Available Records

Today it is time to boost the virtues of electronic medical records (EMR). I may not believe that posting the symptoms of your abdominal pain on Facebook will help you get a better diagnosis nor do I think that EMR is the saving grace for out-of-control health care wait times but I will say this; EMR increases the ease of access to your medical record. If you don't think it is a problem check out this article by the BBC on the state of health records in NHS clinics (UK).

“The HSJ [Health Service Journal] found six out of the 49 trusts had 5% or more notes missing. On average 2.6% of outpatient records were missing.
City Hospitals Sunderland NHS Foundation Trust reported the highest rate, with 19% of outpatient records unavailable at the start of clinic.”

Those are some crazy numbers. Let’s assume that the average general practitioner sees 30 patients over the course of a day. By extending the numbers that means at the start of the clinic 6 of the patients won’t have a chart present, 2 notes will be forgotten (missing) and 1 patient visit won’t be recorded at all.

I will say this for EMR and electronic scheduling; they improve practice management. A record of every appointment is automatically created, no charts will be missing (short of recording the wrong patient name/identifier; but that’s another post) and it is easy to make some sort of a rudimentary note. It’s been my experience that when a clinic is hopping, providers will not make notes whether they are using a paper or digital chart. So missing notes will always be a problem. But, you can create logic in the EMR (or have a staff member double check the computer) to ensure every patient that arrived had a note made by the clinician who cared for them. EMR may not save health care wait times but it will definitely decrease on paperwork chasing.

For a blog-en-blog throw-down about e-Health in general go to Dr. Wes it’s a great read.

Group Practice Levels Scheduling

Do you ever get pissed-off at a colleague because you’re positive you’re working harder or seeing more patients? Nah – me neither. I then read an article at Curious Cat Management about computer programmers and how they can have an order of magnitude (10x) difference in productivity while writing code and that it’s unrelated to skill or experience and I started to wonder if we had the same amount of variation between doctors.

I understand there is a difference in creative work versus menial work (and pulling teeth is menial) but I started to wonder what the difference would be in our own practice. We have an agreement between the doctors that we set global guidelines (block booking) for the schedule in conjunction with our staff & managers then let the front desk run with it. There are, of course, ups and downs and constant critiques but the blocks of time are set 3-4 times a year.

In OFFICE1 there are always multiple surgeons present. In OFFICES 2, 3 and 4 there is only one per day. I had a theory that there would be more pressure in OFFICE1 to conform to the scheduling guidelines. This would result in less variation in the number of appointments per day in OFFICE1 with more variation in OFFICES 2, 3 and 4. In other words, some of the doctors would have more variation in efficiency without peer pressure.

I pulled data for the year 2007 (251 days, 4 offices, 5 surgeons) and compared all offices and doctors. I then preformed multiple statistical tests to prove my theory. To my surprise, there is no difference in the amount of variation per office between doctors. In fact, when you compare each doctor in each office there is absolutely no clinically significant difference over OFFICES 1, 2 and 3. OFFICE 4 is smaller, so we expect to see fewer appointments but it’s uniformly less between the doctors. Putting numbers to it, if we have an average of 22 +/- 5 appointments per day, there is a variation of 0.8 appointments that can be accounted for by a different doctor. That is a whopping 4% of the variation. Compare this to the 10x seen in computer programmers. In fact, the total amount of variation in the average number of appointments seen per day is 7% for all four offices or 4% if OFFICE4 is excluded.

From this data I conclude that:

• We all have the same number of appointments and there are only modest differences between the offices


• That there is statistically no difference between the doctors in the number of appointments


• Setting scheduling policies globally has a profound effect on minimizing variation.


• Group practice applies another major pressure to work efficiently to the standards & expectations of others in the group.

I cannot stress enough the effect of minimizing variation (or leveling a process). It is the single biggest factor in poor patient satisfaction (because some patients will be left waiting much longer than expected) and resources planning. It is much easier to manage a practice when you know that the error on the number of appointments will be +/-0.8 instead of +/-10. In this case we’ve used good lean principals to level a process (scheduling) and block booking which increases efficiency. With the marriage of technology and good practice management this minimizes the health care wait times in our office.

Electronic Schedules

To control health care wait times you need first need to be able to tightly control the schedule. To control the schedule you need to have visual cues. Visual cues are differences in the schedulers appearance based on the type of appointment booked. You're brain cannot process the complexity of a schedule with just a list of names. It processes information much more effectively when it can visualize the blocks of time, appointment types and work to be completed symbolically. In fact, it would process the information best if the schedule were in 3-dimensions and had auditory cues as well!


How do you add depth & visual cues to a scheduler and what makes a good scheduler?


First, if you still have a paper schedule it’s bad. Paper schedules make it nearly impossible to search for patients going forward, block book or retrospectively examine how schedules are being managed. They're completing lacking in richness and visual cues. In addition, when there is more than 1 provider they become hopelessly inefficient.

Now that I’ve got that rant out of the way, what makes a good electronic scheduler? Think back to the blog on the 5S’s of organization: Sorting, Simplifying, Sweeping, Standardizing and Sustaining and apply it to electronic schedules. In terms of an electronic scheduler that means that it should:

Sorting: Show all necessary but no extraneous information on the screen. Unless you need a bit of information on a daily basis it should not be shown, and if you do need it daily it should be. Having email type messages showing is a good example of what distracts the brain and should not be there. Two main items should be present: First each patient name has their contact number in the block and small cues for overdue accounts, pending lab results, etc… In our EMR there are small text messages beside the name for account information, pending lab work, etc... Second and most importantly the schedule is you’re administrator’s digital dashboard to organize the practice. Menus for 95% of the actions (clicking) that need to be competed for clients should be accessible with a right-click on the appointment.

Simplifying: There should be an order to the way patients are shown in the schedule. In our practice we have a ‘priority’ column (for consultations and procedures) and an ‘other’ column for post-op/quick checks. Each appointment type has a colour code to make it easily identified. The menus that allow most patient actions to be completed simplifying the ‘hunting’ that can occur with menus that are at the top of the screen. For instance menus to bill a patient or book another appointment and enter treatment should all be accessible from this main screen.

Sweeping: At the end of each day any incomplete work should be easily identified. In our system the left margin of each appointment has a coloured bar to indicate patient status. The day end cannot be run until each patient has been accounted for. This prevents incomplete work being overlooked.

Standardizing: On the schedule the way that appointments are booked should be standardized (see block booking examples). The background colours of the schedule should indicated which patient groups should be booked into those time slots. This allows visual controls on the block booking decisions that have been made with respect to ideal wait times. In our system we create different templates (all surgery day, hospital day, mix consult/surgery day, etc…) then load them to each day for each doctor. At first it’s laborious but with practice is built quickly and controls the schedule well.

Sustaining: The schedule should allow you to change visual cues on the fly. Appointment type names, colours, block booking backgrounds (and types of block booking templates). The view should be modifiable to change the number of days, provider or offices shown (ours also shrinks to view more days at a time for quick scans to find open appointment slots).


Here's a quick summary of the features I think are important:
Background:
Coloured backgrounds for different time slots to for block booking
Priority and Other column for each provider
Adjustable view for number of appointment and days to be shown
Individual Appointments:
Different colours for different types of appointments
All menus are accessible with a right-click on the appointment
Critical information (Name, Contract Number and reason for appointment) on schedule
Symbols for pending work
Symbols for status of appointment (in ours we use a coloured bar on the left) booked, confirmed, arrived, finished
What shouldn't be on the schedule:
Anything that is not used daily: client address, email messages, etc..

Medical alerts are nice to have on the schedule but my experience has been that the field is often used for non-critical information ("Give pt lab req at next appt"). It tends to clutter the screen and for more personal medical alerts can cause privacy concerns.

The electronic schedule may be the single most important tool in your arsenal to decrease surgical and health care wait times. If you are not familiar with different types, ask you’re administrative staff if they like the current system and if they’ve seen any that are better. when choosing an EMR the work flow to the scheduling screens needs to be a major factor in choosing a vendor. Below is a screen shot of what we use which is provided by Optimicro Technologies. I do not have any financial interest with this company other than using their product.