More often than not I find it helpful instead to reframe the idea into an analogy. I hope this is one of those times.
The idea I, and I think one which others are struggling, is where should physicians—hospitals, clinics, and practices—be looking to see benefits from their EHR, and I think part of the answer is that we may be looking in the wrong place.
Now, if your practice is running like a well-oiled business, this piece will not add another arrow to your quiver. But, if your practice is like many I’ve seen, there may be an ah-ha moment forthcoming. Most practices, rightly or wrongly, have been told to look for EHR benefits in the exam room. While I think those benefits exist, if the rest of the practice—everything that happens between you and your staff, and your staff and your patients—resembles the chaos of an elementary school cafeteria giving away free ice cream, the clinical benefits may be hidden beneath the detritus of discarded creamsicle wrappers.
What if we look at the issue this way? I was asked to paint the metal security door which leads from our laundry room to the garage. The dogs had taken it down to bare metal. In my small mind this should have been a thirty minute task. Not so fast Sparky.
I went to the basement where twenty separate buckets of leftover paint are stored. Found the white paint, grabbed my brush, gave the can a quick shake, and was ready to knock this out before my wife returned home. In walked my supervisor—I was exactly 29 minutes too late.
“Don’t you need to wash the door before you paint it? It is all rough where the dogs scratched it. If you don’t sand it, we will still see the scratches. You can’t use that paint; that is for wood and it won’t stick as well. I printed these instructions from Google,” she said as she handed them to me—I was too busy watching my weekend disappear before my eyes. “It says for painting metal you have to prime use a primer.”
My perspective on doing projects, for what it is worth, you can either tell me to do something, or you can tell me how to do it, but you cannot do both. As I drove clear across town to the paint store I realized she’s never allowed herself to be distracted by my perspective.
Two hours after I had started the project the door was sanded and washed. An hour later the primer had dried enough that I could apply the final coat of paint.
“What are all those white drops on the wood floor?” We both knew she was being rhetorical, but waxing on about rhetoric was not the point of here question. “The directions say you should be using a drop-cloth, and should clean up the paint spatters with a clean cloth and soapy water.” Now why didn’t I think of that? The truth is, I did, but each of those steps looked like they would only lengthen the task.
Five hours after beginning the quest for her holy grail, the door was painted, the splatters were no more, the brushes were cleaned, and the paint cans were stored neatly in the basement. What I realized is that between starting the painting and completing the painting, many other tasks had to be completed that involved much more of my time than the actual process of painting the door.
During the five hours I spent on the project, only 30 minutes of my time was spent applying the finish coat—10 percent of the total time.
It makes the process appear a lot shorter if all one does is focus on one piece of it. The whole issue of an EHR’s impact on your charting processes looks a lot shorter if one’s only focus is what happens to the chart from the time the physician pulls it from the holder on the back of the door to the time it is replaced. In some practices more than a dozen people may be involved in getting it to the door and returning it to the file room. What happens to the chart in the exam room is only a very small fraction of the cost of using paper charts.
It is less expensive to toss $100 bills out of the car than to fund paper charts.
At the end of this piece is a list of some of the chart handling processes I have seen at some of my clients. In some places, there are many more processes than just the ones listed. The average handle time (AHT) for a chart begins the moment a chart is requested, and it does not end until the chart is returned to its proper place on the shelf. Any steps that can be taken to eliminate some or all of these processes, and the cost of the people who perform them, will contribute to the ROI of an EHR implementation. In many cases, eliminating the majority of these steps will constitute the bulk of the EHR’s ROI.
From the perspective of the business, any time you can get rid of a process whose only contribution to the P&L is a cost, do so. Having someone carry a chart, insert papers into it, or file it does nothing to improve care, and it does not contribute a dollar to revenue. Eliminating these processes will make the business function better. It will enable the business to handle growth. None of what you’ve just read has anything to do with meeting Meaningful Use or having a certified system.
In the interest of full disclosure, I actually painted the door while my wife was out of town. It took me thirty minutes, just like it should have—don’t tell her.
Here the list of the manual charting processes that increase AHT, and add no measurable value to your business. They are workarounds, and should be eliminated. A similar argument can be made for dealing with in-bound phone calls, but we’ll save that for the next time I have to paint something.
- Old charts are ordered from archives
- Loose sheets received daily at chart room from offices
- Loose sheets are received from labs
- Loose sheets are sorted by doctor and then either alphabetically or by date
- Loose sheets distributed to clerk serving the particular doctor
- Clerk pulls charts that have loose sheets to be filed
- Clerk inserts chart out card as a place holder
- Loose sheets will be filed to charts stored in chart room
- Clerk hole punches loose sheets
- Clerk returns chart to shelf and removes “out card”
- Clerk crosses out his/her name
- Charts arrive from archives storage to the chart room
- Charts are sent to offices by courier
- Charts are returned from offices to chart room by courier
- Charts sent between offices by courier
- Charts returned to archive by courier
- Patient schedule is generated
- New schedule compared to schedule generated yesterday to determine add-ons
- Clerks determine which patients have no charts at chart room
- Clerks determine which missing charts are at archive
- chart room makes temp chart for add-ons; patients who were added to schedule after cut-off
- Schedules needed are distributed to clerks that serve specific doctors
- Charts on the schedule are pulled from chart room shelves by clerks
- Clerk writes their name and date on out card indicating they have the chart
- Out card is inserted as a placeholder
- If chart is not found, clerk checks out-card to determine who last had the chart
- Clerk tries to locate the chart
- If chart is located, a request is made to send it to the correct office
- If chart is not located, clerk creates a temp chart
- Clerk adds note to temp chart explaining why she created a temp chart
- Clerks match loose sheets against charts, punch and insert them
- Additional forms may be added by clerk to chart
- That chart is inserted into the box to be sent to the doctor
- Boxes of charts returned from offices are distributed to clerks to be re-filed
- These charts are returned to shelves, out card is removed
- Clerk crosses off his/her name
- chart room receives fax requests for charts
- Those requests are delivered to the assigned clerk
- Clerk repeats the chart hunt and pull process
Paul M. Roemer
Managing Partner, Healthcare IT Strategy
1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
Contact me: paulroemer paulroemer paulroemer