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Greetings, all, I've written about once a month over the past few months regarding an evolving impasse at work concerning the requirement to document on EMR.

Now I believe a career crisis is upon me. In an effort to "help" me, the management of the practice has shunted all my new patients to other physicians and has attempted to offload me by giving me urgent care patients to see (in their thinking, the new patients are more detail-heavy and would take longer, but, ironically, I am actually faster seeing new patients because I capture their visits 100% on paper). This was decided for me and I was not involved with the "solution." Even more ominously, the CEO and one of the senior partners met privately with me last week to discuss with me their concern for how "wound up" I seem, and that the staff is complaining that I am asking too much of them. They suggested that I get some counseling because I seem so tense and depressed.

Sounds ducky, eh? The truth is that I am tense and depressed at work only - because I have said all along that the real problem I am having is being required to document on the EMR. On paper I am as fast as I ever was. But on the EMR it is taking me literally 3-5 times longer to encode a visit. The second meeting with me was about how I could streamline my input to cut out detail while still upcoding. I am definitely open to suggestions about how to do this, especially from the senior partner whom I respect (and who is himself not YET on the EMR because he had concerns it would impact his productivity - duh!). I am quite willing to learn. But the atmosphere under which this is being conducted is a damaging one: I am being treated like I am defective and solutions are being dictated to me, while simultaneously, nobody appears to be listening to me regarding what I think would help. That's because what I think is at cross-purposes to what the practice wishes to commit to: now we are "all-EMR, all the time" and despite getting high marks from my patients, I am now a liability because I have not been able to adapt.

So I have been witness to seeing all the patients who wished to sign up with me be distributed to other docs in the practice, and I also put the EMR workout to its truest test this past Thursday afternoon (I round in the hospital on all the hospitalized patients of our practice, mine and others, in the mornings) when I was scheduled for a full load of urgent care patients throughout the afternoon (rather than a mixed schedule of physical exams - which take longer, thus fewer patients get seen but the revenue stream is roughly the same for one physical to 3 urgent care patients). As I feared, having to get on the EMR for 14 patients instead of 5, despite the simpler issues, took me well into the evening and I took work home to get on from home to finish it there. I was falling asleep over inputting - was not even done by 11pm - because I needed to spend some portion of the time after seeing patients to also answer phone calls and sign off on labs and studies to be sure to leave work for my medical assistant to do the following morning while I would be rounding. Thus the documentation following seeing the patients had to come last (which would in the past, on paper, have been done SIMULTANEOUS WITH the patient visit and be DONE when the visit was done).

Bottom line: if this is what is in store for me, I am toast. It has been going on like this since March of this year when I was required to go live. I am quite honestly totally drained since all I do is deal with patient documentation and have not been able to get home night after night any sooner than about 9pm.

And it does not appear to be an option to let me do what I was productive doing previously. I am not given the option of documenting on paper now, even if someone else codes the visit into the EMR. Not permitted.

So hence the crisis. I would appreciate ANY comments from anyone who has faced a similar crisis. I am afraid that a bridge is getting burnt here and do not want to be precipitous in taking my leave but this is not a workable arrangement. I am literally depleted and am now witnessing the draining of future practice-building as well as uncertainty from the staff over how to respond to me since I am clearly so exhausted. It's pretty bad when the office manager wrote me a note in a card expressing sympathy for what has been happening to me and offering to help any way she could - that was certainly a nice gesture but it is hard to see how her help could extend to creating a 36-hour day given how I am told I must work.

Thoughts? To say I am discouraged does not begin to capture what it feels like to have spent 9 years in medical school and residency to reach this point. The first two years went well enough in this practice, under the old rules of how to document. This last year has been a travesty and it's hard right now to see how else to do anything any differently.

xraymd
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Greetings, Kahuna, you are correct that EMR stands for Electronic Medical Record. It refers in this case to an electronic interface that I am now obliged to use to document my patient encounters.

The thought of firing my "Major" made me smile. There is no such chain of command where I am working.

Instead, I am a salaried associate working for (and being paid by) the partners of the practice who have ceded their business decisions to the CEO. He, in turn, made the decision to commit to the EMR and the partners decided as a group to purchase and implement it.

There has been at least one ugly dogfight over it. One year ago, one of the senior partners left the practice, taking all of his patients and 1/3 the revenue stream, because he found he increasingly disagreed with how the EMR would become implemented. He's since opened his own practice (though I don't wish to go to work for him for a host of other reasons). In turn, our practice went into a pretty big deficit for a year while trying to cope with the loss of a productive physician. Just this July, we joined forces with another doc who was partnered with an older physician who wished to retire. Nearly all the patients of this practice came aboard to ours. The joining physician kept his prior patients (his panel has long since been full) and the patients of the retired physician were then distributed among the two junior docs in our practice (me being one of them). So the coffers were once again full - great for revenue but it cost something to buy out the departing doc last year and to fold in the newly-combined practice this year. Clearly it would help if I were a free-standing revenue producer but having been hampered in my efforts to see more patients due to being hammered by the documentation requirements, I am still being subsidized. This is a shame. I have and could see the requisite numbers of patients a day but for having my hands tied by the EMR. I got sort of lost in the shuffle of all the flurry of activity involved in shutting down the dealings with the prior doc and in ramping up the absorption of the newest doc. The net result is the crisis you are reading about here.

xraymd
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Hello, xraymd.

Reading your post brought back some recent memories here. About 1.5 years ago, I was faced with integrating a documentation system into my clinic practice. I worked in an outpatient orthopedic setting where I was seeing 20 to 30 patients daily. You should know that I actually volunteered for the opportunity to pilot the computer software which was to integrate patient scheduling, daily notes, progress reports, discharges, billing, etc. After attempts to bring the program into several other clinics had drastically failed, I offered to test run the program and provide feedback for problems that arose and suggestions for correction. There were many late nights (home after 11pm), many frustrations, and a long list of suggestions for improvement. Eventually, it was yanked out of the clinic and sent back to the drawing board.

Some possible courses of action:

Are there other physicians who are using the program? How are they doing with it? Can they provide any suggestions or guidance with how the manage the system? Are they also frustrated and experiencing the same difficulties? Maybe there needs to be a meeting with managers to express the group's concerns?

How is this respected senior partner regarded amongst other senior partners? Is this someone who could prove to be helpful in getting you back on paper? Discussing the time issues with other partners? Could he have some influence on the situation?

Do you have an HR dept? Can they be of any help?

There likely are some other possible courses that do not come immediately to mind. FWIW, maybe a counselor would help. Maybe it's time for a change in environment. Maybe it's an opportunity to improve your situation. You possess the locus of control.

I prize my life outside work. There are few jobs I would be willing to sacrifice my personal time and sanity to.

Ry.Chil
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Greetings, rychil and thanks so much for your input. We have already had numerous of the meetings you describe. The senior partner is very respected among his colleagues but since he is not yet on EMR, he is generally met with the attitude of "well, if you'd get ON it, you'd see what we are talking about..." and in this case, his trying to get me back to paper is likeliest to fall flat. I have agreed to have him review my paper documentation but the bit he's done, he has no fault with!

Frankly, the suggestion of the CEO and of the senior partner to me that I might benefit from counseling was borderline offensive, except that I revere the senior partner and know he truly meant well (the CEO, that's a somewhat different story). Taking my own emotional temperature, I realize that the cure for what ails me may in fact to take my leave because I am actually quite HAPPY apart from work, and have been saying for months that the best solution to restoring my productivity would be to let me do what I've always done that has always WORKED. And that is to recognize that not everybody is going to be fluent on this godforsaken interface and to let me get back to seeing 23-26 patients a day on paper. Then targets will be met, then I will be home by 7pm or so (NOT 9-10pm), then the missing revenue will be realized. But that has been withheld as an option. So it's no wonder that I have been wound up and tense, since nothing of what I've said seems to be given any consideration, and the so-called "solutions" that have been implemented to get me productive on the EMR have not involved my input.

That said, it becomes ever more clear that this is one of those situations that fall into the category of insanity - that is, the definition of insanity is doing the same thing again and again, and expecting a different outcome. That applies here directly. I am glad of the reminder that I possess the locus of control so that I can act now to take it back - one way or another.

xraymd
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xraymd,

I am not a physician, but I followed your thread on the CC board over here to read of your saga. Let me first offer the most important thing....


{{{{{{{{xraymd}}}}}}}}}

It makes me sad to see someone like you who clearly made a lot of sacrifice to enter medicine as a second career struggling with EMR. You see, I work for a healthcare software company, one that sells EMR software as well as software for almost every other clinical and medical revenue cycle process under the sun. It's possible you are using my company's software, although not hugely likely since my company focuses much more on hospitals/large health systems than on smaller physician practices, which is what your work environment sounds like.

I don't work on our EMR system - in fact, I do not work regularly on any of our clinical systems since I am in the internal IT department. I have gone to a couple of hospitals to support "go live" efforts, but my work was concentrated around order entry rather than EMR.

I wish you luck in adapting to the system, or in finding an alternative place to work that does not require you to use the system, or that uses a better system. I hope you are able to adapt or find a new system, because the trend in medicine is definitely away from paper...but at any rate, I want you to feel better and not be depressed about work.

d
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I am curious about how other physicians are handling this in a much more "time-effective" manner than you are -- but my guess there is that those physicians are inputting things into the computer the whole time that they're interacting with the patients. So in that regard, I sort of wonder how the patients feel about the new EMR system, whether they're being listened to less than before. I know that I've had some visits with physicians that seem positively dictated by the EMR system, and I felt like I could do just as well going to see a robot. Let me ask you about these 437 symptoms before I even ask you why you're here...

From a patient standpoint, I'm happiest with what my current internist does. When you come in and are waiting, they give you a form with, at the top, three places for "concerns you're seeing the doctor about today/want the doctor to address," and then underneath, the checklist of "have you experienced any of these symptoms since the last visit." Then, the MA takes your vitals, updates your medications in the EMR, and does the general questions that always get asked. When the doctor comes in, her sole responsibility is to talk to you. Well, she types in a few lines that would compromise the notes section, "fever present three days, no enlarged nodes..." and the prescriptions are entered on the computer, but the EMR doesn't seem to interrupt the doctor-patient interaction.

I'm not sure what my suggestions are here, unfortunately. I don't know if anyone in the group has thought of asking patients how they feel about the new style of interaction with their physicians. It might be interesting if you could sit in with one of the "productive with the EMR" physicians for a day or two and see how they use it (and whether you think it changes the dynamic too much). Alternatively, it might be interesting to see if you can do what my physician's practice has chosen to do: offload the rote interview stuff to medical assistants.

I wish you the best of luck. I don't know anyone who genuinely loves dealing with their EMR, just people who adapt to it. My husband, as a hospitalist, has used an EMR for 6 years, but he still does dictation of progress and discharge notes and referrals. My previous physician's practice fell apart and I think at least part of it had to do with their choice of EMR. Unfortunately, EMRs are not designed and coded by the people who use them.

Your frustration is resonating across thousands of miles, and I wish I had some magic pill to make it all better. Seeing your personality on the Fool, I can imagine the type of interactions you have with your patients, and I think your practice is losing out if they don't try to keep you around.

Wow, that was a really long way to say two things:
(1) Does the EMR make the patient experience sucky for the patients?
and
(2) Can you offload some of the EMR work to your MA?

<hug>
-- Laura
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Would it be possible to carry around a wirelessly connected laptop or tablet pc that would let you interface with the EMR during the visit, perhaps with a pen-style input? This might help get the job done during the visit so you don't have to duplicate work.

HTH
techtlily
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Would it be possible to carry around a wirelessly connected laptop or tablet pc that would let you interface with the EMR during the visit, perhaps with a pen-style input? This might help get the job done during the visit so you don't have to duplicate work.

The doctors in the practice I used to use do this. I don't know what system it is but it even prints out prescriptions as my doc orders them while talking to me. I just pick them up at the front desk. They have been using the system with wireless interface for about 18 months.
Ted
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Greetings, techtlily, we have pentablets as part of the available input options. I just don't do well at using them - find it far too distracting to think and click and it doesn't matter to me if it is something I cart around in my hands or a fixed data entry station in the exam room. I just am not mixing with the current technology as it presently exists. But your thinking is right on target - it is helpful for those who can. However, even the medical assistants who are the most comfortable on the pentablets end up going back to their base stations because it is unbearable trying to enter more than a couple of words at a time without using a keyboard (not all the data to be entered is sufficiently numerical nor point-and-click). If the technology were swifter I might be, too, but I don't know how else to reckon with the inherent slowdown in trying to overcome a cumbersome interface.

xraymd
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Greetings, Ted, how is it those rx's are signed acceptably for the pharmacy to accept them? And we have not been able to get around the harangue that having to reenter our password for EVERY RX PRINTED has created. What I could do lickety-split by writing out the rx on the script pad now takes a magnitude more time since I have to also SEARCH for the desired med, click onto a box that says I've noted interactions, be sure to note quantity and refills, be sure the date is correct and put my password in for each and every rx I write for a patient - then I have to wait for it to print out and then I have to sign each one. It is agonizingly S-L-O-W. Often I bail and just write out the rx's by hand, especially if there are 4 or more. Then I put it into the computer later - still having to do all the searching and so forth (but at least I don't have to keep re-entering the password if I am not printing it out, and at least the patient has long gone on his or her way).

xraymd
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and put my password in for each and every rx I write for a patient - then I have to wait for it to print out and then I have to sign each one. It is agonizingly S-L-O-W. Often I bail and just write out the rx's by hand, especially if there are 4 or more.

xraymd
==========================
At the risk of asking the obvious: Are you sure the software is incapable of 'remembering' your user name and password from 'your' machine???

If it doesn't do it now, I'd bet there is a switch in the SW that can be enabled to allow remembering such. (Perhaps it was left in the disabled state by an overzealous security freak?)

BB
[Trying to think of things to help. The earlier suggestion about observing someone who apparently is coping with the system I thought was a good one.]
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Ted, how is it those rx's are signed acceptably for the pharmacy to accept them?

Perhaps he actually signs them as i am going to the front desk or perhaps his signature is stored in the computer. Wish I still used that same doctor so I could ask him, but I moved to a different state. Pharmacists in this state will accept faxsimile signatures.

having to reenter our password for EVERY RX PRINTED
He only has to re-enter his password occasionally so long as the RX's come from his carry around terminal and it has been less than so many minutes since he used the terminal.

He has a short list of meds that are frequently prescribed that he just has to click on. Second menu for more rarely used meds. How many different kinds of meds do you prescribe frequently?

How long does it take for the prescriptions to print out at your location?

Why should you have to enter the date? The computer knows what date it is.

Back in the old days there was enough trust of the doctor that he didn't have to verify in writing that he had checked for drug interactions. Sounds like a law-suit prevention thing in your case.

Ted
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xraymd.....dump the job.

Remember back when you were in the throes of sorting out this first career step and I recommended getting a few associatships under your belt so's you could learn from others just how you didn't want to do things should you want to strike out on your own.....this is what I meant.

It's a bit like bad relationships....they start out well, then there's a sticky patch, then you try like heck to fix it (something that's usually unfixable) and then when you make the break, you regret all the time you wasted.

Hate to say it, but I doubt things'll change for you....you're a not-particularly-profitable associate and can't shoe-horn yourself into a mould that the others appear to manage (who knows what compromises they make that you wouldn't be prepared to)

I've been in situations where I had to drag myself to the daily grind and it affected everything about the rest of my life. It was never worth it. Time's too precious to waste treading water in a situation that's dragging you down. You deserve better.

Vivienne
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Greetings, Vivienne, thank you so much for your nice words. Ironically I had the potential to be a profitable associate but not since I've been lashed and bound to a system of documentation that doesn't get along with me. Today I saw one patient of the doc still on paper charts and it was startlingly fast (I'd forgotten how fast it could be). But that alone is not enough for the practice. They really have demonstrated that they don't value what I can do. Every day I am definitely getting more dejected. You are SO RIGHT in your assessment - especially when you say how good it felt at first. I'm squinting now, trying to look back into the far distance at when it last felt easy and good. Since I can't remember, that alone means it's been too long (I think it was last summer before I was ever even introduced to the EMR).

The irony is that I love to interact with computers in other venues. Just not THIS computer software in THIS venue. I am getting readier to have to say this aloud and make it a reality and likely soon. It is just too dreary to be attending yet another meeting about how to "fix" me. Ugh. The real restriction (apart from not having an income!) is that it is hard for me to leave anyone or anything in the lurch: we have patients tightly scheduled into next year and there is no-one else free to do hospital rounds. And since the patients are not the problem, I don't know how to make a graceful exit that doesn't somehow impact them. But I guess I will have to figure it out, even if the exit is not ultimately graceful. It feels just too toxic now and, apart from some of the wonderful interactions with many of my patients, I have stopped having any fun at all.

xraymd
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They really have demonstrated that they don't value what I can do

Well, this is it, isn't it. I've sucked up more than a few less-than-perfect arrangements because I was treated like a valued colleague. Ironically, the practice where I felt I had the most room to grow was the one where I was "just the associate".....in spite of having more knowledge, skill and abilities than the principals.

The real restriction (apart from not having an income!) is that it is hard for me to leave anyone or anything in the lurch: we have patients tightly scheduled into next year and there is no-one else free to do hospital rounds. And since the patients are not the problem, I don't know how to make a graceful exit that doesn't somehow impact them

This is one of the most noble, but least sensible reasons to not look elsewhere. Loyalty is very nice but I've found over the years that all those patients who love you to death will for sure be looking for another "provider" PDQ in the event of their insurance changing (often from their own choice) to one that doesn't have you as aparticipating provider!! You're driving down a one way street with this one, I'm afraid. And since your clinical freedom is now under threat.....

No one said you have to run out the door right now but giving yourself permission to walk away from this situation will feel much more empowering and might make it a bit easier to deal with all the thorns coming your way.

Vivienne

PS You are SO RIGHT in your assessment......now you sound like my daughter who is TOTALLY AMAZED that I have even a glimmer of insight into what a trial boyfriends can be!!!!
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Loyalty is very nice but I've found over the years that all those patients who love you to death will for sure be looking for another "provider" PDQ in the event of their insurance changing (often from their own choice) to one that doesn't have you as a participating provider!!

How very, very true!

I could go on and on about this... but I won't. <G>

4is

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Obviously you need to negotiate from a position of strength. To get a new job lined up with a locum company is just a couple of phone calls. You've probably paid all your social security tax for 2005, so you wouldn't face that problem for awhile. You get credentialed, they offer you an assignment, and you have a talk with the boss. You can't deal with their computer program; you have no life. You recognize that the paperless office is the wave of the future, but this clunky program is unacceptable. You cannot practice medicine to standards acceptable to you in the time alloted. Take an assignment for 2 or 3 weeks, probably covering a solo doc's vacation, maybe in Phoenix or somewhere. If you need another state license, the locum company will orchestrate it and pay the fees. While you are covering that practice, you enjoy being well-treated. If it is covering a vacation, be ready for an offer to join that doc on a permanent basis. You return to Tuscon with alternatives.
How much notice do you have to give? How much would they give you, if they decide you're a liability?
Actually most locums assignments start within a month, commonly two weeks, from when you hear about them. You don't have to be without income for more than a week or so. You do need to get the credentialling process started.
You can go the locum route without changing your official residence. A high proportion of assignments will make you an offer for "permanent".
The problems of what to do with your house and your fiance can be dealt with later.
It is also possible after one short assignment you return to your current practice and say, "I have a nice offer from...... which would free me from this @!! computer program, and it is very tempting to take it. Now, what can you do about this problem?"
Since they are already having trouble recruiting, it puts you in a position of a lot more strength.
Best wishes,
Chris (who really enjoyed doing locums!)
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