Curbside Consult with Dr. Jayne 9/9/24
As I work on optimization projects with different care delivery organizations, I’m shocked by how much waste I see within the system. Many large health systems spent a significant amount of time and money over the last two decades investigating in process improvement initiatives. However, it seems like once focus is lost, waste creeps back into the system and becomes an impediment to efficient patient care.
End users such as physicians and nurses are often experiencing some degree of burnout and may not want to spend the effort pushing back against processes that they know aren’t serving patient care. Others may experience learned helplessness, where repeated stressors cause them to feel that they have no ability to change the situation, so they don’t even try.
Some of the inefficiencies I see are caused by people over-interpreting regulations. For example, two-factor authentication for electronic controlled substances is required. However, it is not required for electronic prescriptions for drugs that are not controlled substances. Organizations that don’t understand the ability of EHRs to have different settings for different types of medications may require two-factor authentication or a password input for all medication, resulting in millions of wasted clicks each year and countless hours of frustration among clinicians.
Other inefficiencies are caused by outdated attitudes towards patient management. In past decades, some institutions taught policies that hinted at the idea that patients can’t be trusted. For example, if a patient was due to have a follow-up visit in 90 days, one shouldn’t write them a prescription with more than 90 days’ worth of refills because then the patient would be forced to come for an appointment or at least to call the office. In contrast, practice management journals have advocating for years that this approach isn’t supported in the medical literature and just creates additional risk of patients running out of their medications as well as extra work for ambulatory practices as they field refill requests.
Practice management journals have also advocated having patients schedule their follow-up appointments before they leave the office, yet many do not. My own primary care practice refused to schedule my annual appointment before I left last year, citing the fact that physician schedules weren’t open yet. They said that normally they have patients fill out a postcard that they mail when the schedules open, but that they were out of postcards and would fill one out on my behalf when they were restocked and schedules were open.
It’s been a full three months, and I have zero confidence that this multi-step process is happening in the office. Given the lag time on getting an appointment in this particular practice, I should probably call this week to set myself up for nine months from now. Of course they don’t have online scheduling open either, so it’s lots of wasted effort when you add up how many patients are impacted by this lack of process.
I also see physicians who continue to retake blood pressures on every patient, regardless of whether values are in or out of range. I would propose that if you don’t trust the blood pressure readings that your staff members are doing, you have two options. One, you could teach them to take readings exactly the way you want them to so they can perform proficiently moving forward. Or, you could have them stop altogether, freeing up their time to do other support tasks. But continuing to repeat on every single patient is just wasteful. I also see the documentation of irrelevant vital signs just for the sake of documenting vital signs. Temperature is generally irrelevant for well visits and most chronic disease follow-up visits, so why does everyone end up with a thermometer under their tongue?
On the positive side, many organizations have taken the advice of their EHR vendor to filter the number of “thank you” messages that make it to physician EHR inboxes. Although this can decrease inbox burden, some of my colleagues report that they miss those expressions of gratitude and that it feels like their inbox is now only full of demand messages. Some ambulatory organizations are focusing on routing messages to ancillary staff, such as medical assistants, before escalating to nurses and to physicians only if needed. I’m seeing a few places adopt delegated refill policies, although there is still much more hand-wringing about these types of protocols than there ought to be.
I’m also seeing more organizations configure EHR message routing so that ambulatory physicians aren’t inundated with inpatient test and diagnostic results. Some are also stopping the practice of automatically copying the primary care physician on tests that are ordered by other ambulatory physicians. This is a plus in two ways – not only does it cut down on inbox volume, but it also prevents confusion as to who is responsible for managing the test results. This creates extra work for consulting physicians, though, who may need to send a specific communication back to the primary care physician to let them know what is going on with the patient. This shouldn’t be too much of a shock to them as they theoretically should be sending a consultation letter already, especially if the primary care physician referred the patient for evaluation.
The most widespread optimization efforts that I’m seeing are in the implementation of ambient documentation solutions. Adoption was slow at first, but is really taking off. At some point, it’s going to become a requirement for facilities that want to attract top physicians. If I was a graduating resident at an institution that had implemented it and I was used to using it every day, you can bet that it would be a must-have criterion for a future workplace. Organizations that aren’t ready to go all-in on the technology should consider other bridge solutions, such as virtual scribes, or at a minimum, human scribes.
In other technology news, I was able to catch a glimpse of NASA’s Advanced Composite Solar Sail System, also known as ACS3, flying through the sky at an altitude of 600 miles on Sunday night. Temperatures have dropped into the 50s overnight here, so it was a perfect excuse to pull out the fire pit, pour an adult beverage, and chill out in a lawn chair as I prepare for the coming week. I’ll have another prime viewing opportunity Monday night, so here’s to crossing my fingers and hoping for a crisp and cloudless night. If you’re interested in trying to spot it yourself, more information can be found here.
What activities help you recharge and get ready for the busy work week? Leave a comment or email me.
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