Finding Utility in an EHR ~ Software Development Process

If you are like most physicians in this country, you probably bought yourself an EHR, either recently or a while back. If you are like the docs quoted on the various EHR vendor websites, you took to it like fish to water and are thoroughly enjoying your new computerized system. If you are like most other physicians, you are slugging your way through, a bit slower than usual, with a bit less money in your wallet, either hopeful that things will get better or perhaps still hopeful that this is just a bad dream. If you are like most EHR users, you probably compromised on an EHR that seemed to be not as bad as the others, compromised with the documentation style seemingly imposed by your EHR and are now dragging a tablet from exam room to exam room, and that tablet gets awfully heavy after a few hours of seeing patients. Perhaps you found nifty little ways to “cheat” and leave the tablet in your office, or maybe you broke down and installed desktops in your exam rooms, or perhaps you tried to use the almighty iPad, and found that it takes a couple of hours to finish your charts after your last patient left the building. People keep telling you that things will get better, that you will get used to it and that practice makes perfect. You may not be convinced, but what other choices are there? You have to “get with the program”, get your Meaningful Use money and adapt to the new ways of doing business in health care. You are wrong.

If you played any type of contact sports in high school or college, you probably bought yourself a mouth guard at some point. You can take it out of the package and pop it in your mouth, and you may have done that in a pinch, but it works and fits much better if you take it home, soften it in boiling water and mold it to perfectly fit your mouth. An old business adage says that you have to spend money to make money. With EHRs you have to spend time to save time (and maybe make a little bit of money too). You have to spend time softening and molding that EHR to fit your future practice. The biggest mistake people make, is to attempt to push and shove an off-the-shelf EHR into their current practice. This is not much different and makes as much sense as using Microsoft Word on a tablet with a stylus to hand write on it. So how do you go about molding an EHR to fit a future environment that is both enabled and limited by the introduction of the same EHR? Is your EHR a chicken or an egg? And no, I don’t think I want to hear the answer to this one.

I’m certain you heard lots of experts talk about “workflow redesign”. In a small practice, there is very little to “redesign” and the work flows predictably from appointment making, to office visit, to claim submission and hopefully payment for services rendered. However, a properly utilized EHR can help create a smarter distribution of workloads.

Figure 1: EHR enabled office visit (click picture to enlarge)

Figure 1 shows a typical office based encounter when an EHR is utilized to redistribute workload. The flow of the visit has not changed, but the workers are now different. Before we examine the new workloads, let’s keep in mind three things:

The EHR is sunk cost. You already paid for it and any additional tasks that can be offloaded to the EHR are net gains to you and your practice.
You are the only billable resource in the practice. Any tasks that can safely be offloaded away from you can increase billings (or leisure time, or quality of service).
Patients are a completely free resource. Granted, not all your patients can contribute the same amount of work (i.e. engagement), but whatever is contributed is again a net gain to your practice.

In our simple example, the computer has picked up a variety of tasks previously performed by staff. These are mostly mundane and repetitive tasks suitable for machines. Patients picked up some tasks for which they are much better suited than any of your staff, with the added benefit of creating an informed and engaged patient. And yes, I know that this is not applicable to 85 years old ladies with a 4th grade literacy level, but surely you have some patients that can and wish to participate in their care this way. Since your staff has a bit less work to do now, they can take on some of the things you currently do. For this to happen, you must staff your practice adequately. If the person that rooms the patient cannot be entrusted with much more than politely sitting the patient in the exam room, this is not going to work very well. Otherwise, the entire “I didn’t go to medical school to be a data entry clerk” quandary should be largely resolved. You will always have to document your exam, and may need to add comments here and there, but basically, your nurse should have checked all the boxes and clicked all the buttons before you entered the room, giving you the freedom to truly listen to your patient without having to worry too much about the computer.

Skeptical? Of course you are. Unfortunately, there are no EHRs that come out of the box with all those efficiencies built in or with simple cookbook instructions on how to get there. So here are a few pointers to get you started.

Make your own visit templates. Either you tweak the ones included in a good EHR or start from scratch and create exactly what you like. In most cases this is immensely time consuming, but if you don’t spend time upfront to mold your visit templates to your liking, you will never derive maximum utility from the EHR. Remember the paper forms you used before the EHR? Somebody had to make those forms too. EHR templates are more flexible than paper forms and creating your own templates will take more time and expertise. You will have to try them out and adjust as you go. You don’t really need hundreds of templates. A dozen or so, well-chosen ones should make a good start. If your EHR allows you to configure flowsheets, make a bunch of those as well.
Create order sets and if your EHR allows, add those to pertinent templates. You can start with simple things and work your way up to more complex visits. You shouldn’t need too many here either. You don’t want to have so many templates and order sets that it becomes difficult to find the one you need. Fewer and more general ones work better.
Configure pick lists and favorites. Everywhere you can, create short lists of frequently used items. This is especially helpful for orders and diagnoses.
Deploy the patient portal that comes with your EHR and don’t be afraid to open it up for patients to do as much as possible online. Have your staff actively promote the portal to patients and give out instructions on how to use it. It will take time for patients to get used to online interaction with your practice, and it will take time for staff to get accustomed to it too, but savings can be significant depending on who your patients are, of course.
Make sure that every automated billing feature available from your vendor is turned on and working properly. It won’t hurt to contact the vendor and find out if there’s anything new in this area that you are not aware of, particularly if you had this EHR for a few years. Some of these things will cost you extra, but are well worth the expense.

Generally speaking, every time you find yourself doing something that is not direct patient care, you should pause and ask if this particular task could be delegated to staff, patients or computers, and if there is a way to use your EHR to that end. The answers are not going to be obvious and since most people use only a fraction of features available in an EHR, it may require some digging, exploring and even advanced training. But if you stick with the principles illustrated in Figure 2 below, you will discover that your EHR, although far from perfect, can and will provide you with measurable utility.