familygal Posted March 19, 2014 Share Posted March 19, 2014 Anyone else have a system that basically requires them to chart at home in the evenings? I really don't know how I can continue to sustain this! I generally take about 2 extra hours in addition to my clinic hours each evening to finish up my progress notes on our EMR system (this doesn't include going through labs and stuff). I'm about 5 1/2 months into my first family practice job (however I've been out of school for nearly 6 years) and the evening charting every night is killing me. Granted, I'm still a bit slow and I know I'll be faster each month. I see 14-16 patients per day at this point, working my way up, and we are using eClinical Works. Its a challenge for me to finish the note on each patient visit during the patients' visits; I will try to get in most of the HPI while I'm there in the room, the physical exam, and bits and pieces of the A/P and billing. There's tricks with the system to make it go faster that I'm still getting the hang of. I've tried to limit the amount I type, i e avoid typing long paragraphs, but the charts just don't seem to get finished and I'm ALWAYS working on them in the evenings. I would think it is just me, but my two SPs aren't able to finish their charts during the day as well and do a significant portion of their charting outside of clinic hours. I have never had this much extra "homework" in other jobs (yes, yes, the nature of FP) When I talked to a few of my friends who work in primary care, they think it might actually be an inherent fault in the EMR system. Nonetheless, if anyone has any tips/tricks for quicker charting it would be much appreciated! Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 19, 2014 Moderator Share Posted March 19, 2014 this is a problem. you are working for free as are your partners. I refuse to do this, but working in em it's easier to do. if I start getting behind I just don't see any new pts until I'm caught up on charts unless something critical comes in. most of the folks with back pain x 15 years in the er at 2 am can wait 15 more min to get my undivided attention. Link to comment Share on other sites More sharing options...
Maverick87 Posted March 19, 2014 Share Posted March 19, 2014 My questions to you: How many hours do you work? How long are your appointments? Do you get lunch? Do you have any additional duties besides seeing patients? I work in a military family practice setting. I'm required to see 18 patients a day. My days are 9.5 hours (including lunch). Basically, what I do is take notes on a piece of paper while I'm talking to the patients in the room. I don't BS with them. I get them in and out as fast as possible. I limit them to 2 complaints per visit. If they have more, I tell them to follow up. I try to finish each note after I'm done with the patient. If I'm unable to do this, I pretty much wrote my note out that piece of paper that I take in with me (I would do EMR during the visit, but the military EMR is awful....so it's not even worth the effort). I also cram patients into 15 minute time slots and see a bunch at one time. I tried setting my template up this week to allow me 30 minute appointments to give me more time with patients. Now, I'm slightly backlogged in encounter notes and massively backlogged in labs. I will revert back to my old template after this week, for sure. Unfortunately for me, I'm still a new PA (1.5 years since graduating) so I still get in over my head at times and need to get advice from the more seasoned PAs and the docs. That also puts me behind, though not as much as spending too much time with a patient and addressing too many needs at one time. Link to comment Share on other sites More sharing options...
Avalon Posted March 19, 2014 Share Posted March 19, 2014 I totally feel your pain. This is all too familiar a story for me. I worked in family medicine for three years in a setting using eCW. I worked through lunch and stayed late virtually each day; then, I logged on to eCW from home for another 2+ hours. My weekend plans always started with deciding what 4-5 hour block of time I could carve out to finish notes, review labs, and preview the next week's patients. Templates were only minimally helpful, as they still had to be ammended for the specific encounter (nothing is really ever that fully "routine"). Admittedly I am a bit of a perfectionist; consequently, I set a high standard for myself in terms of the comprehensiveness of the notes (a standard not even attempted by my SP). Ultimately, I departed for specialty medicine in a practice still using paper charts. It was a difficult decision, and I truly miss the challenge and the breadth of primary care, but my time is now my own after hours and I am no longer, as EMEDPA suggested, giving away my limited family time "for free." I felt quite validated by the study (last summer, I believe?) demonstrating that the EMR in an ED setting added 16 minutes per patient encounter. Best of luck to you in finding a balance. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 19, 2014 Moderator Share Posted March 19, 2014 I have attempted as much as possible to avoid places with terrible EMRs (like medetech). My primary job is still paper charts, but we are going to epic next year. I have used epic in various places and in multiple formats since 2000. it's not a great system but it's not the worst either. I use cerner at one of my rural per diem jobs, which I prefer to epic as it is more intuitive and flows better. rural job #2 is also on epic. My overall preference is electronic T system, but most places are abandoning it for, you guessed it, epic. unfortunately epic is really designed for primary care and we are forced to try to make it work in em with minimal success. VS paper cerner probably adds 10 min to each pt encounter and epic probably more like 15. even a suture removal in epic requires a full note with medical decision making, a full template, a procedure note, etc. totally ridiculous. if places want to double staff to see the same # of patients I guess that is job security for those in medical fields. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted March 19, 2014 Share Posted March 19, 2014 E, why are folks abandoning T-System? I always found it (paper form) to be intuitive and FAST. Aside from some initial consultation work, I never had the opportunity to play with the full electronic system. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 19, 2014 Moderator Share Posted March 19, 2014 WE AS A GROUP NEED TO STOP WORKING FOR FREE Sure the Doc's are doing this but they are PARTNERS and are paid 2-3X's what you are..... It is a horrible habit to start, and one that must stop - schedule a meeting with the doc's - express your concerns - state that you need to be able to finish you notes at work - 15 patient days should be reasonable to finish all notes - ask how to speed up. Advise them that you will not continue to give your free time to the clinic for free and that you don't want to work that much There is some responsibility for you to get it done and learn the system, but after a few months you should be up to speed on that. If you do not use a voice to print (Dragon) ask them to purchase it for you ($1300) - this is much faster then typing Use templates in (I think eCW has these??) - set up for an urgent care visit at min - so that you can just blow through a visit Practice issues - MAs need to be putting in vitals, checking in patient, getting heights and weights and BPs, they enter CC (and yes you have to limit the patient to 1-2 issues per visit) Unfortunately you have to get used to cutting the patient off, being the person to keep the visit on track, keep it flowing. I find that if the visit is bogging down I do two things - first verbalize that they patient needs to pick one thing to address, and if this does not work just stand up and start the exam..... Move it along - most visits should not have any more then about 10-15 min of discussion as most, followed by 5 min exam and Dx/Explanation talk I would say with a typical FP job - 15 patients a day for 4 days a week - 60 patients per week, should be very reasonable and you should be doing your charts at work in reasonable time. 80 is reasonable if you are proficient - anything more then this and it is too much Link to comment Share on other sites More sharing options...
Joelseff Posted March 19, 2014 Share Posted March 19, 2014 I'm in the same boat Family gal. I usually work through lunch and still take charts home. It's one of the parts of the job that I hate. Our EMR SUCKS (practice fusion) there aren't many shortcuts and it's very text heavy. Dictation has been suggested but I think I can type much faster than dictating accurately. In my last practice we used an EMR where you check boxes for HPI etc that allowed me to finish while I'm in the rooms. Sadly my practice cannot afford such a system though we are looking to change it. My physician also has these issues. Sent from my SAMSUNG-SGH-I537 using Tapatalk Link to comment Share on other sites More sharing options...
KMD16 Posted March 19, 2014 Share Posted March 19, 2014 eClinicalWork EMR comes with a manual. Request a copy from your administrator. Read the clinician section front and back. Create your own shortcut or shorthand. Like other had said. No point working for free. Link to comment Share on other sites More sharing options...
whoRyou Posted March 19, 2014 Share Posted March 19, 2014 WE AS A GROUP NEED TO STOP WORKING FOR FREE Sure the Doc's are doing this but they are PARTNERS and are paid 2-3X's what you are..... It is a horrible habit to start, and one that must stop - schedule a meeting with the doc's - express your concerns - state that you need to be able to finish you notes at work - 15 patient days should be reasonable to finish all notes - ask how to speed up. Advise them that you will not continue to give your free time to the clinic for free and that you don't want to work that much There is some responsibility for you to get it done and learn the system, but after a few months you should be up to speed on that. If you do not use a voice to print (Dragon) ask them to purchase it for you ($1300) - this is much faster then typing Use templates in (I think eCW has these??) - set up for an urgent care visit at min - so that you can just blow through a visit Practice issues - MAs need to be putting in vitals, checking in patient, getting heights and weights and BPs, they enter CC (and yes you have to limit the patient to 1-2 issues per visit) Unfortunately you have to get used to cutting the patient off, being the person to keep the visit on track, keep it flowing. I find that if the visit is bogging down I do two things - first verbalize that they patient needs to pick one thing to address, and if this does not work just stand up and start the exam..... Move it along - most visits should not have any more then about 10-15 min of discussion as most, followed by 5 min exam and Dx/Explanation talk I would say with a typical FP job - 15 patients a day for 4 days a week - 60 patients per week, should be very reasonable and you should be doing your charts at work in reasonable time. 80 is reasonable if you are proficient - anything more then this and it is too much ventana: Is Dragon accurate? I remember being a beta tester for Dragon and it was horrible Link to comment Share on other sites More sharing options...
burnpac Posted March 19, 2014 Share Posted March 19, 2014 I have been using an iPad based app, DrChrono.com for two years in my busy private plastic surgery practice, and 99 % of the time detailed consult notes and followup notes are completed before the patient has checked out of the office. It has adaptive medical grade dictation, faxing, eprescribing, links to labs, etc. It is completely customizable by the user. I will never go back to paper records or any other EHR. Sent from my iPad using Tapatalk Link to comment Share on other sites More sharing options...
Febrifuge Posted March 19, 2014 Share Posted March 19, 2014 I can type 45 wpm with no errors, or 55 wpm with about as many errors as Dragon gives me. On the other hand, I I have to spend time charting, I darn well make sure to mark it on my time sheet so I get paid for it. (I'm hourly.) Nobody has ever given me trouble about those hours. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 19, 2014 Moderator Share Posted March 19, 2014 E, why are folks abandoning T-System? I always found it (paper form) to be intuitive and FAST. Aside from some initial consultation work, I never had the opportunity to play with the full electronic system. because everyone is switching to epic, even though they know that t-system is better(and my last job that switched told as this). the reason to switch to epic is the "epic everywhere " function in the new system. if someone was seen across town at another place that uses epic 2 days ago you will see the encounter. most emrs are limited to one place. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 19, 2014 Moderator Share Posted March 19, 2014 dictation for me is the fastest option.2 prior depts allowed this but both switched to epic and did not enable the dictation option. I can dictate an excellent note in about 2 min. Typing the same note takes me 15. dragon is nice , but expensive. one place I was at allowed it, but individual providers had to buy their own set up. no thanks. maybe 3 of 40 folks did, and 2 of them were docs. Link to comment Share on other sites More sharing options...
whoRyou Posted March 19, 2014 Share Posted March 19, 2014 Interesting articles ... EMRs can slow medical charting Tips In Converting Paper to EMR Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted March 19, 2014 Share Posted March 19, 2014 As noted previously, I'm all for dictation. If this isn't an option then the T-System. From E's statement it sounds like the original docs here in the neighborhood who started the system sold out at the right time. Link to comment Share on other sites More sharing options...
Guest Paula Posted March 19, 2014 Share Posted March 19, 2014 Has anyone used Vitera system? That is the one we will be using and I start my training in April. This will be our second EHR and I hope it is functional and doesn't slow me down. I will not take work home with me. I refused a link to the EHR system on my home computer. I refuse to have a link to my work email at home. When I'm off, I'm off. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 19, 2014 Moderator Share Posted March 19, 2014 ventana: Is Dragon accurate? I remember being a beta tester for Dragon and it was horrible OH YES INDEED I type about 60wpm, but dragon is FAR FAR faster and accuracy is great You MUST pay attention to the processor, RAM and machine in general - don't load it on an old machine.... it will stink As for Practice Fusion - if you fill out the PMH tabs you can dump that all into the note with a few clicks in each note Use the templates (easy to set up new one) Pull from old notes for PE (MAKING SURE you read, and change at least one thing - exact duplicates are highly frowned on in audits) I honestly would not use Practice fusion if it were not for Dragon - and honestly the $1300 is worth it if you cn get the employer to pay for it - your charting time will got ALOT Link to comment Share on other sites More sharing options...
cinntsp Posted March 20, 2014 Share Posted March 20, 2014 I type about 60wpm, but dragon is FAR FAR faster and accuracy is great At what point is it really not faster or more accurate? I don't have any experience with dragon so I'm just curious. I type >110wpm with probably 98%ish accuracy. Link to comment Share on other sites More sharing options...
Derbingle Posted March 20, 2014 Share Posted March 20, 2014 Wutthecris your typing faster than dragon. Our dragon works very well but is not that fast. And has errors here and there, better as it learns your voice. Link to comment Share on other sites More sharing options...
SocialMedicine Posted March 20, 2014 Share Posted March 20, 2014 I question how much electronic chart saves clinician time. Absolutely it is more organized and requires less staffing. I am a huge proponent. But the electronic charts have a lot of useless features CLEARLY designed by a public health professional without any concept of the clinic operation. I use e clinical works ... a lot of survey and questionnaires such as the sexual history which take 15 seconds to run through minimum and do not have any clinical usefulness/ the questions are actually a bit odd and am not sure what they assist the clinician with. We are supposed to do it because we received some sort of grant and they want us to compile that data but I stopped doing it.... not enough time .... no clinical purpose .. It sounds like you are disorganized ... no offense. Learn the system. You can get exams saved (for physical and URI complaints) and edit the template based on the unique patient. if you people are spending 2 hours at home that is nuts. Link to comment Share on other sites More sharing options...
mainah Posted March 23, 2014 Share Posted March 23, 2014 I work for a FQHC in rural Maine and I have had the same struggles. Our EMR is slow and clunky (Compugroup), and at one point I figured out that I was spending 30 mins per pt doing their prep work/chart reading, and then typing out the notes. At 15-16 pts per day, that's over 7 hours of paperwork that I have been trying to squeeze in to a clinical day. I get to to work 2 hours early, do around 2 hours of work at home (I take lunch off to walk my dog), and then give up most of my Saturday reading new patient charts and to tying up any loose ends. This makes 0 sense as the clinic doesn't make money when I'm sitting in my office doing paperwork, and it's a huge chunk of my personal time. My SP also has to put in the same amount of personal time. I would love to be in the 18-20 patients per day range but that isn't feasible at this time. The job is challenging because of our remoteness. Our specialists are all over 2 hours away, and a large chunk of my patients can't afford the gas it takes to drive there, or refuse to ride for that length of time (especially during our harsh winters). Waiting times to get into some of these specialties are approaching a year. We also serve a small Canadian population that does not have easy access to primary care in New Brunswick and have the same issues in regards to distance to specialists and wait times. This means more often than not, I'm juggling complex chronic conditions. My average pt has 8-10 chronic medical conditions which I am trying to manage. As much as I would love to limit my patients to 2 complaints, so much would go unaddressed and the general health of our population would suffer. A large portion of our population are fisherman and getting them to come in off the boat to have multiple visits doesn't go over well. We were also understaffed for several months and our clinic is the only accessible primary care within 35-45 mins for a large population, which makes the demand for our services even higher. My clinic has come up with some solutations based on our concerns. First, I've been given 1.5 hours of admin time every day to work on paperwork. Second, I have Dragon, though it doesn't work well on our old laptops and I can type a note just as fast as I could if I were using Dragon. Thirdly, we are looking into hiring an experienced RN to do pre-visit planning: reading the pt's chart to see what they are due for for preventative screening and specialist f/us, calling them prior to their visit to get their labs done ahead of time, and also during a pre-visit phone call seeing what complaints they do have, so they know what to expect during their visit and we can adjust from the typical 20 min visit to a 30 min visit if needed. Our EMR does have a copy forward feature, so I can copy my last note with all the pt's chronic conditions and their exam, and then make changes as needed. I have started limiting my pts 2-3 acute complaints, and depending on the pt, will see if it's realistic to get them back to address their chronic care. We've also managed to recruit an NP to work with us to help relieve some of the pt burden. I love the job but know that this is a recipe for burnout. If anyone else has other suggestions, it would be welcomed! Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 23, 2014 Moderator Share Posted March 23, 2014 sounds bad but skip documenting much - bill level 2 visits for everything passive aggressive move Link to comment Share on other sites More sharing options...
gbrothers98 Posted March 23, 2014 Share Posted March 23, 2014 familygal i work in an ed and not a clinic but our facility installed an integrated emr fall 2012 and productivity has taken a hit since. i can speak directly to what i have done to be able to finish charting and walk out at the end of my shift without extra hours charting. in the ed my appts are not scheduled so it is not unusual for me to be charting on up to 6-7 pts at once. 1. chart at the bedside or in the room. means you have to manage the computer and the pt at the same time but that is what the world has become. 2. use all the built in functions of your emr in order to expedite charting. these would be macros, autotext, precompleted charts, copy forward prior notes. there should be a way for you to also group common orders and common prescriptions to expedite that function. eclinical works is actually a very reasonable system that is mature and well known. it has some if not all of these functions. there was someone responsible to teach you how to use this system, they should come back and teach you further. 3. stop free texting unless it is a few words, one sentence at the most. many emrs come with built in templates and many providers complain about their choices provided to them and want a more personalized note. if you want to continue working many extra hours then do so. i choose not. dragon is a waste of time i feel, much work for little return. 4. create no interrupt time to finish the chart. i choose this at the time of discharge in the ed. i tolerate no interruption unless someone is dying, literally. there is very little in this world that cannot wait 5 minutes. it is very easy to be too accessible to staff. 5. get more organized overall. read the one minute manager, it boils down to prioritize what is important and focus on that. at the same time quickly deal with what is important and dont procrastinate. 6.i agree with the suggestions that you have to focus the patient. school taught you to be warm and fuzzy. i teach students that they can be warm and down to business at the same time. its called being professionally in control and manage the encounter. 7.look at all the things you do as a practictioner and try to find things you can get support staff to do: refills, phone calls, letters, additions to the emr in medications and histories, referrals. 8. look at your usual day in the clinic. is there a pattern? are there many visits that are for similar conditions? can you template much of that? do you structure your appt day, chronic visits and health care maintenance in the am, acute complaints in the afternoon? scheduling the pt with 5 chronic conditions warranting follow up at 430 makes no sense. 9. negotiate for paid administrative time weekly. emrs, the aca and meaningful use have all tried to turn us into the highest paid secretaries and data entry clerks ever. some of this we may not be able to duck and dodge. this should not be take home work for you. i think the issue you bring up here is one that is widespread and rampant. there is no teaching productivity in school and no exposure to the reality of seeing a panel of pts real time and handle the documentation burden that has been placed on us. last, it may be worthwhile to hire a consultant to review the workflow in your clinic and make suggestions on how to be more proficient and productive. good luck, i feel for you. george brothers pac Link to comment Share on other sites More sharing options...
LIPPER Posted March 24, 2014 Share Posted March 24, 2014 We are primary care and are about 15 months into Eclinical works as well. I'll admit the first. 6-8 months were painful. I'm much faster now. 20/day with complete charting is a full day now. you will need to learn short cuts and master the order-sets and pre- entered templates. Gather your favorite rx's etc..... I also do spend maybe 1 hr in the evening if I'm laying around, scanning next day schedules, the hospital records (ps great source to data-mine for dx's/icd codes) .. Chin-up you'll get faster Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
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