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Primary care practice improves EHR efficiency for better physician-patient interaction

When electronic health record (EHR) systems receive external patient documents in a digital bin or queue, it’s up to office staff to file them accordingly in the patient record. However, hundreds of documents coming in daily to an independent primary care practice in Greenwood, Ind., led to an overflowing queue, causing problems with staff workload, billing, and timely access to patient information for appropriate care.

The Problem

Premier Family Medicine's ("Premier") patient portal, or queue, consistently had 1,500 to 2,000 or more “items,” or groups of documents, waiting for filing.  In some cases, the items contained hundreds of documents with more than one patient in an entry. This backlog created inefficiencies affecting both the clinicians and patients.  

“Until the imported items are moved into the patient's chart, they are not accessible to the provider,” said Premier Family Medicine Practice Administrator Michael Yoder. “We had all this information from hospitals, specialists, imaging centers, and labs absent from the patient chart for the doctor or PA to review. When the patient came in for an appointment, the doctor would have to ask a nurse to retrieve the missing information from the source, and the nurse would then import it directly into the chart for the doctor's immediate use. Later, however, as staff went to file the backlogged items, we ended up with duplicate imported items.”

This bottleneck of information also had an effect on the billing process. Lack of timely access to documents limited the amount the practice could bill for encounters. Additionally, if a transcription error occurred, staff would have to manually locate documents in the patient chart and, if the patient was not present, attempt to review the queue manually. If those efforts were unsuccessful, staff relied on calling the patient, resulting in patient irritation and unnecessary work for the staff.

“We would have trouble reaching the patient or the patient would complain that they ‘had given that information at check-in’ or the patient would provide us the needed information. Regardless of which scenario played out, it made us look bad and incompetent,” Yoder said.

The Solution

As a member of the Great Lakes Practice Transformation Network (GLPTN), Premier had access to the GLPTN+LDI program offered through Purdue Healthcare Advisors. LDI or "Lean Daily Improvement" is a quality improvement activity that facilitates making small changes to standard work and then tracking it daily to monitor success, or to create countermeasures if the work is still not meeting a defined target. 

For the practice’s LDI project, Purdue lean experts worked with Yoder to create a system that assigned each staff member a specific tag for filing responsibilities. This tagging system identified imported items according to 1) their department [i.e. front office or billing], 2) process [upload to patient portal, precertification/prior authorization, HIE, etc.], or 3) specialty. Yoder evenly distributed items per employee and then made adjustments to account for specific staff workload. To decrease items in the queue, completed tasks were tracked via a visual management board so that the office could see how they were progressing.

Starting in December of 2017, the practice implemented the new process with more than 600 items in the queue. Three weeks later, the items bloomed to more than 715. “What this showed us was that consistent measuring could help us identify specific problem areas,” Yoder said. “We realized from the numbers that a staff member was out that week, and it allowed us to make adjustments going forward.”

From then on, Premier experienced a downward trend in the number of portal items, with only occasional upward movements. Because changes were tracked daily, the practice was able to identify and address issues that affect improvement. For example, Yoder discovered in February that queue items were not being scanned into the EHR daily, so he implemented a countermeasure to track the size of the queues from the beginning of the day to end. As of March 2018, the total number of items in the queue had been reduced to 37, which represents an overall decrease of 93%.

“The staff was excited. Once they saw the progress, they loved it,” Yoder said. “Once they saw the numbers go down, it made them motivated to do more.”

The Impact

With the available data now at a clinician’s fingertips during an appointment, providers can spend more time focused on the patient instead of on retrieving patient information. LDI also reduced duplicate imports to the patients' charts and minimized the burden on the billing department.

Yoder intends to spread LDI to other areas in the practice. “Absolutely yes.  Any type of medical record flow,” Yoder said. “Throughout the entire practice, compliance, quality control.”

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