A Day in the Office (with EMR)

The headline read: Electronic Health Records Don\’t Lift Care.

Balderdash!

That\’s like saying that cars don\’t improve transportation compared to walking. Now, certainly if people don\’t know how to drive, cars are not much use to them, but there is no way I would ever go back to practicing without my EMR. I couldn\’t do it in good conscience.

To show why this is the case, let me go through my day today for you (this is not made up).

8:00 AM – Arrive in office, Log on to EMR. Check Schedule. Look over unfinished work on desktop. Look over labs from patients in office yesterday that came through interface. Any abnormal results are flagged and put on the top of my list.

Gentleman with wt loss and abdominal pain whose labs were OK, although sugar is up. I\’ll address that later. Send him a letter:

Dear X:

Below is a summary of your recent labs:

Sodium: 135 Normal 135-148
Potassium: 4.3 Normal 3.5-5.5
Chloride: 99 Normal: 96-109
CO2: 23 Normal 20-32
BUN: 9 Normal: 5-26
Creatinine: 0.9 Normal 0.5-1.5
Glucose: 247 Normal 65-115
Calcium: 9.4 Normal 8.5-10.6

Summary: Electrolytes and kidney function are normal.

White blood cells: 6.3 Normal 3.5-10
Hemoglobin: 14.1 Normal 13-17
Hematocrit: 41.5 Normal: 38.5-52
Platelets: 266 Normal: 150-450

Interpretation: Normal – No Anemia or sign of infection.

Other labs look OK

All lab results get a letter. As of September we should be doing this through secure e-mail. I can\’t wait.

8:15 AM – Check on Billing and Collections for the month so far. On target to be an OK month.

8:30 AM – Pretty much caught up on notes now. 1st patient (finally) in exam room. Check Protocols on each patient for labs/tests due and order appropriately (A1c, Lipids). I have actually picked up hypothyroidism a number of times as this reminds me to check a TSH on all patients with hyperlipidemia or osteoporosis. I have also become obsessive about mammograms/colon CA screening and have picked up a number of patients with early breast CA and adenomatous polyps.

I get a Framingham CV risk on each patient with hypertension, hyperlipidemia, and diabetes. This is how I gauge my treatment of lipids and hypertension. I generally show patients their risk on the screen in the exam room.

8:45 AM – Between patients, look over lipids that came back from yesterday. I run a Framingham risk on these as well and check all against NCEP guidelines:

Then I check to see how this compares to previous:

Doing better. Send a letter saying he is doing well.

9:00 AM – Noon

• Adult patients: We are enrolled in a clinical trial of reminders for GERD patients and the elderly on NSAID\’s. Reminder only pops up when appropriate. This has definitely improved my care, as many patients don\’t tell you if they are having significant GERD symptoms because they think it is just normal. Also it has helped me remember to use gastro-protective drugs when using NSAID\’s in the elderly. Plus, we get paid for this. Not bad.
• I had a few patients I changed medical regimens significantly and so I printed a handout detailing the changes, giving them their medication list. They always appreciate leaving with something in their hands
• A gentleman came in for a depression recheck. He fills out a Beck inventory for depression and we follow the score serially. We do that on all depression rechecks.
• I alternated between adults and well-child checks during the first part of the morning. I love the little babies (especially the 2-6 month visits). Our EMR calculates the growth percentiles and automatically populates the growth curves. We print them out along with a table of the growth numbers, giving to the parents at each well visit. We also have a standard set of handouts given at each visit (that can be downloaded in PDF format from the website) and they put them in a 3-ring binder we give them at their first visit.
• I had a few patients who needed an EKG today (I do them every 5 years for hypertensive patients). The nurse hooks the leads directly into the USB port on the computer in the room and the EKG is imported directly into the patient\’s chart with an interpretation. This makes it really easy to compare from previous EKG\’s.
• When I do a routine follow-up for diabetes or hypertension, I check preventive protocols. I ended up ordering one mammogram and flagging myself in the future for when a colonoscopy was due (from a past history of polyps).
• Scheduling tests/consultations takes 2-3 mouse-clicks. I associate a diagnosis with the referral type and send it to our referral coordinator. Pt is sent to facility appropriate for their insurance with authorizations gotten if needed. This is often finished before I finish with the patient in the exam room.
• When we write prescriptions now, we fax them directly to the pharmacy. This ensures that the prescription gets there and it is generally ready when the patient arrives at the pharmacy. They love this fact.
• We are doing the PQRI pay for performance with Medicare. We are actually using a paper version of this because we could not think of a more efficient way to do it with the EMR. Our goal is efficiency, not being paperless. Yet the EMR helps tremendously when we have to look for DEXA scan results or diabetes numbers from the past. We should have no problem qualifying for the bonus (meager as it is).

I got done around 12:15 PM (I saw 13 patients this morning). Over lunch I catch up on any flags the nurses have sent regarding phone calls from patients. No charts are ever pulled for phone calls, and most of the phone calls are handled through protocols on our phone template, negating need to talk to the physician. Even if there is need to ask us questions, the process is very efficient.

Called Mrs. Dr. Rob at home. We got a piano delivered today. It\’s the one I learned to play on that was in my parent\’s home. They moved, and so needed to get rid of it. Yahoo!!

Also made plans to go to Borders tonight to wait with the kids for the release of the new Harry Potter book. Who will get first dibs? I have seniority!

1 – 4:30 PM

• Mix of well/sick, adults/kids – I generally see about 50/50 adults/kids, which I like. The sick visits take me about 5 minutes in general, and all documentation is done at the time of the visit. The well visits/routine follow-up take 15-20 minutes. The complicated follow-up is the main thing that requires some documentation after leaving the exam room. The rest is done when I leave.
• We do our billing on the EMR, sending it over to our billing software. Most of our billing is done when we leave the room, including immunizations, office tests, etc. Generally sick visits are 99213 (I almost never do a 99212) and rechecks are 99214 if there is any level of complexity to them. With EMR it is simple to appease the E/M gods – we have a way to check, but I know it well enough that I don\’t have to check anymore.
• Sent off some labs and x-rays this afternoon. The local labs and radiology facilities accept the printed order from our EMR and don\’t require paperwork.
• ADHD visits this afternoon – follow-up using Conner\’s scale – form calculates T-Scores based on the age, sex, and whether parent or teacher is filling out form. We follow these scores serially as well.
• Old consults and radiology reports are scanned as PDF and in the patient\’s chart within a day of receipt. Had to check cardiologist\’s note to check patient\’s story with what cardiologist said. Looked at old chest x-ray where patient had "Pneumonia" in the spring – just atelectasis.
• Last patient of the day had chest pain. It always happens on a Friday. EKG OK and had recent stress test. Start on Toprol and have him see Cardiology Monday. Send urgent flag that will appear on the desktop of our referral coordinator on Monday. She will fax my note and the EKG and get patient in on Monday or Tuesday.

It is now 5:45 and I am done. I have some labs to follow-up on, but I think I am going home and will just log on from there. I saw 13 patients this afternoon (total of 26 today – a fairly average day). Nurse questions are all answered. There are just 4 charts that need finishing (including that last patient). I\’ll do them over the weekend when I get a chance.

I\’d have been done much sooner if I had not been doing this.

You see how central our EMR is to basically everything I do. It improves my quality (without a doubt) and makes me more efficient. I\’d probably do better without my stethoscope than without my EMR. Seriously.

Time to go home and play the piano.