Thursday, May 27, 2010

Practice Interruptus: Those Invisible, Inevitable Interruptions

The world teems with practice management experts.

They are full of advice telling doctors how to practice more efficiently: consolidate time, delegate to others, avoid useless meetings, have patients submit questions to be answered, let nothing interrupt time with patients.

But somehow: bureaucracy always wins, it’s not over until the paperwork is done, the telephone and the computer are enemies. In other words, Interruptus Uber Alles.

Don’t take my word for it.

 Richard Baron, MD, an internist in a small group in Philadelphia, using electronic health records, documented exactly how many phone calls, emails, prescription refills and lab reports he and his colleagues handled during an average day in 2008. His analysis gives a peek into the “invisible” work not involving a patient visit. Here’s a breakdown of the metrics per doctor, per day:

• 23.7 telephone calls, most of which the doc handled directly

• 16.8 emails, most for interpreting test results

• 12.1 prescription refills, not including those part of a patient visit

• 19.5 lab reports

• 11.1 imaging reports

• 13.9 consult reports

 A group of Australian researchers carried out a time-and-motion study in the emergency department of a 400-bed teaching hospital, observing 40 doctors for more than 210 hours.The researchers found each doctor was typically interrupted 6.6 times per hour; 11 percent of all tasks were interrupted, 3.3 percent of them more than once. They calculated time spent on tasks and found that physicians spent less time on interrupted tasks than on uninterrupted tasks. In addition, doctors were multitasking 12.8 percent of the time. Doctors did not return to 18.5 percent of the interrupted tasks.

 Wesley Curry, MD, a California ER physician, says the computer is a big time interrupter. He spends 2-3 hours each workday logging in, inputting or requesting information, and logging out of 6 to 8 software programs that have become mandatory in the patient encounter. One program may be for obtaining lab results, one for x-ray, one for discharge, one for recalling past charts, and so forth – and each one log-in log-out requires more time for getting through the various security screens which shut down the program if there is no activity after a few minutes, when the provider is away from the computer seeing patients. logging takes at least 30 seconds to one minute for each program, and in aggregate takes a significant amount of time which could be used to see patients. These programs help retrieve past medical records, and other useful information and document the encounter, but, he asserts. They have little value in creating real time efficiency. Proliferating independent electronic medical records and other software programs are simply not clinically useful yet.

Of this comedy of inefficiency, Groucho Marx might say,
Hello, Goodbye, I’ve got to be going, I’ve outlived my stay.
Because you again interrupt,
I really must be abrupt.
My time, it’s gone that away

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