After Hours EHR Time is a Problem for Physicians

The patient encounter doesn’t end when the patient walks out the exam room door. Those are words no primary-care physician needs to hear, but it represents reality.

Most physicians are not just documenting the patient visit in the EHR, but approving prescription refills, reviewing labs, responding to patients’ questions via the patient portal, keeping tabs on diagnoses from referring physicians, and managing the overall health of their patient panel.

Primary-care physicians are hit the hardest by excessive EHR time because of the nation’s transition to value-based care, where they act as the “quarterback” of the care team. In that role, they also serve as the default physician contact for updates on all the patients in their panel, says Jane Fogg, chair of internal medicine and population health at Atrius Health, a Newton, Mass.-based health system.

Fogg says the clinicians on her team are often logged into the EHR at 5 a.m. and don't log off until the late evening hours.

A recent study in the Annals of Family Medicine found that physicians were spending nearly six hours a day in the EHR - nearly 90 minutes of which is spent after clinic hours and often at home, which they dubbed "pajama time." The study included examining 142 physicians over three years and recommended that some of the work docs are doing in the EHR could be delegated to other staff members.

Specific recommendations by the study’s authors include:
• Proactive planned care
• Team-based care that includes expanded rooming protocols, standing orders, and panel management
• Sharing of clerical tasks, including documentation, order entry, and prescription management
• Verbal communication and shared in-box work
• Improved team function

Tech Solutions

The study’s finding that physicians were spending two hours in the EHR for every hour they were spending with patients was no surprise to Fogg. While she encourages physicians to pursue ongoing training in the EHR, she says they really need the support of their practice in order to be more efficient. Specifically, Atrius Health has undergone several initiatives to help physicians achieve this EHR optimization.

• Smarter inbox management. The physician’s inbox is where they receive questions from patients and referral requests and updates from specialists. Until recently, all of the updates from specialists arrived in the primary-care physician’s inbox at Atrius Health, and that was the case whether it was just a message informing the doc that their patient was fine or if there was something problematic.

All of those updates informing primary-care physicians that their patients’ status is unchanged are effectively taking over physicians’ inboxes, and they don’t deliver clinical value, says Fogg.

That’s why she worked closely with the heads of the clinical departments to ensure primary-care physicians only get updates if there’s a negative result or a significant medication change for their patients. Because Atrius Health, like many healthcare organizations, has many specialties within its network, this required that she coordinate with her in-house clinical leadership team.

For example, if the specialist told the patient that they had a cold and they would be better in a few days, there’s no need for that notification to arrive in the primary care physician’s inbox, she says.

• Dashboards flagging hospital stays and emergency room check-ins. Fogg says primary-care physicians get too many notifications for their patients when they’re checked in to the hospital. That’s because they receive as many as five to seven notifications for each patient’s journey: When they’re checked in at the emergency room, when they’re admitted to the hospital, when they’re discharged, when they’re checked into a skilled nursing facility, and then when they’re discharged to their home.

While these alerts present valuable clinical information, Fogg says it’s likely physicians won’t receive them in real time, since the messages arrive in their inboxes, where those updates are competing with as many as 400 other messages each day.

Instead, Atrius Health has developed a dashboard that primary-care physicians see when they log into the EHR. On a given day, a physician may have no patients in the hospital; on another day, they may have ten patients in the hospital. The benefit of the dashboard, says Fogg, is physicians see it every time they log in to the EHR, which happens many times during the day.

This means physicians have close to real-time insight into their patients’ status at the hospital. What’s helping shaving minutes off the pajama time they used to spend in the EHR at night? Having all of those alerts collapsed into a meaningful dashboard.

• A system-wide template for the annual wellness visit. Fogg says that documenting the annual wellness visit was such a challenge that internal quality controls revealed physicians were only documenting such visits appropriately 20 percent of the time. That’s when Atrius Health started working directly with physicians to develop a uniform template to fully document the annual wellness visit that would be reimbursed by Medicare.

Before creating this template, some clinicians were documenting too much, which contributed to pajama time, and some weren’t documenting enough. What matters is they weren’t documenting what they should have been documenting, and Fogg says they are documenting appropriately today.

Using this template for annual wellness visits, physicians achieve a 96 percent pass rate, or the rate Atrius Health’s internal quality team deems as appropriate for payment by Medicare.

Real-time Documentation

Allen Schultz, MD, an Abilene, Texas-based family practice physician, credits voice recognition, a fast internet connection, and investing in faster computers and other technology with helping him document patient care in real time. As a result, he documents 50 percent of patient visits in the EHR by the time the patient leaves the exam room, and 75 percent of patient records are fully documented by the time his patient hits the parking lot. He stays late at the office until all of his documentation is done. Thus, Schultz spends zero time documenting at home.

Schultz has a long relationship with many of his patients - thus, they understand his “quirks,” he says. This includes using a 17-inch gaming laptop so that patients can watch the words he’s typing into the EHR during their patient visit and using voice recognition and his headset to update the patient chart. He introduces the use of voice recognition by telling patients in real time, “I’m just going to update your patient record now.”

The benefits of displaying patient information on the big laptop screen include collaborative medical decision making and the ability for patients to correct information as it's entered into their record, says Schultz, who also uses templates based on condition or disease type that he can update based on the specifics of a patient’s health.

One thing that slows him down is when he has to deliver bad news to a patient - perhaps about a cancer diagnosis. “With these emotionally charged conversations - especially those with a lot of anxiety and emotion-I can’t always document patient care. There’s no macro for that.”

Kim McFarlane, PA-C, medical director at Green River Medical Center in Green River, Utah, also sets his charting aside when he supports a patient during a difficult diagnosis. “That’s when you could spend time talking and hand-holding - without the computer,” he says. In these instances, he usually documents the patient’s visit before he sees his next patient or takes a few key notes to update the complete record at the end of the day.

Different Model

Daniel McCarter, Richmond, Va. chief medical officer with ChenMed, a Miami Gardens, Fl.-based primary-care provider, says that his practice’s model of care, where patients are seen by clinical staff as many as ten times a year, can make documenting the patient visit easier. That’s because instead of having to cram a year’s worth of clinical documentation into a single patient encounter, his clinical team members are often able to focus on one or two conditions per visit.

The practice’s EHR helps with this. For example, he may need to address a patient’s blood pressure and blood glucose levels at every visit, whereas there are other conditions that only need to be addressed on a quarterly or yearly basis. McCarter notes that when a patient’s chronic conditions are up-to-date in the EHR, those conditions are marked green. Conditions that are marked yellow need to be addressed soon, whereas those marked red are overdue, he says.

Brian Arndt, a family practice physician in Verona, Wisc., and a co-author of the Annals of Family Medicine article, says physicians also have a duty to manage their patients’ expectations regarding how soon they should expect responses to questions asked via the patient portal. While he attempts to respond within a day to patients’ questions, he tells them that it may take him as many as three days. He notes, of course, that patients are told to contact the practice immediately by phone if they’re experiencing an urgent healthcare event.