10 Reasons Doctros Are Pulling Their Hair Out

In the 2013-2014 era, doctors and providers are being asked to adapt to massive changes in their practices, businesses, and their modus operandi.  The stress from all these changes will be felt in the doctor-patient relationship.

Why are doctors unhappy?

1. Conversion of ICD-9 to ICD-10.  Nobody is sure of its value, but are painfully aware of the costs.  Having a code for a crash landing in a space craft would be relevant only for Sandra Bullock in Gravity!
2. Confusion created by the Affordable Care Act roll-out.  Not sure who's on first?  Who's covered? What's the fee schedule?  What are the new, complex rules?
3. High deductible insurance plans making payments at time of service mandatory.  Creating a new class of de-facto self-pay patients who formally were covered.
4. Acute or chronic reimbursement issues as? Fee for service will be replaced by outcome measurements.  What outcome measurements?  Who's measuring?
5. No relief from malpractice liability in most states.
6. Dealing with the Electronic Health record.  Did I purchase the right one?  The continuous moving target of getting meaningful use money. The accompaniment of possible claw backs if the data is not filled out correctly.
7. Hiring more help (scribes, medical assistants, Nurse Practitioners, and Physician Assistants) to see potentially less patients.
8. Hiring more consultants to see potentially less patients.
9. Becoming the most expensive data technician in the room.
10. Fill in the blank __________________ yourself.

 

Practicing medicine is rapidly changing and providers will have to adjust to the new realities.  At what cost to the provider and patient will be determined in the future.

Decrease the # of Clicks and Improve Navigation

At the present time, the number of clicks necessary to fill out a chart is endlessly time consuming and non-productive.  The cost per click is now being calculated (see my prior blog) and quantified.  The work flow is slowed down and there is a real-not imagined- price to pay.

 

One solution is to create an auto-flow sequence that is tunable by site or provider and that comfortably guides the clinician from one area of the chart to another in a logical-customary- sequence.  If an out of sequence entry is desired, this should be easily accomplished.  A system with automatic guidance will eliminate the need to figure out where should one go next, especially if one is interrupted.  When it is acknowledged that one area is complete, it then moves to the next area when documentation is continued or resumed.  Once the area is completed, the list shrinks.  Your favorite click might be auto-sequenced.

 

An example sequence could be...

• Vital signs
• Triage sheet
• Past medical history
• Nursing notes
• History and PE in logical order
• Medical decision making
• CPOE
• Lab and x-ray results
• Clinical course
• Final diagnosis
• Disposition
• e-Prescribing
• Patient education
• Follow-up
• Review nursing notes
• Sign the chart

Navigation would be significantly simplified.  The provider can always go to any area directly and in any order.  Nursing notes might be reviewed, if easily accessible.  Training would be simplified and hopefully stress-reduced.

Liability and the Electronic Health Record

The electronic health record (EHR) should lead to patient safety and help minimize liability, but there are built in-traps that come with it. These traps can be subtle and can lead to quality reviews and potential liability for the provider.

Potential Traps:

1.      Timestamps—all over the place. These can be recorded but may not necessarily reflect true clinical activities. Not paying attention to document when things really happened.

a.      EKG was signed off 1 hour after the patient was already in the cath lab

b.      Clinical course out of sequence with CPOE and nursing notes

c.       When a consultant was called  and their advice

2.      “cut and paste”---“cut and paste”  Copying and pasting information can be as harmful as it is helpful. Information can easily be repeated or copied into the wrong section.

3.      “Cookie-cutter” charts that are  loaded with data that may or 

      may not have occurred.

4.      Inability to easily access nursing notes- and the converse. The world famous “DR aware” note.

5.      Not knowing the status of treatments orders, even though the computer says they are signed off.

6.      Clerical errors on the CPOE.

7.      Not creating a work-flow that emphasizes timed data points that affects LOS/time to provider/time to decisions. If the providers are not “clicking” the tracking board, the     data suggests inefficiencies. Hospital management only looks at the data and rarely any excuses.

8.      Timelines are much easier for the plaintiff's attorney to create, which may look jumbled even though the reality was different.

9.      Not checking the output on key areas to make sure it reflects what was supposed to be communicated.

10.  Receiving a transfer patient with “40” pages of computerized documentation and missing the key.

Dictation Software - The Best Way to Avoid Traps:

In the clinical course, use dictation software or voice-activated technology to create a recap of all the events. I prefer to use Dragon Medical dictation software. A quick summary will indicate the battle plan, the response, and the disposition.

Paper, dictated, and electronic charts are all good for the initial evaluation and the disposition, but the clinical course is usually murky and left up to the imagination.