Home Forums Discussions Problems DEEP THOUGHHTS by Walter Handy

This has been facinating. I don't remember a post that has gained so many and so lengthy responses in a 48 hour period.

I read it yesterday, thought about what I might add and came back and there is a whole lot more. I am another who does not leave the room without completing the note.

Much of what I would say echo's the others here.
1) Try to get the MA's to do some of the work. Even just putting a generic template in place to modify will help. Using checklist forms can make it easy for ROS and some disease processes, then she reviews the information and does not have to enter it in the computer.

2) Seriously look at old notes and see what repetitive text can be converted into a template. Especially look at the top 10 dx. You can cut and paste the text then right click and alt button will create a new template.

Even if she modifies it more, it will cut down on typing.
Easy to make a 99214, use it more. I forgot about the 9905x codes, I will have to use those more as well.

3) She should start timing herself as to how long it takes her to do a note. Perhaps even break it down by section (of course having someone else doing the timing) to figure out where the bottleneck exists. Once you know the problem you may be able to attack the solution.

4) Hardest thing to do is realize you cannot solve all the issues in one visit. There are times with a complex patient I will put in chief complaints x 4-6 and then fill in the blank later in the day, but this is probably 1-2 times a week. the rest needs to be in the room. Sometimes you need to have them come back to tackle some of the problems. This not only generates another visit, but it will make the patient understand that you will only deal with so much at one visit. With the especially long winded multi problem patients, they will begin to see that they cannot keep dumping multiple problems when they have to come back.

5) Learning how to type, talk and look at the patient will help a lot. Perhaps changing the angle of the computer screen or the layout of the room will make it more condusive to achieving this.

That's my 2 cents worth. Some are other's pennies as well, but bear repeating.

More sleep makes your brain work better. I like sleep.

Wendell, I again want to defend those of us who cannot walk and chew gum at the same time against the relentless onslaught of templates.

For me, trying to do the in depth part of the chart in the room is distracting; I want to be paying attention of the nuances of what the patient is saying, ask questions at just the right moment, etc. I would never, never trust a third party to do what I consider the most critical task in internal medicine; getting a coherent chief complaint is problematic enough. I use the computer to take brief notes for the HPI. With an established patient, the PH, FH, SH are all there.. otherwise, again with brief notes. The ROS starts with a negative template, gets modified. The physical exam is left blank. Prescriptions and orders autofill as I go.

I conclude with the patient. My schedule is such that I always have 5-10 minute breaks. I put the laptop in its cradle, switch on Dragon, dictate the HPI using no template other than the introduction with the %MR %LNAME placeholders. Template the physical exam, modify it. click on the plan, dictate not only what I did, but even more importantly why I did it, what I was thinking, and where I am going. All of that takes much less than 5 minutes, most of which was gleaned by NOT spending time mumbling over the computer in the room and dealing with which of 100 templates I want to use. My full attention is on each task. The patient knows he/she is being listened to. I am done before the next patient is ready to be seen. I am out the door 5 minutes after the last patient of the day.

Clearly, templates are a godsend for many. But, not all. All 4 of us in this office have adapted to doing pretty much as I described. All of us go home on time. Our notes make it clear that care was given by a physician, not a MA with a keyboard. I only need to log in from home on weekends to check labs and UpDox.

Square pegs don't go into round holes very well. But, a properly sized square peg fits very nicely into the properly sized square hole, and the end result is just as nice.

For us its not templates, its the inablilty to finish the chart in the room. Alice just can't seem to get a patient to stop trying to ask additional questions if she tries to do it. She can get some of the note done there, but to end the visit she has to physically say "we're done" and leave. And then sometimes these NYC people still try to stay in the room because they "Have just one more question" translation: I have one more PROBLEM I want to ask you about. Then I get sent to kick them out. Everyone hates me. Bascially because I have to job of, when you need someone to tell someone else "NO", I'm the one that gets called.

Just remember, the 9905X codes are kinda new. One or two years old. It takes awhile to get the insurance companies to pay for new codes. Aetna usually pays it.

David,
I think it is a little different for us in IM. We are not generally seeing 25 -35 patients per day. A busy IM day might be 15 -18. I use to do it in a similiar manner as you do. What I found was that once I left the exam room, there were all sorts of fires to put out, ie: something that was going to take away my 5-10 minutes. To each his/her own, but I like being done with the chart when I leave the room.

Tom

I took Bert's advice and for the last three to four weeks, I have been taking the laptop in the room with me. This did take some getting used to.

Usually before I enter the room, the chief complaint and vital signs are in the chart. It's more tedious on the first visit as much of the PMH, meds etc aren't in the chart and need to be entered. I write most of my note in the room. When I'm done and the patient is getting dressed, I write any orders, Eprescribe (after asking their preferred pharmacy) and finish my note.

Since I have been doing it this way, i have not had a stack of charts on my desk in the evening. It's been great, thanks Bert.

I also have the problem where patients want to talk about other things not related to the current visit. When possible, I schedule them for follow up visits.

My big thing was I did not want to see patients and have my back to them. I'm with Wendell in that I look at the patient while I'm writing my note. Fortunately for me, I can type.

This may not work for everyone, but it works great in my office.

It is interesting to see how everyone does it differently. I do disagree though with the assumption that if you finish your note in the room, that you aren't paying attention to the patient. I glance at a VERY well done CC and HPI by my MA and then take a more thorough HPI. I then examine the patient and decide on my impression and plan. It is only when I have listened intently to the patient, examined the patient and discussed options, etc. do I turn to the computer and write out the HPI, use a template for the exam (as David does), then enter my impression and plan.

One nice thing about my MA taking the history is she knows they are here for a sinus infection. When they start talking about foot pain, she stops right there and makes an appointment for them or tells them I probably won't be able to deal with that. Now if they say their left ear hurts, I will look at that.

I don't let the patient go on and on. I just tell them it sounds like we need more time for that in order to treat it correctly.

I also like to be finished and walk the patient down the hall. It's a nice touch.

I also agree that time between patients is time I want to spend on other things or answering messages with my MA.

You're most welcome, Marty.

9905x codes also apply to visits before 8am and saturday - I start seeing patients at 7 am - break between 1pm - 2 pm for admin/lunch then finish pt visits by 4pm - another 1-2 hrs of admin stuff and I'm done. usually by 5 pm somedays 4;30! But I avg only 12 pts per day. My goal is to avg'g 15 pts daily in the same # clinical hrs.

Seems the more charts completed in the exam room, the earlier I go home - so I am making whatever changes possible to facilitate real time charting. Most patients don't mind my typing so long as I maintain appropriate eye contact and when looking down give the appropriate verbal and facial cues. They also like it when I dictate (DNS)the HPI or A/P - a chance to hear a summary and occasionally correct. I am still developing a style but find both effective. Either way, it comes down to taking time to make time - producing templates, training DNS, preparing handouts, learning to touch type (it is doable !) etc. i have also scribbled hand nots on paper during an exam and then dictated a full note next door while the patient dressed. My goal is only touch the HPI ,Plan and when indicated the PE then correct the CC. I am still trying to figure out ways to have staff do all the other stuff... maybe as hosting options for AC are deployed there will develop shared virtual backoffices - or virtual practice managers ...different post

I am slowed down mostly when searching for ICD 9 codes or when stumped and need to complete realtime review or get distracted and talk politics/sports.

i suspect that when i achieve efficiency nirvana i will remain financially in whatever the opposite of nirvana is ?? I don't know the term but we all know the feeling. For independent IM docs in Maryland, medicare generally exceeds private insurance reimbursement - hence the growth of practices that bend the revenue curve - again, different post.

I enjoyed reading the posts here - some benchmarking, new ideas and a reminder to myself of what i need to do. It is also encouraging to see so many comments to help a fellow provider in distress.

I too finish my notes in the room. I salvaged some old typewriter tables that my laptops sit on (one in each exam room). This allows me to position myself directly in front of the patient. I am not a skilled typist so I always apologize to the patient that I may not be able to maintain eye contact with them. I also talk first, then examine then type while I discuss the plans with the patient. Mine are really forgiving. I also maintain that the patients need to be a part of their record. They need to know just what we have to do to document the visit and formulate and transmit the plan. And, with the Health Maintenance module, this time spent has tripled. I anticipate once I start MU it will require even more time in the room. I go home at 4, never have any charts left. Then my real job starts! Currently in the hay.

I love you all. Splendid responses and we do need more, wrenching ideas. Different styles all work equally well but I like to see an overall framework first then break them into smaller details.
I 've been our Forum dedicated reader for past 3 years mostly to learn tech tricks, others just for fun and more med jargon to 'sometimes' holding up to my smarty girl. When I was younger I told my self to love smart peoples but now a day second thought as it might be too much, simple souls make simpler life. Don't scold me for distraction.

Like Wendell just mentioned, all lengthy or short inputs are so valuable as I really like to have one topic covers all, might be too much to read at one time, but like an unorganized collection, to find something and to relax to our friend thoughts and ideas for effective charting some PMs, it there.
I have more to ask ... How to effectively charting seniors? One friend is a geratric prof, he deals with seniors differently as he working for university, he can do whatever he wants but not our solo practitioners.

Walter,

No offense, but don't you have enough ideas to work on? Many of these take days to implement.

I can see that there is also a great difference in our practice profiles, as it were. I see very few acute problems... my PA's do that... so the "one more problem" issue does not apply... I start each visit by bringing up the problem list, each is reviewed, and then I ask "what else do we need to discuss?" My schedule is designed to deal with that. I can see it would be a horrible death if you thought you were going to see someone for sinusitis. I made up a few pretend patients to see how it would go with an acute self-limited problem, and you are right; the templates could prove lifesaving.

Marty, when we started with AC, we looked ahead to the week and pulled all the paper charts for the coming week's visits. We then did a visit note, CC "initial data entry" and put in the PH, FH, SH, problem list, vaccinations, procedure dates, etc. so it was there at the time of the visit. Important selected labs or procedure notes could be pulled for scanning. We then used a hole punch and punched the paper chart so the staff would know it did not have to be pulled at the time of the visit. It was a horrible amount of work, lots of evenings and weekends, but the day went much more smoothly. Now, 15 months later, it is only new patients who need the data entered.

Walter, what do you mean by "effectively charting seniors?"

"Ok, here's your prescription for your sore throat"

"Can I ask just one more questions?"

"What?"

"Well, I keep getting this pain in my side."

"How long have you had this pain"

"Since forever." (or, alternatively, "For some time now, Doctor."

My favorite is when they say they have had cough "for a year" and then you go back through their last five visits and there is no mention of it.

Bert, Yes, it definitely take mos to implement and to see how one is more effective than others but I like to comeback to this post and to update and let you know the progress to cheer me up. Also to give more weight to the persuasion. One friend has an idea does not mean much but 5 friends same idea.

A little demo here so you have an idea,our database count is almost 4000 after 3 years, but many of them non reg, moving from one doc to another. Extremely competitive, she is the rookie compared to others. That would bring database realistic number down to 2000. Not like smaller town setting, we have about 15 docs. We are friendly at meeting, but you know what.

I've read and most saying better to own our place of practice than keep on leasing it. Many of our local docs doing that, they own whole building not a single units, effectively good source of incomes, eventually, practice or not, full or part time don't make any different... Docs tend to be most responsible and motivation group of people ....

My doc is sensitive and very caring type so I don't think she could do what Wayne been doing so effective. That makes her time management harder.

We rarely overbooked, but some days all 15 min slots filled up and mostly seniors, seniors taking much longer and many new patients bring along 15 (dramatized a little)empty bottles to refill. Their meds were out completely and did not want to back to their long time doc...they would next month.

Dave, that what I meant 'charting seniors'. Not reg, too many problems. Some of our local docs have strict policy, if patients don't follow instructions and/or to difficult to deal with, they send out registered dismissal letters. Then they looking out for newbies. We definitely lacks in this policy enforcement but don't think we can implement that either or turn them away legally without receiving letters.

Also unfortunately our employees not that efficient, difficult now a day to get good people, solo practice could not effort a higher pay structures. I am not so sure about medical field but in IT, employees not loyal, to get a star performer you just give them more. We pay competitively but not higher than others. One local doc got a star off manager, he paid her double the rate! (he has been around long enough).

We still need to have more patients to meet all expenses and save for uncertain environment, at same time need to reduce workload so doc can survive.

So this topic not only to help to troubleshoot our own problems, charting one of them , but might bring about some effective survival guide for newer EMR using soloists.

That is why I'd like to see more comments from our friends.


To sum up our own problems:

Ineffective time management
Ineffective charting techniques
Ineffective supporting staff
Insufficient supportive materials
Insufficient capital resources
Ineffective doc companion (that me, I need to learn to help more)

To fix all those above....!!!

Does it bother her when patients leave for other doctors?

A lot, Bert. She is an introvert. Keeping to herself but loosing sleep over some patients. Days like that 4 AM ER called, she are their PCP.... 2 hours of sleep, 1 hours at ER, 8 hours at clinic. Going home and crashed. Hospital priviledges good for rookie credentials but bad for health. I told her to drop hospital....

I know the feeling of being hurt when patients leave. I always consider charging them for their records.

Walter, it hasn't been easy for me to teach Alice some of these things. Still working on it as we go, but we have made progress.

I remember when she first asked me to help market her practice. She'd been here 4 years, but had hardly any patients. And then still wouldn't listen to my advice (after she asked me for it). But her file cabinet had only 65 charts.

One issue was she felt she needed to personally call each patient and discuss on the phone their lab results. It was her responsibility as their doctor.

Now, this is a laudable sentiment. But...completely impracticle. We had some "heated discussions" about this. Then one day, I walked into the office. She was sitting their looking lost. There was a stack of 45 charts on her desk (This was after I had successfully begun to build up her patient volume). She was trying to call them. So I interrupted her to begin this conversation again. This time she looked at me, then looked at the stack. Then grudingly said "maybe you're right. yes. I just don't have the time to do this. And the insurance companies wont' pay for a telephone consult." Only after this was I able to make headway on these issues.

If your wife is like my sister (sounds like she is), and has this type of feeling of duty to her patients (which she probably does) then I do understand that you can't just suddenly get her to agree to alot to these things. Its a continuum. And some things she will eventually feel comfortable about, and some not. But it sounds like she is far past the point Alice was. She will physically not be able to continue unless she changes some things...but its obvious that you know that already. Often, the last person to notice that someone is really truly burning (burnt) out is the one who IS burning out. It happened to me when I was a consulting manager.

I know it bothers Alice when patients leave for another doctor. Frankly, it bothers me too. But here in NYC people switch all the time at the drop of a hat, so once you begin to realize that its easier to accept. Having other patients that have been with you for years helps too.

One thing that will happen as you start implementing stricter policies which allow you to be profitable and sane is that the patients that were happy because you were so lenient will leave to look for someone else who lets them get away with these things. You (she) has to be able to accept that, and it will help when she notices that other patients don't seem to mind, or will comment that their previous doctor did the same thing. So you really can only change one or two things at a time to limit the sudden loss of income and to not run into a wall of self-doubt.

This is the single hardest thing for me to handle in medicine. They don't teach it in medical school. Maybe part of it is my own pride. But, it is true. Our office goes out of the way for our patients. The hardest part is not knowing why. I really despise doctor shoppers.

Bert, I knew you are the caring type! Many of our patients said they love their doc and her staffs, all female all sweet.

Wayne exactly right on many things, patients here in DFW same mindset like in NYC. We have many difficult patients and they know how to take advantages of sensitive doc. We learned and did implements some changes to deal with them but still...an all female practice.

Anything to tempt you enough to come to DFW for a visit Wayne? I have some free miles...

Since this has sort of segued into a thread about how we run our practices, I'll keep going.

Walter, we bought our office space many years ago, convinced it would be a good investment..Then, we were rudely reminded of the second half of the basic definition of fair market value, "what a buyer is willing to pay..." A medical office building can suddenly become a white elephant, since it may only be suited to a medical practice. The hospital bought our building, and now we rent. We have 1 year renewable leases year after year. I can walk out the door any time with a maximum of less than 1 year rent at risk. Freedom is a wonderful feeling. I once calculated that over the 20+ years we owned the office, our group paid out over $1,000,000 more for office space than if we had rented. We got back about $200,000 when the hospital bought it.

Wayne, we use UpDox to contact each patient with their test results. We actually do use the dreaded templates here, saying things like "Your lab is basically normal..." and adding that if there are further questions they should feel free to make an appointment. We also offer to answer brief questions by e-mail for a fee, warned insurance won't pay, and have almost no takers. Of course, if it is abnormal, we contact the patient to make an appointment to discuss. UpDox lets us document what we told the patient as well. It averages about 2 minutes per patient to import labs, notify patient, etc. I have 6-7 labs a day, and it gets done in the morning while I'm sipping coffee. Some patients don't want to use the portal, and we graciously offer an appointment. I have been known to say "The folks you voted into office forced us to to go electronic, and if we suffer, you suffer." Using UpDox slams the door on the discussion that morphs into a free office visit by phone.

Now it's time to poke the hornet's nest again.

We fire patients with minimal provocation. If someone is nasty to my staff, misses multiple appointments, exhibits drug seeking behavior, etc., they are history. They get 30 days of emergency access, then bye. I don't usually do this for simple non-compliance; I take those folks as a challenge to try to figure out how to get them involved in their own care. This topic has come up before, and always ignites a storm. Let's just say that we have almost no patients whom we dread seeing. Also, we practice in an area where primary care is hard to get, so it is sort of a seller's market, and we've been in practice for a long time. That certainly helps in the confidence arena, and a patient leaving now is merely a curiosity (mixed with the smug knowledge that they were pretty spoiled with us, and "brand X" is not going to treat them so well.)

Our community is constantly trying to recruit new physicians, offers all kind of incentives, and is a really magical place to live if your tastes run to the mildly exotic. I have never heard of anyone with a lick of sense who did not prosper. However, it is really tough to find docs who will practice here, and once again, reading posts by folks who are having a tough time financially, I wonder why. We should be beating you off with a stick!!

Part of this argument is based on whether there is a surplus or a deficit of physicians in the area.

If there is a surplus, the patients bounce around and doctor shop. If there is a deficit, they stick and the doctor can be more selective, firing patients who are not nice.

I work in an underserved area. I know I spend more time with patients and parents than most of the other physicians in the area.

When we have a patient ask for medical records, sometimes I am sad because I thought we had a good working relationship. Sometimes I am glad because the demanding ones are more likely to leave.

I do have one consolation, I know they will not get the same level of service from the other offices they get from ours. Call it egotistical. I know we are more friendly, flexible, and spend more time with patients. If I am wrong, at least I am happily deluded, but I am comfortable that I am not.

I rarely take a patient back who has left. Occasionally for the few insurances I do not take, but that is not common.

We rarely fire patients. We probably should fire more than we do. Many of our parents are rude and I think this is their basic personality. Most of them soften up over time but some don't.

Again, we are in a shortage area, so while they can find another doc, they will have to travel a good distance for inferior care. Ultimately there are more patients out there to replace them so we are not hurting for patients. Now only if they were not predominately medicaid.....

See, in NYC there is of course a surpluss of Drs. So, while we do fire patients, we don't do it "lightly." But we also have alot of turnover since the issues of "how to do business" were not thought out in advance. So as things are implemented, you lose people who don't like that change. But even with the large number of doctors, it is NYC so there is a large number of patients for you to eventually get your volume back up.

We are also located in a section of NYC where there aren't that many doctors, so the people who do work near there don't want to go across town to where all the other doctors have set up.

David, I'm wondering about Updox. It has some things we could use, but it overlaps with the portal we initially and currently use...RelayHealth.

Now that AC has the eRx, we won't be using that portion of Relay very much, if at all. And apparently Updox has the secure messaging and is actually integrated into AC. I just need to find another way to do our online consultations...but we really don't do alot of business with that, so I'm not certain how important it is.

Wayne, UpDox serves as our fax machine and portal. We don't do many online consults, but sometimes I wll ask a patient to send me serial blood pressures or the like, and it's nice for that. We mostly use the portal for outgoing notifications, and it's really nice that it integrates with AC. it has several other features like online forms that we use some. All in all we are quite happy with it.

And, Wendell, I'm really intolerant of patients who curse or threaten my staff. My staff has very little power, whereas I have lots. To quote Spiderman "with great power comes great responsibility" and for me that means I am responsible for my staff's working environment.

We have our own share of difficult people, patients who use the staff to vent frustration about their problems with the medical system, not usually our office in most instances. I guess we are the only office who will answer with a live person or call them back.

Even though most of my staff are veterans, my partner and I have an afternoon staff seminar every other year about managing difficult people. The last one was sponsored by our liability insurer (I guess that makes sense), and the docs attend also. The seminar leader did some role playing (the staff loves it when we physicians play their role, and they play the "patients from hell"). The lesson learned for the staff is that they are not powerless, they can control many behaviors by their responses, attitudes and "deflecting not reflecting".

It's very interesting the few weeks after the seminar, how the staffers that take these lessons seriously tame the real PITA patients. The office can break out in applause for a particularly tough phone call done well.

Bert said don't need to thanks so many times as we are all professionals and always short of valuable time. I still want to say thanks, sorry Bert. We are on tract to do a full management shake up but now have to deal with a more critical issue of couple key employees departing. Good employees hard to find, work attitude is no longer here. 40 years brings lot of changes. I don't like the way technology brings about.

We are very lucky with our staff. They are all good and all get along. I think Leslie is too. Hang in there with the technology. Get yourself an iPad 2 and play a little.

Yup, my staff have been with me a long time. We travel together, camp together, ( and as Wendell can attest) "socialize" together. But in the office, it is professional. I am the boss, they are the employees. My sister is the one who had the hardest time with this, but even she has learned that her baby sister's word is the last one! LOL

I usually get the last words in also. Especially when my consultant wife has a comment on how I "manage" my office staff! It's usually something like this, "Yes dear, I'm an idiot dear, I don't know what I was thinking!" With this said, I can live, eat and breath again!

Tom,

You should be so lucky as to have a wife who could play the role of office manager. What I would do to have an office manager who could ruthlessly enforce the rules. (Not that your wife is ruthless).

"My consultant wife". I like that term.

Wikipedia says, "A consultant is a professional who provides professional or expert advice in a particular area such as management, accountancy, the environment, entertainment, technology, law (tax law, in particular), human resources, marketing, emergency management, food production, medicine, finance, life management, economics, public affairs, communication, engineering, sound system design, graphic design, or waste management."

Or in the case of a consultant wife, all of the above.

Said with the utmost respect for my own consultant wife and life partner.

What is "accountancy?"

Haha, Jon I love your quote, you are the most fortunate one.
A real story, happened last year, somewhere on the East side. A doc who had a consultant wife and office manager. She turned his practice into a ... he closed up his practice (not able to find any buyer) and went to work for government. Now he is free during office hours. Why did he not fired his consultant then?

Before I had my own practice, I worked for three groups. In each one, the office manager had considerably more power than I. They made my life miserable.

Ahh, the beauty of solo practice! I just love it!

Half step forward, one step backward...ta tata ta....Correction moves started to take place at our clinic but like my earlier update, our main MA departing next week, 2 week notice , she is going back to school for 'real' nurse degree, higher salary prospective. We have one full and one part time.

With internet, employees are highly 'educated' and 'motivated' . We put out local ads, many interviews but not yet suitable candidates. EMR needs time to learn, some just out of school, some matured thinking of leaving their current and been on paper charts... so if we get a newbie (easier to 'mold') then our doc has to take over the role of a trainer (our part time MA is just that), doc is busy more than enough. Best is to have a MA with AC knowledge....

For those lucky to have loyal and more than one MAs, this might become a none issue, is any doc out there in same situation. Not too long ago, many docs could do everything himself if needs be... opt out of insurance/medicare is suicidal, some can do that but not us, referrals become very time consuming , too many carriers, many selective specialists, for those older and by themselves patients need us to look for their specialists,

beauty of solo, ugliness of practice....

One thing you can do... look at your local MA programs and see about having interns. Not a lot, just say one per "class". They do about 200-300 hours depending on the program. They can help out, learn AC, learn how you operate and you can see if they are kind of smart, motivated and have good work ethics. When you find one you really like, hire her. This may take awhile.

That's a great idea, Wayne.