Coping with incoming patient records
When I started practicing in 1991, the cry was that insurance companies were requiring too much paperwork and that it wasn't adding value to the patient's care. But even without that, we would always have to deal with patients' questions after the visit and their calls between visits, with lab and test results, and with prescription refills. Now, in a primary care medical home model, we are the providers 24/7 in an continuity of care spectrum, and we have to learn how to handle that kind of practice. We used to say "I sell my knowledge and training, and everything requires an office visit." We now need to have visits only for those things that need face-to-face time and the laying on of hands for an exam or for comfort and condolence.
In our practice, we define all the work we perform outside the visit as indirect care. That includes prescription refills, answering questions by phone or e-mail, handling faxes, reviewing lab results, going over outside medical records and specialist consultation notes, completing forms, reviewing physical therapy notes and nursing home requests, and anything else we deal with that's outside the "face-to-face" encounters.
My primary care colleagues and I have spent considerable time and resources, using "lean" methodology, to determine how much indirect care each of us has every day and to work out ways to incorporate that into our daily work and avoid huge batches and backlogs. We found that the average is, at a minimum, 110 pieces per day. Holy crap, Batman!
This is why many primary care doctors work 2-4 hours into the evening, take work home, come in early, work on weekends or just plain get behind. Of course, getting behind results in repeated calls from patients and various other sorts of rework, and it results in dissatisfaction for all – patients, physicians and staff. In some instances, of course, it also delays crucial care or response to really bad results.
I'm going to be writing a few entries about how we deal with the indirect care in my clinic. Today, I'll start with how we handle outside medical records that arrive in our mail room. The sight of these wasteful tomes, and the thought that I would have to comb through pages and pages of single-sided print to glean the numbers and other nuggets of information I need, used to fill me with dread and loathing. We don't scan outside records into our EHR, so we have to selectively enter important information into the Health Maintenance Module – the outside labs and the problem and allergy lists, as well as any important results summaries and recommendations.
Currently, when a new patient's records arrive, one of our medical records/customer service reps (CSRs) goes through all the paper to reconcile the problem list, take any data on health care maintenance (preventive care dates and results), and where there is simply a consult note from a specialist, take the assessment and plan. The CSR then enters all this into the EHR. Then the paper records come to me with a top cover and I go through and highlight with yellow marker anything else that should be entered. I can generate a message for the patient if follow-up is needed. We have been trying this with our internist/geriatrician who receives way more than her share of this on complex patients who have moved to our community to be near their adult children. I am finding this to be very streamlined and can keep up on a daily basis, instead of adding the piles of paper records to bigger piles of things waiting for a time when I can finally peruse them.
I'm wondering how those docs who actually just scan all this in are doing. I would hate to see all the wasted data in those pages perpetuated in our system. For now, I prefer this information mining and documentation. Until the day when patients actually get their records exported to a flash drive from wherever they receive care, or have a web portal where all their information is collated, we're doing incremental improvements.
How do you handle incoming records in your practice? Have you found ways to ingest all that information quickly? If your practice scans the paper, I'd be particularly interested in hearing your rationale.
Stay tuned for more on the flow of indirect care.