I have always felt the pressure of the balance between productivity and quality. I respect what the health care administrators do; they keep operations running efficiently and effectively. By doing so, the clinics have the resources to provide care. However, sometimes I am really at odds between the need for greater productivity and the importance of quality care. Can you have both at the same time? Sometimes they seem inversely proportional.
I have always believed an ounce of prevention is worth a pound of cure. But how much time do you really have during a patient appointment to address these very important issues, before you have to say “please schedule up a follow up appointment so we can address your other concern?” I understand that it’s hard to get out of work or school to come back to the clinic or hospital for another appointment, and again sit in the waiting room. I’ve sat in that same waiting room, sometimes for hours, so I truly understand how time-consuming and frustrating it can be to “follow up” and address an issue other than your chief complaint.
However, the preventive medicine part of me knows that if I can get a patient to follow up and spend the time to address a preventive problem, such as tobacco use, by initiating a tobacco cessation program, the patient has a much better chance of quitting. Nearly 20 percent of American’s smoke cigarettes today, leading to approximately 443 thousand deaths a year. These preventable deaths cost the nation approximately $193 million in health care costs annually. In addition, I have treated the patients who suffer from serious illnesses related to smoking, such as emphysema or chronic bronchitis. In those cases, the patient’s quality of life has become very poor and I feel compelled to do what I can to inspire them to quit tobacco at that time. So how, as a healthcare provider, do I find the time in a short 15-minute appointment block to address not only the patient’s chief complaint, but also other preventive measures? Amazingly, I found the time I needed through the use of electronic health records (EHRs).
Not so long ago, I was one of the lowest producing providers at the hospital where I see patients, due to the fact that my total Relative Value Units (RVU) were just too low. At the clinic, we used an electronic health record (EHR) that did automated coding. As you can imagine, I quickly blamed the EHR for my performance. Truth be told, I am not an expert at coding. I was awful at filling in a bubble sheet and although the EHR seemed like a vast improvement, it was still coding! Well, the excuses didn’t get me very far. So what changed? Our current chief medical officer (CMO), who at the time was an EHR trainer for the Department of Defense (DoD), came to clinic one day with the premise that he could help me better optimize my use of the EHR. I thought, “Optimize me? Really?” But he assured me that he could optimize even my patient documentation in the EHR. He observed my practice and provided me several pointers on how I could use the EHR more efficiently. There was nothing major, but the collection of small best practices returned minutes on every patient note and throughout the day, that added up. That was certainly a good start. But what about the RVU? Well it turned out that by simply making sure I correctly placed the diagnosis in the proper order, everything had changed – I went from one of the lowest RVU per hours per day, to one of the highest. The best part was I really didn’t have to make dramatic changes and it gave me time back, which I would have otherwise spent documenting patient care. I was then able to shift the time I was spending on coding to focusing on preventive care. In the end, I was able to have my cake and eat it too.
I was so inspired by what that EHR trainer did for me in clinic that he now works at MicroHealth as our CMO. I realized that day that he wasn’t just another physician or EHR trainer; he was, and still is, a clinical workflow guru. He made a program that seemed otherwise static, dynamic and accommodating to my workflow. I believe he can do that for anyone feeling frustrated with his or her EHR. But, what he really did for me is resolve my odds with productivity and quality. I no longer had to compromise and could spend the time I needed on preventive care, patient education and care plan management. I am now looking forward to reviewing the data from the population health system to see the impact made with regard to disease and injuries. As a public health practitioner, I have to believe, the difference has already been made and that time will prove the value of prevention at the point of care.
