Physician Health

Increase practice efficiency with EHR inbox management and prescription refill strategies

. 12 MIN READ

AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.

How to improve EHR implementation and documentation efficiency with time-saving strategies for physicians and resources to reduce physician burnout.

Our guest is Marie Brown, MD, MACP, director of Practice Redesign at the American Medical Association. AMA Chief Experience Officer Todd Unger hosts.

Speaker

  • Marie Brown, MD, MACP, director, Practice Redesign, AMA

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Unger: Hello and welcome to the AMA Update video and podcast. Earlier this year, we looked at the impact that prior authorization has on physician well-being. Today, we're going to talk about how inefficient workflows can also lead to burnout. I'm going to share two time-saving strategies that physicians can implement right now.

Joining me in our Chicago studio is Dr. Marie Brown, director of practice redesign at the AMA. I'm Todd Unger, AMA's chief experience officer. Welcome Dr. Brown.

Dr. Brown: Great to be here.

Unger: It's so amazing to have you in our studio today and excited to talk to you. I think we would be in complete understatement territory to say that physicians have a lot to do. Obviously, on top of caring for their patients, dealing with just the daily level of administrative burdens, there's also a lot of inefficiency that's just kind of built into their systems and it takes up a lot of time, maybe even like you don't even know how much time it's taking up. Let's start by talking about what the biggest workflow problems are that you see.

Dr. Brown: Well, thanks, Todd. And I'm glad to be here. It's wonderful that you framed it as what are the two strategies. And it really is simple. You can either stop some of the unnecessary tasks, so that you have time to start some changes and add to some workflows and team-based care.

So we strongly suggest to take advantage of all the unnecessary tasks that are there. And we have to stop this checklist. We have a deimplementation checklist of all the unnecessary tasks that add no value to the patient, no value to the organization, and lead to physician burnout. And if we focus first on eliminating those, we're headed in the right direction.

Unger: Now we're going to talk about in more specifics what those strategies look like. Again, I think one of the problems is people didn't even know the efficiencies that are kind of built into the system. What kind of toll do these kind of daily inefficiencies take on physicians?

Dr. Brown: An enormous toll. If you add up all the unnecessary tasks and the redundancy, and the duplicative work, it may add up to two or three hours a day of waste.

Unger: And that in an era when we already know physicians don't have enough time to spend with their patients, so they're spending probably twice as much time behind a screen as they are face to face. That's a lot of time.

Dr. Brown: That is. And what do our patients want? The last thing they want is to see the back of the physician. It takes time to build that relationship, to develop trust. So the same thing that the patient wants is our undivided attention is exactly what brings joy to the physician. That's why we were called to this wonderful career, to have time, to develop a relationship and to give our patients our undivided attention, to find out what's going on, what is that chief complaint, what is that symptom.

Let's develop the differential diagnosis. And then for chronic disease, we need trust to be sure that the patient is continuing on the regimen that we prescribed or the chronic medications.

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Unger: Well, that's a good place to start. Because let's go searching for some of that two to three hours a day. And one place we're going to start is with prescription refills. I think the information you've got is going to really surprise a lot of people. What should be done relative to what's happening right now?

Dr. Brown: Well, you can think of it as stopping the way we're usually writing refills, which is—And this is for chronic medications that aren't going to change. And so many of our patients are on antihypertensive medications, diabetes medications. And they're probably going to be on for the rest of their life.

And writing them 30 pills with 6 refills, and then the patient going back every month to the retail pharmacy, is just a waste of their time. Or even writing it for 90 pills with 1 refill. So we strongly suggest, and research shows, that writing it, writing a chronic medication prescription for 15 months, we say, 90 times for call me no more.

If you simply do that, which takes no extra time, no extra cost, and in some organizations have defaulted to 90 times four. Now you can change it back to 90 times 1 for whatever reason. But you've halved the work of meeting the refills. So we have nurses and team members who are the refill nurse for the day.

When their skill set is so wonderful and so expansive, they should be working with patients, not talking to every retail pharmacy in the Chicagoland area. So that one simple change, writing 90 times 4 or even 365 pills for the year, decreases the work by half. And that can be an hour saved for the physician and another hour or more saved for the team.

Unger: That's a huge amount of time.

Dr. Brown: Huge.

Unger: So let me ask you the obvious question. Why isn't everybody already doing this?

Dr. Brown: Well, it's because doctors care very, very deeply about the quality of care they give. And many physicians, when I speak with physicians around the country, are concerned that their patient won't come back in six months. And we need to work with our administrators to have a foolproof system in place. It's two parts.

One, the patient needs to absolutely make another appointment when they leave this appointment today. And if they miss that appointment, we have to have—And this is where the EHR can help us, a fail proof system to capture that missed appointment so that we can reach out to the patient.

We don't regularly have that in place. That is absolutely fail proof. So the physician uses that prescription as that holding the patient hostage. You know, most of our patients are going to come back as we prescribe, but we are so afraid that we'd miss that one patient. And we think first do no harm that we will put that extra hour of burden on our team, that extra hour of burden on our physicians and then that extra effort of all the other patients for fear of missing that one patient, who might be harmed if we don't follow up more closely.

So we don't have to do it for every single patient. If we're afraid that a patient won't come back or a certain medications needs closer follow up, then we don't write a prescription for more than six months. That's fine. And we continue to see the patient as often as we need to. It's not instead of.

So we write it once. And then when I see that patient in three months or six months, I'm not dealing with refills again. I know they have them for the whole year and we can focus on are you taking your medications?

Unger: I totally understand that as a patient. I really appreciate getting a longer prescription, like you're talking about. And I completely understand that I need to get back in and see my physician to get another refill for a long period of time. And that's in my best interest too.

So you talked about how much time that can save. It's the physician. It's the nursing staff. It's the office support across the board. How about another idea? Find us another hour.

Dr. Brown: The approach to the electronic health record. The burden that has put on the whole team. Yes, there's advantages, but an unintentional time wasted looking at inbox messages that do not need the attention of the MD or the DO.

So we have an approach to eliminate first messages that never should have entered the inbox to begin with. We are in a workforce-shortage time. Right? We can focus on hiring more people to empty the inbox or we can go upstream and say what really needs to be in the inbox. And we shouldn't think of it as the doctor's inbox. It is the practice's inbox.

So that the whole—It's triage. So the clerical staff receives messages that need to go there. The AMA receives messages that she or he can handle, same thing with our nurses, and our other providers. So the physician is rarely looking at the inbox.

Refills are handled automatically in some organizations. But certainly we talked about they wouldn't they'd be cut in half. But dc the cc. Discontinue the copying of result that's already in the chart. Remember what cc stands for. It stands for carbon copy. Right?

Unger: A bit of an old paradigm.

Dr. Brown: Yes. So we all share the same chart now. We have access to the same chart. So I don't need to see something that my trusted colleague that I've referred my patient to has done or test that has ordered. So if we do see the cc, we can save another easily hour a day and thousands and thousands of messages that unnecessarily hit our inbox.

Unger: And that's a big problem, because I think we all know now, at this point, especially with the pandemic, that these kind of patient portals, the amount of email coming into them, has just exploded. Hasn't it?

Dr. Brown: Right. And we have a tool kit on the patient portal. And whereas when we first wrote the patient portal tool kit, we were encouraging people to use it. Well, everybody's using it now, but we haven't changed our workflow to have the time to address what's there.

And it needs—the messages from the patient in the patient portal should never go directly to the physician. They should be triaged to the appropriate people in the team. And if it's something that needs to be addressed, it can be turned into a telemedicine visit. But we can also send out questionnaires, depression screening, social determinants of health screening.

We can start the chief complaint in the present illness. The patient can do it at home when they have the privacy and maybe some help from family. They can begin medication reconciliation at home, online. And then, when they come into to the doctor's office again, we give them their our undivided attention. And much of that paperwork, that solution, that production work is already done.

Unger: Now, these kinds of strategies that we've just talked about today, there are more, there are a lot more learning. Where can physicians go to find out more and how to implement these ideas?

Dr. Brown: Again, this is open access. This is at stepsforward.org. And we have 70 toolkits. Now, that's a lot. So we have taken the highlights and the best of those, and put them in playbooks. So the one that we're talking about today is called the Saving Time Playbook.

And there's three strategies. One, we start with stop the unnecessary tasks. And then two, change the workflow to be more efficient. And then three, make the business case, because we also all have to keep in mind that we need more access for our patients and provide them the tools they need.

And then, the second playbook is the Taming the EHR Playbook. And there we have things that you can eliminate pretty quickly. And when people have done that, including another one that I'd like to share with you, is the unnecessary re-entry of a username and password for a non-opioid drug every time you write that prescription in the electronic health record.

Somebody set that up with that many, many years ago when the EHR was beginning, and we didn't turn it off. And it's absolutely unnecessary. So just this year, two of the largest organizations in the country stopped it and saved billions of clicks.

Unger: That's amazing. Dr. brown, thank you so much for being here today and for all the work that you and the rest of our team do to really put the joy back in medicine. And again, if you're interested in finding out more about this, please visit stepsforward.org. So many incredible resources there to help you and your practice.

The AMA's Saving Time Playbook is just one of the many resources that we provide as part of our ongoing work to support physician well-being. The links are provided in the description of this episode. So make sure to check that out, including our next Saving Time: Practice Innovation Bootcamp. So check that out in the description.

And if you want to support AMA's efforts to reduce physician burnout, then join the AMA. You can do that at ama-assn.org/join. That wraps up today's episode. And we'll be back soon with another AMA Update. Be sure to subscribe for new episodes. And you can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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