As we are preparing to launch the Serenity Medical Records system, I would like to talk to you this week about workflow. Workflow tends to be a word that you read and hear about in the discussion of EMR’s. What is workflow exactly? How can we improve workflow? How can we take the answers to these questions and apply them to an EMR system?
The way I look at it, there is only one way to “improve” workflow. Make it so that I have to do less work. Seems simple enough, right? But the details of how to do this often elude us all. I see two main ways that I can improve workflow in my office. And yes, these same two things apply to an EMR system as well. Either someone has to do my work for me, or I need less work. I’m going to talk about the first of these today and then the “less work” idea next week, especially as it applies to EMRs.
How can I get someone else to do my work for me? When it comes to seeing patients, there are several things that I do. My typical workflow is:
Now obviously several of these things should be done only by me. But many things can and should be done by the nurse. Let’s talk about all of these in order:
Reviewing the old chart. Ideally the nurse should gather information and have it in a centrally identifiable area. I should be able to see what their chronic problems, allergies, and med lists are. Additionally, what were they here last time for and what has happened since the last visit? Any labs, consultations, or other results that need to be reviewed? Have your nurse compile all these items and have it in one place so you can ‘review’ the chart in just a few seconds.
Obtaining history. Now I know we all do our own history. Even if my nurse does some history, I still will ask the questions myself. But a good nurse (and system) will obtain the basics of the history. For acute problems, have them find out (and document!) the HPI items like location, quality, duration, timing, etc. For chronic problems, have them identify all the chronic problems that will be discussed, as well as what medications they are on. Also document the coding information: any side effects? disease progression? Exacerbation? How severe? These questions will not only help your documentation but also determine the level of service.
Updating past medical/family/social history. We should usually review this information (depending on the patient). However, we need a nurse to do it first. Find out if it is up to date. If so, indicate it. If not, then get it up to date and note any changes. Of course we can ask questions about this, but it is much more efficient if the nurse “pre-gathers” the information for us to sift through it as we will.
Physical Exam. We always do the entire physical exam, right? Well, not really. Who does vitals? The nurse. And that is part of the Constitutional Exam. Also, they can fill in some of the exam themselves (well-appearing, well-nourished, hypertensive or tachycardic or tachypneic if appropriate, normal gait, etc.). Then we finish it.
Ordering tests or procedures. Have a system in place to determine who needs what to be done, both in your office and as outside orders. Anything that should be done in-house before the physician enters the room should be done right after check-in. And have the nurse document the results if appropriate.
Writing prescriptions. Depending on the patient, there are many times the nurse can write prescriptions. Follow-up of chronic problems that are stable should probably have refills ready for their drugs. If the strep is positive, go ahead and write a script. Clip these to the chart/superbill. At worst, you can throw them away but very likely it will save you a lot of time.
Documentation. Review the last 6 paragraphs. If it is done correctly, the nurse should have documented your chief complaint, History of Present Illness, Past Medical History, Social History, Family History, part of physical exam, chronic problems, and medication list. You just have to fill in the rest.
I’ll talk to you more next week about other ways to improve our workflow.
For those of you that missed it last week, I’ve attached a video showing a general overview of our system. Or you can also watch it here. For best results, be sure to click the button to watch it in HD mode and full-screen.