Improving Efficiency Using the EHR

By Erica Remer, MD, CCDS

During our hiatus, I read an article from the AMA entitled, “With 2 new patients a day, medical scribes are profitable in one year,” by Sara Berg. As I am sure you are all aware, physicians are experiencing burnout directly related to spending excessive time managing the medical record instead of the patient’s medical care. 

This article led me down a rabbit hole of other references and some AMA (CME credit provided) modules regarding scribing, team documentation, and eliminating inefficiencies derived from the EHR. Here’s what I learned:

  • The number of additional patients per day to recoup the cost of the scribe varied according to specialty and whether the patients were new or established. The addition of 2 new or 3 returning visits per day resulted in profitability across all specialties. 
  • There are two models:
    • Clerical documentation assistant (CDA) model where there is one dedicated CDA per physician who accompanies the provider into each patient encounter and their sole purpose is to assist with record-keeping. This is the traditional scribe model, and the scribe is anchored to the provider.
    • Advanced team-based care model, where there is a set of nurses or medical assistants who perform both clinical support functions and do the clinical documentation. They do pre-visit duties like take preliminary histories, set up orders for health maintenance tasks, and review medications; they return with the provider and scribe during the visit; they do post-visit provision of med list, visit summary, and patient discharge counseling. This model anchors the assistant to the patient freeing up the provider to travel to the next room, patient, and medical assistant.
  • There is a significant increase in provider and patient satisfaction with the use of team documentation or scribing

In the AMA STEPSforward module from 2014 they detail the process to effectively design and implement team documentation. In a nutshell, you need to determine who will participate in whichever model selected, start with a pilot of motivated personnel and use it on a limited basis initially, design and plan the work flow within your system, and conduct weekly touch-bases to assess, review, and tweak the system.

Another click of an embedded link led me to an article from February 2020 regarding a program implemented by Hawaii Pacific Health called, "Getting Rid of Stupid Stuff." The concept of this initiative is to identify and eliminate EHR inefficiencies. More details were forthcoming in the original NEJM article by Dr. Melinda Ashton and in another STEPSforward module

Employees (including healthcare providers) were enlisted to identify interactions with the documentation experience which they perceived as being poorly designed, unnecessary, inefficient, or “just plain stupid.” The justified suggestions fell into 3 broad categories:

  1. Never meant to occur and should be eliminated promptly (10%)
  2. Needed, but could be more efficient (75%)
  3. Required, but not understood (e.g., those tools existed already, but the user was unaware of them) (15%)

Actions included elimination of fields or tasks, adaptation of templates, reduction in number of clicks required, removal of gratuitous alerts, and education of providers of capabilities already built into the EHR. The healthcare system was surprised at the amount of time (and money) saved. Decrease in documentation burden increases job satisfaction and productivity.

A final suggestion comes from my own repertoire. Providers should confer with their partners or colleagues and compare tips and tricks. The first day of my PA orientation, I saved a seasoned CDIS 20 minutes a day by teaching her about the trend function in our EHR. Up until then, she would open a lab, review and close it, open the same lab study from the previous day, close it, and repeat. Another tip is to import and utilize colleagues’ acronym expansions or macros. 

The best people to improve efficiency are the ones who use the system and need to be efficient. Anything we can do to improve the function of our medical staff will improve our lives and the care of our patients.