Curbside Consult with Dr. Jayne 6/24/24

I’ve spent the last couple of months mentoring a medical student who wants to include clinical informatics in their future practice. She’s doing an elective where she spends time with various physicians who hold informatics roles. She asked me to review a paper that she wrote about her experiences.

As part of the rotation, she worked with an optimization team that works with medical practices that are being acquired by the health system that is affiliated with the medical school. Her paper was about those experiences and how clinical informatics principles might be applied to scenarios that she witnessed during site visits.

First, I was impressed at her level of thoroughness. Despite not having a lot of formal experience in process improvement, she was able to document and categorize workflows and make suggestions about how they might be modified before the practice joins the larger system. She correctly identified that there will be a fairly steep learning curve, not just due to the EHR transition, but also due to operational processes that are outside what we would consider best practices. Some of the items she witnessed can make a big difference in a practice’s success.

Although I was surprised by some elements, others fell into the “no surprises here” category.

One of the first things she called attention to in her write-up were regulatory citations that were made by staff that didn’t actually align with the regulations in questions. These included telling patients they couldn’t give family members access to their records “due to HIPAA” even when patients were making HIPAA-compliant requests for information sharing. The office was also engaged in information blocking, telling patients they couldn’t see their own records. That will need to change, because I’m sure the health system doesn’t want the liability of someone creating a situation that results in a fine due to noncompliance.

Misinterpretation of the rules happens often, and the student listed the health system’s standardized annual training as a potential strategy for mitigation. I recommended that she also confirm that the optimization team planned to circle back after that training to make sure that any regulatory myths were fully debunked during the course of the training.

Another thing she noticed was physicians and other clinicians using EHR note templates, but not editing them to match the patients, such as including a bilateral lower extremity exam on a patient who had undergone a lower limb amputation. The clinicians claimed that they didn’t know how to modify the template, but the student was able to give some on-the-spot training.

She was shocked to see some physicians signing their notes without even reading them, and I hated to tell her that in some organizations, that is the rule rather than the exception. She was even more shocked to hear about the notes that I’ve seen where people add phrases like “Dictated but not read, signed to expedite communication,” which we both agreed is absurd as well as being a medicolegal risk.

She noticed that the practice was taking complete vital signs on all patients regardless of the reason for visit, and provided a nice discussion of why that might not be necessary. It turns out that the EHR was configured so that all vital sign fields were required, which is undoubtedly a huge time-waster for the practice as well as an inconvenience to patients. Examples provided included a patient having full vital signs documented for a suture removal, when really all that was needed was documentation of the procedure that was performed and the status of the wound in question. Knowing the EHR they will be converting to soon and how it is configured, this is a problem that will be easier to remedy once they’ve made their transition.

I chuckled as I read the portion of her report that dealt with prescribing habits. The physicians in the practice who complained the most about refill request volumes were, unsurprisingly, the ones who refused to follow processes that have been best practices for more than two decades, such as writing a patient’s prescriptions to cover the maximum duration allowable by law. For a compliant patient who is stable on medications, there is no reason not to write their prescriptions for 12 months if it’s legal. Not only do shorter refill periods require more work on the part of office staff as they process requests,they are also a risk to patients who might not take their medications as directed if there are delays in the refill process. She actually overheard one of the physicians tell a patient to “just call the office when you need a refill” despite the practice’s policy that refills should be requested through the pharmacy since the office receives electronic refill requests.

She had a question for me about how her paper should address the issue of physicians who are unproductive in the office yet blame the EHR even though they were doing a significant amount of non-work activities during office hours. She actually had observational data on how much time physicians were spending on Instagram, Snapchat, Facebook, and other social media during times that they could have been documenting patient visits, addressing lab or diagnostic results, or managing the inbox. For one physician who the team shadowed, the number of personal phone calls made during the office day was quite high. It’s hard to avoid so-called “pajama time” documenting at home when you’re not making the most of the time available to you at work. I asked her to work with the optimization team to find out how they address these issues with the organization’s physicians and staff, and to provide a similar treatment in her final paper.

We had a good discussion about what life was like in the time before smartphones and how the constant connectivity to information and communication tools has changed how many people work, both inside and outside of healthcare. During a recent trip to the airport, I watched a member of the housekeeping staff hold their phone watching videos with their left hand while mopping with their right hand. If that’s not an example of the addictive properties of certain technologies, I’m not sure what is. We had some good conversations about work-life balance and how the habits she’ll be forming in residency will influence her later actions, so I’m hoping she’ll take a mindful approach to how she is managing her own time and activities.

Due to the nature of the shadowing experience, she wasn’t able to get into much EHR optimization, but I’m glad she had the opportunity to do a little teaching about templates. In a recent conversation with some other clinical informaticists, one asked if we thought our roles were becoming obsolete. As long as there are EHR (and other solution) features that aren’t being trained to end users or that aren’t being used to their fullest, there will always be room for informaticists to help improve the daily work experience.

What are the small improvements you help your users with on a daily basis? Leave a comment or email me.

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