the physicians felt they were overworked. Unless they’re willing to shift work to team members, they’re going to be doing it at home in the evening or at times they’d otherwise prefer not to be working.

As an outside observer, it felt like the physicians were happier to spend the afternoon complaining about it rather than rolling up their sleeves and trying to find solutions since none of them were willing to take a lower salary for any reason. Although I do feel like we made some progress on a subset of quick-fix issues, I’m not sure this group is going to find its happy place anytime soon. I’m glad my role with them is limited and the engagement a short one although it was fun to be in the field after a long stretch at home.

Do you have persistent “paper problems” at your organization? Are providers willing to help address them? Leave a comment or email me.

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