Achieving Efficiencies in Computerization

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Achieving Efficiencies in Computerization

• Secrets for the Clinician
• Karim Keshavjee, MD, CCFP
• University of Toronto
• Leadership for Change in Primary Care
• April 5, 2005

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Learning Goals

• Participants will learn
• the top three drivers of efficiency in
  computerizing a practice and how to achieve them.
  
• Information presented will be based on
• A systematic review of the literature
• Site visits to computerized practices across
  North America
• Experiences reported at conferences
• The experiences of 33 physicians who participated
  in the landmark COMPETE study in Hamilton,
  Ontario.

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Drivers of Efficiency in Practice

• Unfortunately, most efficiencies from
  computerization are achieved at the
  administrative level
• Fewer charts pulled and refiled,
• Faster billing,
• Less time spent in keeping track of patient
  appointments
• How do we gain efficiencies in the clinical
  practice?

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Focus on the common

• Efficiencies are easiest gained in activities
  which recur or which require a lot of time
• Most time is spent in patient encounters
• 400 min/day, 11 minutes/patient
• 100 min to chart/day
• Many encounters occur frequently allowing
  efficiency gains
• 20 diagnoses in top 80
• Many encounters dont recur enough for us to gain
  tremendous efficiencies
• 80 diagnoses in the last 20

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Top 3 drivers of clinical efficiency

• Where, when and how you chart
• The art of chartmanship
• Optimizing processes for commonly seen problems
• Utilizing information and existing systems to
  gain efficiency

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The Art of Chartmanship

• Always chart in the presence of the patient
• Charting is faster when you chart during the
  encounter you dont have to rack your brain
  later for details of each patient
• If you want to leave when the last patient
  leaves, complete the chart after each patient
  leaves

Chart in the presence of the patient
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The Art of Chartmanship

• Charting and documenting in family practice takes
  many forms and structures
• Examples SOAP format and the CPP
• Other examples include
• flow charts (Rourke Well-baby),
• structured (antenatal forms)
• coded (lab requisitions)
• narrative (counselling notes)
• forms (scripts, referrals)
• Decide before-hand how you will chart particular
  encounters

Develop strategies for each type of charting task
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The Art of Chartmanship

• Most EMRs allow you to enter information in
  different ways
• The key to achieving speed and efficiency in
  charting is to find the best strategies for
  entering different types of encounters
• Each EMR has its own preferred method of
  capturing information
• Point-and-click, typing, flow charts, forms,
  trees
• Learn the one for your system and use it to your
  advantage

Learn keyboarding skills payoff in EMRs is great
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The Art of Chartmanship

• Start out by entering one or two simple types of
  encounters (annual physicals and hypertension)
• progress to more complex types of encounters
  (psychosocial and internal medicine type
  problems)
• Develop templates most physicians find 10 is
  just right
• Biggest obstacle Charting multiple complaints
• Find out the best way to structure multiple
  complaints in your EMR compare notes with other
  users

Review progress monthly, solve remaining charting
problems
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Optimizing Processes

• Do you know what the top ten diagnoses are in
  your practice?
• Typical Top 10 Diagnoses
• Hypertension
• Upper Respiratory Infection
• Anxiety
• Annual Health Exam
• Diabetes Mellitus
• Osteoarthritis
• Lumbar Sprain
• Dyspepsia
• Well-baby care
• Leg cramps

Common visits can be optimized for faster
charting
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Optimizing Processes
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Optimizing Processes

• Sit down with staff and plan out how to make
  common visits more efficient
• Make out large index cards with things required
  for each type of visits
• E.g., handouts and requisitions for annual
  physicals, doppler for prenatals, urine dips for
  female abdo pain
• Ask staff to make sure those things are
  done/available when patient is placed in exam
  room
• Plan what information needs to be captured for
  each type of visit
• Make up templates or plan out how that particular
  visit will be charted
• Pre-fill information into the template to
  decrease entry
• Copying a previous visits chart can make
  charting go faster

Plan for efficiencies during visits
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Optimizing Processes

• Consider booking certain types of visits on
  particular half-days
• E.g., Physical exams on Tue mornings
• Allows you to have everything prepared and
  optimized for patient visits quicker and better
  care

Cluster common types of visits to enhance
efficiency
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Why Optimize Processes?

• Experience and research in many industries has
  shown IT only increases productivity when we
  modify our processes
• Difficult to do on a large scale in family
  practice, as the scope of practice is very large
• Use of information technology may help

Fine tune current processes to achieve higher
efficiency
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Using Information
Ive ordered more sophisticated diagnostic
software
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Using Information

• Conducting simple queries for fun and profit
• Easy to do
• can provide high payback
• Faster visits, better care

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Simple Queries

• Patients over 65
• Flu shots
• Female patients between 50-69
• Mammography
• Patients with particular diseases
• Asthma 493
• Diabetes 250
• Birthday letters
• Mailing list of all patients whose birthday falls
  in a particular month 12 mailing lists
• Send letters each month for annual physicals

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Simple Queries

• Generate phone lists
• Call patients up if the disease list is short
• Generate mail merge lists
• Send a letter if the list is long or if there is
  a recurrent reason (e.g., annual physicals,
  mammograms, pap smears, immunizations)
• Keep lists for patients with different diseases
• Quickly send off a letter when needed
• Question who will do all this?
• As you computerize and optimize, your staff will
  be doing a bit less work (no more chart pulls,
  less filing)
• Train them to do more of this proactive kind of
  work

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Conclusion

• Using technology to achieve efficiencies requires
  care and thought
• Optimizing charting can lead to faster ramp up,
  but not likely time savings
• Using information could lead to improvements in
  efficiency and time savings (still to be proven)