Quickie post

Just a quick post before I go off to work. Had a real day yesterday. Several people just didn't show up, which is unusual. Nuts, there goes my productivity. On the other hand, I was much closer to running on time, at least in the afternoon.

My Mondays are very busy days. I usually have a full slate of patients, and then have a meeting to run at noon. I was pretty relaxed going into the day yesterday, because it was supposed to be the all clinician meeting, which, interestingly enough, I'm not involved with running. I say it's interesting because I'm the Chief of Physician Services, so you'd think I would be intimately involved, but that generally isn't the case. Yesterday, the meeting was cancelled and suddenly it was mine to run.

Meanwhile, I decided to admit one of the patients I was seeing in the office straight to the hospital, right about the time I was running the meeting. I spent half the time answering the phone and trying to write orders for his admission. Alan, my boss, stayed to explain our conflict of interest policy, which let me off the hook for the firt half hour. After that, I had to race through a description of how to make a chief complaint. In a way, this was a good thing, because the last time I planned a meeting to discuss this, we got bumped by a physician interview. I really need the help of my colleagues in customizing, because there's just too much to do it all on my own.

Alan grabbed me to talk to me about some issues, in the hall. We have been going through the annual review process, which also includes planning for the next year. I got everything done right on time, but then sent it to HR, not realizing that the next step was to send it to Alan. I've been a manager now since May, but every time they have a new manager orientation, something has come up so I can't make it. I hadn't realized how much a problem that would be until now--when I don't know the proper process to go through! I had thought I had gotten everything rerouted properly, but apparently Alan hasn't received it, so I'm going to have to get a whole bunch of signatures all over again and just sent it to him. Urg.

I think Alan and I don't communicate enough. It's a real issue. He's only here on Mondays, when I'm doing my headless chicken thing, and barely have time to say hello to him. He relies on email to contact me, which would be great, except I'm so damned busy, I almost never get to my work email. I think I'm going to have to set up a telephone conference with him on Fridays or something so he can keep me updated on his expectations of me. I also need to press to find out when the next new manager meeting is, so I can make sure I'm able to actually attend.

So, where does the time go? That's what I want to know. There just never seems to be enough to do everything that needs to be done. I'm really looking forward to that time management course, if I can find the time to actually schedule it.

Oh, just another post, very late (with much crabbing going on)

Busy, busy, busy. That's me. I think my job really is eating my brain. I'm trying to find ways to beat it into submission, but as far as I can tell, doing so will require another full year of extra hours over the extra hours I'm already putting in. Argh! Meanwhile, my husband is working too hard and stressing out and whining that I'm not paying enough attention to him. As if there were any neurons left over to think about anything but work.

Our new EMR is a huge anchor attached to my butt and dragging on the ground behind me. (This is not a new phrase--I find myself saying it at work all too often) We live and die by our little portable Fuji lifebooks. I can deal with the itty-bitty font pretty well, since I'm not yet so deeply in the land of presbyopia that I have trouble seeing it. It's the damn touch screen that's a problem. I have to touch and scroll, and when I try to find something on it list, it goes like this:

Scroll down down down down---
Oops! way overshot!
Scroll up up up up-----
Oops! overshot!
Um, maybe I'll just press the arrow key--no wait, I've slipped to the top of the list again!
Darn, and to heck with it! I guess I'll just keep pressing the key until I get there.

Click!

OK, now I've checked off that test. Hmm. Got to run a search to get the text up for follow-up.

Click on search tab. Press "d" for discharge summary. Tab, tab--oh wait! didn't work! Click on the box, enter d, then press enter, then tab, tab. Cool. Enter "follow" and hit enter button. No wait, in THIS field, when you hit enter it tries to include. Hit enter to get rid of the annoying pop up message and then press search.

Scroll down down down....

I think it's taking me anywhere from 2-10 minutes just to finish up an assessment and plan for each of my patients. Appointments are scheduled for the supposed 15 minutes you need to see anyone. Mind you, studies suggest that the average appointment to see patients is about 18 minutes. My patients generally are way pre-booked, since my schedule is so tight. They seem to sit at home and make lists of all the things they want to talk to me about when they see me, and don't take very well to getting cut off without covering everything.

Medicine has gotten increasingly demanding. Turn around time for anything has shrunk at a rate that seems almost geometrical. We can access information on the web, fax reports and records anywhere, and of course, are always available by pager and cellphone. Not only am I compressing more and more into my office time with patients, but the messages and reports have gotten swollen and bloated as well. On Friday, an inch thick wad of paper and reports was dropped on my desk in the afternoon. I would estimate that the reports take about an hour a day to take care of. I believe I probably get somewhere around 30-50 per day, as well as anywhere between 5 and 20 lab reports that automatically upload on the EMR. On a day where I have 8 hours of patient office time, that leaves me with somewhere around 1-2 hours of time taking care of reports, another hour taking care of telephone messages, and often an hour finishing up the notes from seeing the patients.

All of this work was time consuming before. The sole advantage of the EMR is that I can now go home to have dinner with my husband and do the extra hours there. The crunch comes when I'm on call and have to go to the hospital to admit patients. One night, I had to do 3 admissions. Those take anywhere from 30-60 minutes each, as well as travel time of about 40 minutes altogether. When that happens, I start falling behind on my paperwork, and can't catch up.

Sadly, I am still unable to see as many patients in my 8 hours as I was before we went live on the EMR. It has me very worried. Not only are my patients crabbing that they can't get in to see me, but my salary is now tied in to productivity, and if I can't keep up, I'll end up having a loss of income that I can't afford while I have still got 2 kids in college (3 this year only, thank God).

So, here's the basic situation:

Things I can't change:

1. The EMR is here to stay. It ain't going anywhere.
2. There is an irreducible amount of work that needs to be done, including reading reports and lab results and taking care of telephone messages.
3. I will need to see an average of 10 patients per session to maintain my productivity, which would come out to about 60 patients per week.

Here are the areas I can affect:

1. The amount of time it takes to enter information into the EMR with each patient visit.
2. The amount of time it takes to select an assessment and plan.
3. The amount of time it takes to handle telephone encounters.
4. The amount of time it takes to handle lab and other reports.

So, how to do it? Well, my boss has talked to me about delegation. That's an idea. And customization of the EMR...so here's the plan:

1. Customize the chief complaint section of the EMR so I can accomplish what I need to, take credit for all my hard work, improve patient care, and not take forever doing it.
2. Customize the assessment and plan lists and see if there's a way I can move my favorites to the top, so I won't have to constantly try to get past the nurses' list (our whole office seems to consider it more appropriate to cater to the needs of the support staff than to that of the doctors sometimes--there are short lists in assessment and plan and the top on is automatically open when you get there. Our administration has insisted that the top, always open list be the one for the IM nurses. Go figure. Like the nurses are the actual source of income for the facility.)
3. Find new ways to delegate certain activities to the support staff in areas of telephone messages and patient notification.
4. Customize the appointment request lists so I can print them up without spending an extra 30 seconds per patient doing it (I know, I know, but it really all adds up.).

There's probably more, but I'll have to think about it. Probably one of the things on my list will have to be figuring out what Kevin Pho, one of the other doctors in my office, is doing, since he always seems to leave right on time with all his work done. And, he's really productive.

So that's it. I'm off to plan and plot and try to figure out a way to get my life back. Thank God my kids are all off at college, because I'd really have no time to do anything with them if they were actually here!