The next to last step to work on, on your march towards EMR mastery:

Step 4: The 80/20 Rule

Also known as “The Pareto Principle,” the 80/20 Rule is extraordinarily useful. It’s a principle of economics and management, and is most often cited today by entrepreneurs (like Tim Ferris) needing to keep vast amounts of data and responsibilities manageable. Sound familiar?

At the EMR 101 level, the 80/20 Rule goes like this:

• the vast majority of your daily patient encounters occur around a handful of clinical diagnoses

which translates into

• the vast majority of your daily documentation can be done with a handful of templates or pages.

This was alluded to in the last post, under Step 2: Get Familiar With TWO Workflows, Tops. You can go far with this one; long after you’ve graduated to speedier, more specific templates, you’ll still be able to fall back to your “old faithful” workflows whenever confronted with a condition laying outside of what your EMR was designed to handle.

But this principle extends way beyond this:

• 80% of your headaches come from 20% of your patients
• 80% of your office income comes from 20% of your health plans
• 80% of your inbound calls are about the same 20% of daily tasks (e.g. refill requests and lab reviews)
• 80% of your going home late comes from 20% of your documenting habits (e.g. doing crib notes, then going back later to reconstruct the full notes)
• and so on

Once you start seeing these trends, you can start to prioritize where to direct your attention most efficiently. In medicine, of course, you’re trying to encompass 100% as your goal; the 80/20 Rule is NOT about letting 20% of your work go undone, or missing the critical diagnosis 20% of the time!

But if you’re swimming in a morass of seemingly undifferentiated tasks, this rule can identify what to fix first to give yourself the most breathing room. Make 2 or 3 changes that lift the “crush” of your workload off of your back, and you will be much less worn down.

And “much less burnt out” means “less likely to miss critical things.”

Take That Step, You Can Do It

Think about it: take a bit of time now — when you’re floundering, I know — to regain yourself heaps of time from now on.

Push back from your desk and find a handful of problems to fix — pick 2 to start with. I’ve had great success with the following, which ultimately enabled me to end my workdays about an hour earlier than before:

1. batch processing lab reviews or med refills for 15 minutes at noon, and 15 minutes at the end of the day (instead of sprinkled throughout the day — barring any urgent values, of course)
2. finishing notes as you go, and getting rid of the “crib notes/reassemble later” habit

See how much time and energy you get back with just those changes. Then look again, find some more “big bang for your buck” issues, and go at it again.

Reclaim your day, one swipe at a time.

Next time: EMR 101, Part 3 – The Final Chapter

I’ve seen it in a variety of practices, my own being no exception.

Free texting to document a patient encounter.

You’ve got your clickers, the orientation spiel goes, and ya got your typers.

Me, I’m a typer, but the system allows you to document any way you like. To each his own, and I love the look of my own text!

So, when your IT folks suggest that you align yourself with the clicker column, so to speak, you might find yourself getting a mite…testy. Vocally belligerent, even — it’s a free country, and I’ll free text, doggone it.

What follows are some thoughts about why you might want to reconsider. Reeeally reconsider…

“Join Or Die”

America’s first political cartoonist, Benjamin Franklin, penned the following image, encouraging the colonies to pull together, during the French and Indian War:

A bit ominous, granted, but you get the drift. United we stand, divided we fall. And if you’re curious, the officially sanctioned “EMR cause” to join these days is discrete data entry — button clicking.

Free texting is that squirrelly separatist inclination that weakens everyone, in the face of hostile forces. Which makes sense from a strategic perspective: everyone proudly doing their own thing with a disdain for documenting consistency, can’t be good from a unity standpoint.

But in this case, the enemy isn’t France and its agents on the 18th century frontier — and if you want to text freely, the enemy isn’t your EMR vendor, either.

It’d be easier for them to make an EMR into a big, free-text machine (they’re called “word processors”), and infinitely harder to make it into the interlocking databases that true EMR’s are. Keeping track of button clicks and cross referencing list choices must be planned out in advance, with tons of user input and testing. If it’d get the job done, EMR vendors would be ecstatic at doing away with all that data juggling, and letting doctors type, cut, copy, and paste on blank screens.

Collectively, the “enemy” of free texting your entire note is any and all forces that make discrete data tracking a necessity. I’ll come back to that in a bit, but for now, remember:

Lesson #1: There’s a wolf at the door, and much as we’d like to blame the establishment, it’s NOT the EMR vendor.

So Big Vendor’s Our Friend, Eh?

You’d better believe it.

Keep in mind that any business, especially a moderately big one, will prefer to keep its internal processes simple, and its customers happy.

In EMR Vendorland, the current trend is towards button clicks and list choices, despite the fact that

1. doing so involves much more programming complexity, and
2. loads of physicians, especially from small groups or solo provider offices, want free texting

Better yet, this same group loves text macros — small programs that can run in parallel with EMR software, enabling sentences or paragraphs of a doctor’s own text to be recalled and inserted with a few keystrokes.

So are EMR vendors purposefully peeing into the wind? Doubtful, or they won’t be around for long.

Lesson #2: The EMR vendor wants to keep you a happy, faithful customer; there’s a reason for the apparent paradox in not recommending free text, everywhere for ever and ever, amen.

So What’s More Important Than Market Share?

And quite a slice of the marketing pie it is.

According to the National Ambulatory Medical Care Survey in 2003, 38.5% of physician practices are solo practices, with 73.1% of all patient visits occurring to doctors offices with 4 or fewer providers — and more than half of those visits are to solo practitioners’ offices.

And pardon me for saying so, but there’s a certain correlation between small/solo practices and wanting to document freely. You can’t make it in a small private practice without singing “My Way” in the shower all through med school.

Put 2 and 2 together, and you’ve got a lot doctors and patient visits potentially leaning towards the free texting movement. As in, “2 out of 5″ practices, and “7 out of 10 patient visits.”

If EMR vendors aren’t aware of this math, and are deliberately pissing off folk who may prefer documenting their own way, that’s a pretty suicidal business strategy.

UNLESS…there’s something more detrimental to the vendors’ future than pissy small or solo group customers.

Lesson #3: If the healthcare system itself tanks, we’re all going down.

“I’ll Kill You Later”

I’ve alluded to better and brighter minds than mine in a previous post. Apparently, the new Health & Human Services Secretary, Tom Daschle, and President-elect Obama are among them: EMR’s are figuring universally in any major plan to fix the American Health Care system.

My understanding of this is evolving, but in a nutshell, whether fatally broken or just really badly in need of repair, you need accountability to have a hope in heck of fixing the system. Meaning, track what is going where, how much it costs, what your outcomes are, and how long it takes you to get there. Get a baseline, tweak, reassess, and repeat.

THAT’s the basic, iterative mechanism that is coming (and It Cometh On Like Gangbusters):

• What’s your specialty’s average “score” at treating Condition X?
• How does your particular practice measure up?
• What are your competitors’ scores?
• How do they compare on cost?
• How do they compare on convenience?
• Why should patients come to you if your overall measures are lower?

You see where this is heading?

Re-rank the following, in order of overall significance:

• Survival of the entire healthcare system
• Survival of your practice within it
• Your insistence that “ctrl-U” spits forth your personal Urinary Tract Infection protocol on the progress note

Lesson #4: Time to get our heads out of the sand — we can argue documenting convenience later, but we will need stats and numbers to fight with real soon. For the survival of our practices, as well as the system, itself.

Youcandoitthehardway…

Or you. Can. Do. It. The. Easy. Way.

Believe me, you’ll want to do it the easy way, because “it” is going to mean combing through the data of your practice, your region, maybe even your specialty, not just for one medical outcome, but many, and not just once, but periodically, on demand, as your practice and patient demographic changes.

Again, this is the Iceman that is coming. THIS is the wolf at the door: assessing, improving, and justifying your practice’s data. It won’t matter whether it’s for your medical director, your IPA, an insurance carrier, or a government agency — data mining is as inexorable as an avalanche, and as such, you don’t argue with it, you just deal with it.

Free text strings are gobbledygook to computers. The most beautifully worded, stylistically perfect text paragraph is just one long ream of alphanumeric characters to a computer. Meaningless, so far as data mining goes, like a string of Attic Greek characters with no spaces in between.

That’s nonsense, you say, I can run a search on my text heavy records, by specifying a search string! I always use “A1c” when referring to my diabetics’ glycohemoglobin, and I always put it in field 271 on the progress note! Don’t tell me my EMR can’t accommodate my particular free texting when it comes to running reports on my diabetics!

That’s great, really it is.

What about your partner? Or your other local colleagues, or your group as a whole? Are all of them using “A1c,” or or some of them using “HbA1c,” or “a1C?” Maybe some of them put the value in field 271, but others don’t enter it at all, it’s entered automatically into the lab module via a lab interface, on page 2, field 37(b).

Your report generating strategy takes a geometric leap upwards in complexity, the minute you step out of your own practice. Why can’t different EMR’s consistently talk to one another? Sheesh, why can’t individual doctors document in the same way?

It’s Like The Jim Croce Song

Listen to a copy, if you can find one; it’s a cutie:

You don’t tug on Superman’s cape.

You don’t spit…into the wind.

You don’t pull…the mask off the old Lone Ranger,

And you don’t mess around with Jim.

Lord knows, solo and small group providers fight the good fight, every day. And not all such doctors resist “documenting digitally,” as I put it, i.e. with discrete data clicks.

But as anyone in the industry knows, it’s a recurrent phenomenon, and a recurrent refrain:

I want to document in the free text blank spaces, I want to copy and paste previous just-so notes, and I want to do so everywhere — history, exam, plan, all at once, preferably.

That impulse is understandable; it’s behind some vendors’ efforts to create “do it once, remember it forever” options for saving and re-using favorite pages.

But too often, there’s another impulse on the heels of that one: I could care less about data mining, or defending myself in case of a chart audit, or making it easy to compare my “numbers” with my peers’. Less, in other words, about any concern but my own documenting speed and ease.

Newsflash: if you count yourself among this group, the days when speed and ease were your biggest worry are OVER.

There’s a reason for going along with clicks, and it’s spelled D-A-T-A. With it, you and your fellows can go toe-to-toe with The Wolf, The Iceman, Jim, and his successor, Slim.

Just Click and Save, boys. Just Click and Save.

I’ve never read anything by Joseph Stalin, but I gather he’d be much in demand for implementing EMR’s. From the management side, not the physicians.’

Dr. Cephus Allin’s presentation today, which referenced the late Soviet dictator, was titled How To Go From Paper To An EMR. It totally rocked; I wish I’d attended his other session, Why Everyone Needs An EMR. But that’s what happens when you have awesome content hidden behind modest titles.

Major take home points:

• shunt work more efficiently away from physicians onto support staff when possible
• less MD time/task = more patients scheduled/day
• abstracting the chart is much more important than scanning it
• limit the abstracting to absolutely necessary items (like problem list w/ICD-9’s, allergies, meds)
• limit the scanning to 10 pages per physician pass, and 3 passes, max, before bye-bye chart (ekg, last CPE, critical study reports/consults)
• when staff are limited and already multitasked-out, extend the go-live timeline, and adopt more incrementally and slowly

And that, indubitably, there are practices that just ain’t suited for EMR.

It’s not easy, defining the 6 Deadly Features, or whatever, Of Practices That Are Destined To Fail Implementing An EMR. There are too many ways for such a complex endeavor to go south, in what Dr. Allin termed “the toughest transition a doctor will ever do.”

Plus, it’s understandable that an EMR vendor isn’t going to dwell too long about clients it won’t be selling to. That’s a matter for the MSO’s that implement the setups, which must budget enormous but finite time and manpower resources to making things work.

What was more widely agreed upon across the expo’s sessions were the features of implementations that succeeded. Not surprisingly, the most important of these starts at the top, with our good friend, Joe.

There Must Be Champions, And There Must Be Management

Or as Dr. Allin put it, Mother Teresa and Joseph Stalin.

Good Cop, Bad Cop.

In a small practice, these two hats may have to be worn by the same person: setting the positive, “We can do this” tone, and cracking the “Failure is not an option” whip. But ideally, this is done by folks dedicated to these separate duties, which also extends post implementation to balancing wish lists of new custom features (Doctor Teresa) and hard-nosed reality checks (Office Manager Stalin).

One audience member cited the extreme case of a large group that had to be coerced into EMR; the local organizing entity refused to renew the contracts of MD’s who did not adopt it. While not standard business practice, it was the second time I’d heard of things going that far.

Translation: There are a million ways that an implementation can fail, and ten thousand excuses. But it all starts and stops with the absolute commitment to success from the folks at the top. “Yeah! We can do this!” and “You had better believe we are gonna do this.”

You Have GOT To Be Serious

The key phrase, here, is absolute commitment.

Why does every talk about EMR implementation start with the requirement of having a “physician champion”? Even though the physician may not be the key to the smooth functioning of the office (whereas a good office manager always is)?

Because like the fighter jet examples that Dr. Allin used, it really is ultimately about the pilot, i.e. the physician. The fighter jock couldn’t get off the ground without a crew chief, team of mechanics, communications assist, etc. But in the end, nobody argues: it’s all about getting the pilot in the air.

And if the pilot’s attitude sucks, then everything is for naught.

It’s natural to be cautious when examining the prospect of change, and to chew your lip when contemplating a transitional drop in income, and resource allocation for training yourself and your staff. But once you make the choice to proceed, you must be positive, motivating and encouraging. Lead, and lead by example, that this will all work out, you’re all in this together, and everyone’s efforts during the transition are vastly appreciated. Your support crew, be they two or twenty, will take their cues from you.

Sometimes the physician champion isn’t you, it’s a colleague who years ago was standing exactly where you are now, and has successfully navigated the process. Take heart from that, but do your own due diligence: in addition to training arduously at navigating the system, go visit your colleague’s practice and learn how he or she works the workflow. Dr. Allin called this “double shadowing”: folks shadow you to teach you the EMR in your environment, then you shadow a successful adopter to appreciate how an efficient office can and should function.

If you can’t be King Arthur, no one should be seen working harder than you-as-Lancelot.

And Now…Back To Joe

It’s relatively easy playing Mother Teresa; what’s hard is saying “No.” Or, “No thank you, we won’t be needing your services any longer.”

This is hard in small offices, where a staff member may have been with you for years, but is obstructing your path to EMR, repeatedly, and seemingly immune to more training sessions. The nuclear option of letting someone go in a small office can mean losing 50% of the support staff. It can seem especially unthinkable when that support staff is family — an all too common scenario noted by presenters and implementers, especially in 1-2 MD practices.

“And for what — a new way of taking notes?”

This goes back to that squiggly target of What Will Sink An EMR Implementation, but you have GOT to have Joseph Stalin on your side. Or put another way, if your practice’s Joseph Stalin isn’t as committed to adopting EMR as you, the champion, are, and isn’t murmuring, “Failure is NOT an option; we’ll float this puppy, one way or another, never fear,” you are doomed, doomed, doomed.

The Round Table would’ve sunk — did sink — once Lancelot undermined Arthur; if the crew chief doesn’t sign on to the latest engine upgrade, the fighter jet stays on the ground.

This isn’t about taking something that’s a monumentally bad idea and cramming it down your throats — if that’s your conclusion after considering EMR, either of you, then stop right now.

It’s about adopting a technology that will in the foreseeable future be required to continue the practice of medicine in America, at one level or another. A technology that will in the near future post implementation, enable you to see at a minimum your same, pre-EMR patient volumes, with greater coding efficiency, accuracy, and therefore reimbursement.

A technology that if you persist in refining its use, will enable you to see more patients than before, with greater patient safety, fewer callbacks, and the capacity to do previously unimaginable things, like notifying all patients on a just-recalled medication, or checking what percentage of your diabetics really do have HbA1C’s less than 6.5, or sending letters to all your patients overdue for their last fill-in-the-blank test or visit.

It’s an adoption process that can be gotten through. If other staff is less than enthused, you can still get through it, if you’re leading from the front, and your Joe Stalin is pushing or yanking or replacing them from the rear.

Without Joe’s support, not even Mother Teresa and King Arthur combined will float your EMR.

There’s a time to scramble, and a time to sit down and get deliberate.

When I first started working in a non-academic, community based practice, my medical director advised me to handle “tasks” on the fly: between each patient seen in the clinic, take care of 2 things, like a med refill, patient callback, or lab result.

For the first several years before EMR, this worked well enough — I didn’t have huge piles of paper to contend with — but there were still times I walked to the car at 7 PM.

As a primary care physician, the mass of incoming tasks, in order of bulk, was

1. lab results
2. appointment requests
3. medication refill requests
4. patient callbacks

In order of urgency of outgoing tasks, however, the list was more like this:

1. patient callbacks (especially for come-in-now problems)
2. grossly abnormal lab follow-ups
3. specialist call-ups (for appointments, or ambiguous notes)

Either way, the mass of data and time to be processed was huge, and never ending.

There’s A Time To Bump, And A Time To Grind

Even in the first few years of EMR, I continued to deal with these tasks in between patient rooms, but it was taking a toll on my staff. See a previous post for an explanation why.

Furthermore, it became clear that there were 2 sets of urgencies: 1) things that were sheer volume based (bale this boat regularly or drown), and 2) things that were time based (few in number, but each needing 20+ minutes to complete).

Your own workflow is much the same, regardless of specialty. Some tasks will be simple and numerous, and others will be moderately complicated.

Your first impulse will be to apply the “whiz it out” method to everything, but it only works for the simple stuff. The complex tasks, it can worsen by shifting tremendous burdens to your support staff.

“Batch Processing” To The Rescue

Timothy Ferris elucidated this concept in his book, The 4-Hour Workweek. As I’ve noted in my other medical blog and podcast, busy medical professionals can learn an awful lot about time management from busy, financially driven entrepreneurs.

Batch processing means that you group similar tasks together, then deal with them all at once. The business analogy is that eternal time waster, email: doing one task, answering a few emails, doing another task, answering a few more emails, and so on. Business folk can have hundreds of emails a day, not unlike physicians having hundreds of labs and prescription refills to review each day.

Instead of mentally shuttling from task 1 to prescription refill, then out to task 2, then back to refilling, then out to task 3, and so on, you just get into refill mode and blast through all your refills. And eliminate all the little back and forth transitions between the different types of tasks.

This seems to work best on items of moderate complexity, like lab results, or chronic medication refills. Sometimes you can just look at a lab or refill request and quickly address it, but often you’ll have to think about the patient’s other chronic conditions, and when they were last seen or tested. This consideration involves a certain mindset, which may be very different from the patient care mindset you’ll use 3 minutes hence.

Shift mental gears less often, and you’ll move quicker and be less fatigued at day’s end.

And again, by batching similar tasks, you avoid passing needless scut to your staff, just because you’re in “bump” mode, and you hit upon a “grind” task. (Ferris characterizes this as not increasing the entropy of the universe — working leaner overall, instead of just passing the buck.)

Make Batching A Regular Part Of Your Day

Set aside a couple brief chunks of time — say, the first 15 minutes of your lunch break, and the last 20 minutes at the end of your day — to batch process your medium complex tasks. (Take the first 1-2 minutes to quickly review your “pile,” to set aside any quickie or critical tasks that may have snuck in.) Then grind your way through, uninterrupted.

You can always handle the quick and numerous tasks as they come in — you will have to, to avoid death by a thousand cuts. But batching gives you another tool to attack your workload, one that puts more of your focus where it’s needed for patient benefit, saves you time and mental fatigue, and decreases staff stress.

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