Efficient MD https://efficientmd.com Improving physician efficiency Wed, 03 Apr 2019 20:48:42 +0000 en-US hourly 1 https://wordpress.org/?v=5.2.2 140971972 Could Patients Be Their Own Scribes? https://efficientmd.com/could-patients-be-their-own-scribes/ https://efficientmd.com/could-patients-be-their-own-scribes/#comments Tue, 02 Apr 2019 17:10:28 +0000 https://efficientmd.com/?p=181

One day while on shift in the emergency department, I looked out into the waiting room at the dozens of people waiting to be seen.  Many had been waiting for hours. Some looked bored. Others appeared agitated by the long wait time. One thing that nearly all of them had in common, though, was the presence of a smartphone within arms reach.  I wondered, rather than spending their time mindlessly scrolling through their Facebook feed or playing Candy Crush, whether they might be able to somehow use their smartphones and their idle time to expedite their own care.  The idea crossed my mind that there may be a way for them to actually begin writing their own charts. Could they act as their own “patient scribes,” so to speak?

What is a scribe?

Before I go any further I should define what a scribe is.  I’ve written previously about scribes, but, in brief, a medical scribe accompanies a physician or other healthcare provider as they see patients and assists them by documenting the medical chart.  Scribes can allow providers to see more patients, document more accurately, and free up time for more face-to-face interaction with patients by minimizing time spent on clerical work.  Some potential downsides of working with scribes include cost, variability in the quality of scribes, and the necessity of having an additional staff member in the exam room.

Patient scribe model

Imagine a scenario where patients who are waiting to be seen in the emergency department are initiating their own workup, prior to being seen by a provider.  After being triaged, each patient is instructed to download an app which allows them to start inputting information regarding the details of their chief complaint.  

The program would use simple language to elicit details regarding their presenting issues.  The layout may involve drop-down menus for each element of the specific chief complaint. For example, if someone is presenting to the emergency department for abdominal pain, they would select “abdominal pain” from a drop-down menu of chief complaint options.  This would trigger a series of additional drop-down menus specific to said complaint. For this particular example, there would be a “location” tab that brings up a picture of an abdomen and asks the patient to point to the location of their pain. They would then select options from the “severity” tab, “duration” tab, etc. Once they have filled out each of the tabs they would “submit” it to the EMR.  There could be an additional “free text” option where patients could write additional information they may feel is relevant.

After  the patient submits their information, the EMR would construct a preliminary HPI for the provider to review.  There would be an “abdominal pain” template that simply plugs in the relevant information provided by the patient.

For example (the information provided by the patient is underlined):

John Doe is a 52-year-old male who presents to the emergency department for evaluation of abdominal pain.  When asked where his pain is located he notes that it is in his right lower quadrant.  He states that the pain began at 8am this morning.  The pain has been constant and non-radiating.  He rates the pain as 7 out of 10 in severity and says that it is exacerbated by walking.  The pain is associated with nausea and vomiting.

With such a system in place, the provider would have all of these details prior to walking into the exam room.  The patient interaction will be streamlined as the provider only needs to confirm these details rather than having to elicit them from scratch.  Once confirmed, the provider would then only need to modify or add to the HPI as necessary. In addition, the chart will be as accurate as possible, since the details are being provided directly by the patient, rather than being recalled by the provider later.

Potential pitfalls of “patient scribes”

  1. Lack of patient interest – It may be the case that patients would view the process of inputting their own data as a burden that they would rather not be bothered with.  Maybe some would prefer to mindlessly browse their social media rather than convey the details of their complaints. However, I believe that most patients are eager to engage in their own care.  Having the ability to describe their presenting issues prior to seeing their provider would allow patients to feel like they are taking a more active role in their visit. Patients may be less concerned about the harried physician missing details of the encounter if they knew that they had already communicated this information.  Currently, as patients sit in waiting rooms, they are in no way contributing to their care. I have no doubt that being able to communicate via such an app would empower patients and make them feel as though they are doing something.
  2. Technology barriers – Without question, the more tech-savvy patients would be more apt to embrace this type of technology.   To overcome this issue, such an app would need to be extremely user-friendly and intuitive to use. The language would need to be in plain English, lacking any medical jargon. Furthermore, not everyone owns a smartphone. For these patients, the department can provide tablets that would allow them to input their information.
  3. Cost – The cost of implementing and maintaining this type of program would likely vary greatly depending on the size of the department, logistics of EMR integration, etc. However, once it is up and running, the ongoing costs ought to be significantly less than the cost of maintaining a full staff of in-person medical scribes.
  4. Privacy – Obviously, such a program would need to be secure and HIPAA-compliant.  Some patients may not be comfortable filling out a form with details of their condition while in a waiting room full of other people.  It would be simple enough to create a separate area in the waiting room with partitions between the chairs that is designated as private space for patients to fill out their information.  

A way to make EMRs more bearable

Utilizing an app that allows patients to document their own HPI could help to make the process of EMR documentation faster and more accurate.  There is a growing body of literature showing that EMRs are contributing to physician burnout 1.  Anyone who works with an EMR regularly can attest to this.  Implementation of a program like the one I am describing will not fix our EMR debacle but may ease the burden for many providers.  For many of us, every little bit helps.

CMAJ 2017 November 13;189:E1405-6. doi: 10.1503/cmaj.109-5522

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Sleep and Productivity https://efficientmd.com/sleep-and-productivity/ Wed, 27 Mar 2019 17:45:26 +0000 https://efficientmd.com/?p=159

“AMAZING BREAKTHROUGH!  Scientists have discovered a revolutionary new treatment that makes you live longer.  It enhances your memory and makes you more creative. It makes you look more attractive.  It keeps you slim and lowers food cravings. It protects you from cancer and dementia. It wards off colds and the flu.  It lowers your risk of heart attacks and stroke, not to mention diabetes. You’ll even feel happier, less depressed and less anxious.  Are you interested?”

-Excerpt from Matthew Walker’s book, Why We Sleep

What would you be willing to pay for such a miracle “drug”?  If there were a pill that conferred such benefits it would be priceless and impossible to keep in stock.  This “revolutionary new treatment” that Matthew Walker, PhD, refers to in his book, Why We Sleep: Unlocking the Power of Sleep and Dreams, is, unsurprisingly, a good night of sleep.

While we all are aware that getting adequate sleep is beneficial, the claims made in the above paragraph may seem exaggerated and overblown.  At least, this would have been my reaction prior to reading the book. However, sleep scientist Dr. Walker makes a very compelling argument for sleep being the foundation upon which nearly all aspects of our well-being rely. Citing numerous sleep studies from the past two decades, he powerfully conveys the enormous impact that sleep has on our overall health, mood, ability to learn, creativity, and ability to work more efficiently and effectively.

In his book, Dr. Walker takes us on a fascinating journey as he explores:

  1. The science of sleep, including how sleep cycles differ between humans and other animals, as well as how sleep changes across your lifespan
  2. The innumerable benefits of sleep for both our brain and our body, including how insufficient sleep may lead to illness and even early death
  3. Why we dream and the impact it may have on our creativity
  4. Why sleeping pills are not an effective solution to our sleeping epidemic, as well as non-drug therapies that are likely safer and more efficacious
  5. The impact that insufficient sleep has in education, in medicine and health care, and in business

Two-thirds of adults in developed nations fail to obtain the eight hours of nightly sleep that is recommended by the World Health Organization and the National Sleep Foundation.  I imagine that this percentage is even greater among us chronically sleep-deprived healthcare professionals.

If you’ve completed a medical residency, you know first-hand how profoundly sleep deprivation impacts your medical decision making, work efficiency, and concentration.  Dr. Walker cites studies looking at the impact of sleep in the workplace, which “demonstrated that shorter sleep amounts predict lower work rate and slow completion speed of basic tasks.”  These studies also found that sleep-deprived individuals “generate fewer and less accurate solutions to work-relevant problems they are challenged with.”

I am not a great sleeper.  For most of my adult life, I’ve found it difficult to fall asleep at a reasonable hour and have always attributed this to my being born a “night owl.”  Working in emergency medicine has allowed me to accommodate my odd sleep schedule, where I can choose to work mostly evening shifts that don’t start until after noon.  However, when the inevitable early morning shift/meeting/appointment would arise, I would have to endure the day in a semi-awake state, attempting to force my brain into a morning-person mode with repeated boluses of caffeine.

In the past year I have made efforts to improve my sleep hygiene and improve the quality of my sleep. The things that I have found to be most helpful include sticking to a regular sleep schedule as best I can, reducing or eliminating screen time an hour prior to going to bed, exercising daily, not consuming caffeine after 10am, and keeping the bedroom cool.  While I have made progress in this area and have felt the impact in various areas of my life, I still have more work to do. I think we are all aware of the importance of sleep but the information presented in Dr. Walker’s book highlights precisely how significant it is. As a result of reading his book, I’ve redoubled my efforts to prioritize sleep in my life and to do everything in my power to get a good night sleep each and every night.  

I hope you find his book as interesting and insightful as I did.

This post contains affiliate links, meaning, if you click through and make a purchase or sign up for a program, I may earn a commission. This is at no additional cost to you.

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The Best Emergency Medicine Apps https://efficientmd.com/the-best-emergency-medicine-apps/ Fri, 28 Dec 2018 16:35:48 +0000 https://efficientmd.com/?p=130

I surveyed a bunch of EM physicians on Facebook, Reddit, and in person, asking them their favorite apps to use in the emergency department. This list is a compilation of the replies that I received. Most of the apps are available for both Android and iOS but a handful are exclusive to just one platform. If there are others worth mentioning, please let me know.

Categories

  1. Clinical Reference
  2. Calculators
  3. Drugs
  4. Pediatrics
  5. Ophthalmology
  6. Ob/Gyn
  7. Orthopedics
  8. Infectious Disease
  9. Toxicology
  10. Ultrasound
  11. Resuscitation
  12. Education
  13. Miscellaneous

Clinical Reference

WikiEM

Availability – Android and iOS

Price – Free.  Offers in-app purchases.

Rating – 4.5 (Android) – 1,713 ratings.  4.8 (iOS) – 2,100 ratings

Description – “WikEM is an online wiki and database of emergency medicine knowledge to assist physicians with their daily practice. The content is continuously updated from WikEM.org allowing for rapid reference of key information. The content is available offline with this mobile application. WikEM is intended for clinicians only and not directly for patients.”


UpToDate

Availability – Android and iOS

Price – Monthly recurring: $53/month; 1 year: $519; 2 year: $929; 3 year: $1229

Rating – 4.4 (Android) – 6,200 ratings.  4.0 (iOS) – 132 ratings

Description – “UpToDate® Anywhere registrants and individual subscribers can answer their clinical questions anytime, anywhere by downloading this App for iOS onto their iPad®, iPhone®, or iPod touch®.  UpToDate is the leading clinical decision support resource with evidence-based clinical information – including drug topics and recommendations that clinicians rely on at the point of care.”


QuickEM

Availability – Android and iOS

Price – Free.  Certain features cost $2.99 to unlock

Rating – 4.6 (Android) – 124 ratings.  4.7 (iOS) – 5 ratings

Description – “QuickEM is a rapid bedside reference designed by an emergency physician for medical students, interns, residents, and attendings who are working in the emergency department. For those who are new to emergency medicine (medical students, new interns, and rotating interns/residents in other fields), there is an included list of tips, basic overview of trauma, “must know” list of medications, and recommended resources for learning. For experienced clinicians, there are tons of quick reference sections to act as a secondary brain for calculations, decision tools, drug doses, and much more.”


palmEM

Availability – Android and iOS

Price – $19.99

Rating – 4.2 (Android) – 68 ratings.  4.5 (iOS) – 19 ratings

Description – “palmEM is an all-in-one, rapid and succinct, evidence based emergency medicine quick reference.”


ERres

Availability – Android and iOS — March 2018 update regarding Android version of app: “Unfortunately this app will NO LONGER BE UPDATED. Developing apps for Android devices has become increasingly frustrating and time consuming over the past few years. As a result I am no longer able to produce timely updates of good quality.

Price – $4.99 (Android), $9.99 (iOS)

Rating – 4.2 (Android) – 45 ratings.  4.4 (iOS) – 22 ratings

Description – “ERres is an easy-to-navigate bedside tool containing the various medication lists, algorithms, decision rules, clinical policies and core content most often looked up by emergency care providers.”


Pepid

Availability – Android and iOS

Price – $169 (1yr), $338 (2yr), $507 (3yr)

Rating – 3.9 (Android) – 323 ratings.  4.8 (iOS) – 2,100 ratings

Description – “PEPID gives healthcare professionals all the tools they need to treat patients at the scene, en route and/or by the bedside. With just a few taps, access the largest drug database on the market, medical calculators, high-res pill photos, illustrations, and much more!”


5 Minute Emergency Medicine

Availability – iOS

Price – Free to download.  Offers in-app purchases. Appears to cost $99.99 to unlock full app.

Rating – 4.7 (iOS) – 80 ratings

Description – “Rosen & Barkin’s 5-Minute Emergency Medicine Consult delivers practical, quick-read information on over 600 medical conditions seen in emergency medicine directly to your smartphone and tablet. Search and browse for answers in concise topics organized to help save valuable time. Written and edited by practicing clinicians, this mobile resource is ideal for confirming accurate diagnoses and beginning treatment in the fast-paced environment seen in urgent and emergent care.”


Visual Dx

Availability – Android and iOS

Price –  Complete (1yr) – $399,  Add DermExpert (1yr) – $99.99.  Complete + DermExpert (1yr) $499.99

Rating – 4.1 (Android) – 289 ratings.  3.9 (iOS) – 22 ratings

Description – “VisualDx is the single source for diagnostic clinical decision support. Searchable by symptoms, signs, and patient factors, VisualDx is the fastest path to a customized differential diagnosis. Tens of thousands of images and graphics speed comparison, recognition, and diagnosis. VisualDx is used to validate a diagnosis, access next steps for management and care, and for patient education. The VisualDx decision support and reference tool for physicians includes more than 3000 diagnoses and over 41 000 medical images. REQUIRES a VisualDx subscription.”


DynaMed Plus

Availability – Android and iOS

Price – $395 (1yr)

Rating – 3.7 (Android) – 150 ratings.  3.1 (iOS) – 12 ratings

Description – “DynaMed Plus™ is the clinical reference tool that physicians go to for answers to clinical questions. Content is written by a world-class team of physicians and researchers who synthesize the evidence and provide objective analysis. DynaMed Plus topics are always based on clinical evidence and the content is updated multiple times each day to ensure physicians have the information they need to make decisions at the point of care. Physicians turn to DynaMed Plus because it includes robust features like overviews and recommendations, graphics and images, precise search results every time, expert reviewers, specialty content and mobile access.”


The Chief Complaint

Cover art

Availability – Android and iOS

Price – Free

Rating4.7 (Android) – 111 ratings. 5.0 (iOS) – 13 ratings.

Description – “The Chief Complaint app uses an algorithmic approach to over 50 of the most common complaints encountered in emergency medicine. Never feel lost or overwhelmed again, not knowing what the next step in the work-up is. Not sure what tests to order or if the patient can go home? The Chief Complaint helps you answer all those questions and more!”


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Calculators

MDcalc

Availability – Android and iOS

Price – Free

Rating – 4.8 (Android) – 834 ratings.  4.9 (iOS) – 11,700 ratings

Description – “MDCalc is created exclusively by board-certified physicians for use by physicians, physician assistants, nurse practitioners, pharmacists, and medical students. The simple yet sleek app provides access to more than 450 easy-to-use clinical decision tools including risk scores, algorithms, equations, diagnostic criteria, formulas, classifications, dosing calculators, and more.”


QxMD

Availability – Android and iOS

Price – Free

Rating – 4.6 (Android) – 10,398 ratings.  4.8 (iOS) – 2,100 ratings

Description – “Founded by medical professionals, QxMD is dedicated to creating high quality, point-of-care tools for practicing health care professionals. Recognized as a leading developer of free medical software for mobile devices, QxMD develops content in cooperation with expert physicians from their respective fields.”


Mediquations Medical Calculator

Availability – Android and iOS

Price – $4.99

Rating – 4.3 (Android)

Description – “Mediquations for Android brings over 235 medical calculations and scoring tools to your fingertips with simplicity and elegance. Mediquations is the smart choice for anyone looking for a medical calculator for Android.” (Android version)

“Mediquations is the original, most comprehensive medical calculator on the App Store. Mediquations makes it easy and efficient to get the answers you need. With more than 234 formulas and scoring tools housed in an intuitive interface, Mediquations is the smart choice for anyone looking for a medical calculator for the iPhone, iPod Touch, or iPad.” (iOS version)


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Drugs

Sanford Guide

Availability – Android and iOS

Price – $29.99/yr

Rating – 4.5 (Android) – 1,560 ratings.  4.6 (iOS) – 235 ratings

Description – “The Sanford Guide to Antimicrobial Therapy ($29.99/yr In-App subscription) app includes all the information you’ve come to expect from our print guide, with expanded digital-only content and numerous interactive features that make it an indispensable resource for today’s medical professionals. Full text search provides fast access, detailed search results, and highlighted search terms. Intuitive menus provide another way to navigate and see the organization of our extensive content collection. Together with bookmarks and notes, you can access content according to the way you work. Your annual subscription includes ongoing content updates, so you’ll always have access to the latest information.”


Epocrates

Availability – Android and iOS

Price – Epocrates Essentials: $159.99/yr; Epocrates Plus: $174.99/yr

Rating – 4.3 (Android) – 24,093 ratings.  4.3 (iOS) – 1,000 ratings

“Join over 1 million health care professionals worldwide who use Epocrates in the moments of care:

  • Drugs – Review essential drug prescribing and safety information, including adult and pediatric dosing, adverse reactions, contraindications, black box warnings, pregnancy and lactation considerations, and more—for thousands of drugs
  • Formulary – Access national/regional healthcare insurance formularies for co-pay tiers, quantity limits, step-therapy guidelines, prior authorization requirements, and alternatives
  • Interaction Check – Identify clinically significant interactions between brand, generic, or OTC drugs and access actionable recommendations to mitigate potentially harmful effects
  • Tables – Use our concise, quick-reference guides to find drug information on a wide range of topics, including ACLS protocols, drug class comparisons, endocarditis prophylaxis, vaccinations, Zika virus, and more!
  • Calculators – Quickly access dosing calculators, medical equations, and more tools for easy use at the point of care
  • Guidelines – View patient-specific recommendations from our library of evidence-based clinical guidelines—designed to be used in under a minute
  • Pill ID – Quickly identify and verify drugs by imprint code, color, shape, or other attributes”

IBM Micromedex Drug Ref

Availability – Android and iOS

Price – Free if you already have an Internet-based subscription to IBM Micromedex.  Otherwise, $2.99/yr for the IBM Micromedex Drug Reference Essentials app

Rating – 4.0 (Android) – 1,355 ratings.  1.8 (iOS) – 33 ratings

Description – “IBM Micromedex Drug Ref for Internet Subscribers provides clinical care professionals with on-the-go access to the industry’s most trusted drug information, when and where it’s needed most. Users will find peace of mind knowing the content is backed by the same thorough, unbiased editorial process as all IBM Micromedex®.”


EMRA PressorDex

Availability – iOS

Price – $16.99

Rating – 3.2 (iOS) – 6 ratings

Description – “Newly revised and updated for 2015, PressorDex is a comprehensive therapeutic guide to the myriad of pressors, vasoactive drugs, continuous infusions, and other medications needed to treat the critically ill patient. Written by emergency medicine physicians for emergency medicine physicians, this indispensable app gives you concise tools for choosing the right medication and dosing regimen every time, even during the busiest of shifts.”


EMRA Antibiotic Guide

Availability – Android and iOS

Price – $9.99/yr

Rating – 3.0 (Android) – 9 ratings.  3.0 (iOS) – 7 ratings

Description – “Find the most current antibiotic recommendations based on organ system, diagnosis, or organism; virtually every type of infectious disease is covered. This powerful app includes:

  • Dosage Calculator: Get a fast, accurate calculation based on your specific patient
  • Universal, predictive search for speedy navigation
  • Antibiotic costs
  • Choosing Wisely recommendations
  • Pregnancy and Pediatric guidance
  • Recently FDA-approved drugs”

Lexicomp

Availability – Android and iOS

Price – Essentials package: $119/yr; Professional Package: $179/yr; Premium Package: $799/yr

Rating – 4.2 (Android) – 1,932 ratings.  2.6 (iOS) – 57 ratings

Description – “Lexicomp drug reference on mobile apps are unique in the industry for being as extensive as our online drug reference offerings. No content is abridged. Users can view more than 20 databases, featuring timely, in-depth information on drugs, natural products, interactions, medical calculations and more, whether in the hospital or on-the-go.”


Pill Identifier and Drug List

Availability – Android

Price – Free

Rating – 3.9 (Android) – 572 ratings

Description – “Pill Identifier and Drug List – Patient Care Edition is a FREE tool that helps you identify Brand and Generic drugs by name. This is a Drug Reference Guide that provides information about 60,000 + drugs. The Pill Identifier tool is of great help, it helps identify a medicine by its color shape and imprint. This Pill Finder tool lets you find information about generic and branded drugs in United States.”


Pill Identifier by Drugs.com

AvailabilityiOS

Price – $0.99

Rating3.7 (iOS) – 37 ratings

Description – “The Pill Identifier app is a searchable database which includes more than 24,000 Rx/OTC medications found in the U.S.

Search by imprint, drug name, shape and color. Access a wealth of information, including drug images, description/indication, pregnancy category, CSA schedule, strength and Rx/OTC availability. Connects to Drugs.com for additional information (where available).“


GoodRx

Availability – Android and iOS

Price – Free

Rating – 4.8 (Android) – 69,673 ratings.  4.8 (iOS) – 241,800 ratings

Description – “GoodRx makes comparing prescription drug prices easy. Our app provides current cash and sale prices, coupons and valuable savings tips for thousands of prescriptions at pharmacies near you. GoodRx tells you which pharmacies have drugs for less than $4 per fill, and some where certain prescriptions for free! “


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Pediatrics

Pedistat

Availability – Android and iOS

Price – $4.99

Rating – 4.6 (Android) – 135 ratings.  4.1 (iOS) – 14 ratings

Description – “Pedi-STAT is a rapid reference for RNs, paramedics, physicians and other healthcare professionals caring for pediatric patients in the emergency or critical care environment.

Pedi-STAT features include:

  • Rapid results for airway interventions including endotracheal tube sizes, depth, intubation medication dosages, ventilator settings, and sedation
  • Cardiac resuscitation data including weight specific dosages for resuscitation medications, cardioversion, and defibrillation
  • Access to age and weight specific pediatric equipment including foley catheters, airway management, chest and NG tubes, peripheral and central line sizes, and more
  • Seizure medication dosages
  • Management of hypoglycemia including age specific dextrose concentrations
  • Reference of age specific normal vital signs
  • Procedural sedation dosages including single dose meds and infusions, as well as reversal agents
  • Calculated pain management medications
  • Medical management of allergic reactions and anaphylaxis”

PediQuikCalc

Availability – iOS

Price – $4.99

Rating – 5.0 (iOS) – 7 ratings

Description – “Pedi QuikCalc gives you instant access to weight-based drug dosing, IV fluid rates, and weight conversions. Pedi QuikCalc contains only the information you actually need every day, so you can find it fast. I can’t tell you the last time I needed to calculate the A-a gradient! Additional calculators like an Estimator for weight- and length-for-age, Growth Charts, Weight vs Gestational Age, Bilirubin evaluation, BMI-for-age, Blood Pressure Percentile, Adjusted Mid-Parental Height, and a flexible Dosage Calculator expand on these core functions.”


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Ophthalmology

Eye Handbook (EHB)

AvailabilityAndroid and iOS

Price – Free

Rating4.2 (Android) – 717 ratings.  4.8 (iOS) – 8 ratings

Description – “Eye Handbook is a diagnostic and treatment reference smartphone app for eye care professionals. It is the most comprehensive app specific to eyecare available on a smartphone. Recently we have added a new EHB profile, EHB directory, and EHB forums. You can now connect with eye care professionals across the world. With EHB forums, you can post pictures and ask questions in a wide variety of categories.“


Eye Emergency Manual

AvailabilityAndroid and iOS

Price – Free

Rating4.4 (Android) – 112 ratings

Description – “This app is designed for use by all medical, nursing and allied health clinicians in Emergency Departments across New South Wales. It provides a quick and simple guide to recognising important signs and symptoms, and management of common eye emergencies.”


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Ob/Gyn

LactMed

AvailabilityAndroid and iOS

Price – Free

Rating4.3 (Android) – 586 ratings.  3.7 (iOS) – 11 ratings

Description – “LactMed, part of the National Library of Medicine’s (NLM) Toxicology Data Network (TOXNET®), is a database of drugs and dietary supplements that may affect breastfeeding. It includes information on the levels of such substances in breast milk and infant blood, and possible adverse effects in the nursing infant. Suggested therapeutic alternatives to those drugs are provided, where appropriate. All data are derived from the scientific literature and fully referenced. Summaries of the reported information are provided and include links to other NLM databases. Supplemental links to breastfeeding resources from credible organizations are also provided.”


OB Wheel (Pregnancy Calculator)

AvailabilityAndroid

Price – Free.

Rating4.2 (Android) – 2,385 ratings

Description – “Multi-function pregnancy calculator.”


Preg Wheel

AvailabilityiOS

Price – Free

Rating4.0 (iOS) – 58 ratings

Description – “Simple and fast pregnancy wheel available for the iPhone, No need to carry a paper wheel.”


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Orthopedics

Ortho Traumapedia

AvailabilityAndroid and iOS

Price – $9.99

Rating4.5 (Android) – 75 ratings.  3.6 (iOS) – 21 ratings

Description – “Ortho Traumapedia is designed to provide quick access to information important to the treatment of adult skeletal trauma. Based on extensive literature review, Ortho Traumapedia compiles the current standard of care in a high-yield, easy to use format including dozens of original images to help visualize fracture patterns and radiologic findings.”


OrthoFlow

AvailabilityAndroid and iOS

Price – $4.99

Rating5.0 (iOS) – 7 ratings

Description – “Welcome to OrthoFlow…the orthopaedic specialist in your pocket! This new way of learning is designed to help you diagnose and manage orthopaedic trauma with simple, easy to understand decision ‘Flows’ that quickly guide you to the correct diagnosis and management plan. With hundreds of unique diagrams and illustrations accompanying evidence based, clinically relevant information, OrthoFlow provides the knowledge you need for trauma and orthopaedics.”


Sublux

Cover art

AvailabilityAndroid and iOS

Price – Free

Rating5.0 (Android) – 3 ratings. 4.8 (iOS) – 22 ratings.

Description – “Sublux is the radiology app for the rest of us. With our intuitive stepwise approach and gorgeous anatomy overlays, we make X-rays accessible for all medical providers– not just radiologists.. Hundreds of diagnoses, all with sleek overlays highlighting pathology, make it easy to get comfortable with plain films. Each diagnosis has a tailored description with clinical pearls and evidence-based management. Proprietary features allow you to toggle between normal and abnormal X-rays, and optional image annotations mean that you’re never going to be left guessing where the pathology is.”


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Infectious Disease

Infectious Disease Compendium

AvailabilityAndroid and iOS

Price – $3.99 (Android), $5.99 (iOS)

Rating4.7 (Android) – 68 ratings.  4.5 (iOS) – 42 ratings

Description – “Over 600 pages of information on antibiotics, organisms and diseases. Intended as a quick reference for non-infectious disease practitioners”


CDC STD Tx Guide

AvailabilityAndroid and iOS

Price – Free

Rating –  4.8 (Android) – 94 ratings.  4.3 (iOS) – 8 ratings

Description – “The STD Treatment (Tx) Guidelines mobile app serves as a quick reference guide for doctors and related parties on the identification of and treatment for sexually transmitted diseases (STDs).”


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Toxicology

ACEP Toxicology Antidote App

AvailabilityAndroid and iOS

Price – Free

Rating4.4 (Andriod) – 80 ratings

Description – “The Antidote app is a resource for emergency care providers to have easy access to dosing regimens for a variety of medications and antidotes used for common poisonings encountered in emergency medicine. It is a succinct resource designed for quick access that is essential to emergency care providers. It was created by the Toxicology Section of the American College of Emergency Physicians (ACEP), the world’s largest medical association for emergency medicine specialists.


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Ultrasound

One Minute Ultrasound

AvailabilityAndroid and iOS

Price – Free

Rating3.6 (Android) – 1,313 ratings.  4.4 (iOS) – 8 ratings

Description – “- Efficient 1-Minute Demonstrations

  • Full Lectures
  • Instant Access to an incredible amount of content
  • Videos demonstrate all aspects of the scan, including:
  1. Hand Position
  2. Descriptions
  3. Normal images
  4. Pathologic images

SonoSite SonoAccess: Ultrasound Education App

AvailabilityAndroid and iOS

Price – Free

Rating4.1 (Android) – 346 ratings

Description – “When you download SonoAccess you’ll get a first-class ultrasound app with extensive clinical education content, How-To videos and reference guides for over 12 medical specialities. With the latest version of SonoAccess you can download content for offline access, customize your user profile to generate a recommended list of content, and use the “What’s New” feed to browse the latest content.“


Emergency Medicine Ultrasound

AvailabilityiOS

Price – $1.99

Rating4.2 (iOS) – 16 ratings

Description – “EM Ultrasound is a quick reference and learning tool to aid clinicians with bed-side ultrasound in the emergency department, ICU & primary care settings. This application was developed by a board-certified Emergency Medicine physician.”


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Resuscitation

Code Blue Pro

AvailabilityAndroid

Price – $4.99

Rating4.3 (Android) – 11 ratings

Description – “Code Blue is a specialized stopwatch application that allows you to record the actions that take place during a cardiopulmonary event. This application was made for medical professionals to keep track of key events during the management of a cardiac arrest.”


Full Code Pro

AvailabilityiOS

Price – Free

Rating3.1 (iOS) – 5 ratings

Description – “The American Heart Association’s Full Code Pro (FCP 3.4) is a free, easy-to-use, mobile app that allows you to quickly document critical interventions during cardiac arrest resuscitation events. This app lets you focus on the patient without sacrificing proper documentation.”


The Difficult Airway App

AvailabilityiOS

Price – $2.99

Rating4.4 (iOS) – 8 ratings

Description – “This app rapidly and easily selects the right drugs for RSI, automatically adjusting for obesity and hemodynamics. Pediatric dosing and equipment selection is a snap using the Broselow-Luten color system or the child’s estimated weight.

Stay out of trouble! The Difficult Airway App™ guides the user quickly and easily through key algorithms, predictors of the difficult airway and the step-by-step approach to RSI taught in The Difficult Airway Course: Emergency™.“


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Education

Figure 1

Cover art

Availability – Android and iOS

Price – Free

Rating – 4.5 (Android) – 13,065 ratings. 4.7 (iOS) – 823 ratings

Description – “Figure 1 gives you free and instant access to thousands of real-world medical cases from healthcare professionals across 185 specialty groups and prominent institutions, including the American Cancer Society, BMJ, Doctors Without Borders, and Mount Sinai Health System. View and discuss cases you may never see in your own practice, expand your clinical knowledge, and access a community of millions of healthcare professionals.”


Resuscitation!

AvailabilityAndroid and iOS

Price – Free

Rating4.1 (Android) – 939 ratings.  4.5 (iOS) – 279 ratings

Description – “Resuscitation! is the award-winning virtual patient simulator that makes learning medicine addictive! Resuscitation gives you a case presentation of a patient who is ill, and you play the role of the health care provider. You are in control and can take a history, perform a physical exam, develop a differential diagnosis and administer therapy to treat the patient’s underlying problem. You can place the patient on a monitor, start IV’s, perform procedures, administer medications, obtain radiology studies, EKGs, and a LOT more.”


EM:RAP for Emergency Medicine

Cover art

AvailabilityAndroid and iOS

Price – Requires a subscription to EM:RAP. Physician – $445/yr. RN/PA/NP – $245/yr. Resident – $145/yr.

Rating2.5 (Android) – 204 ratings. 3.4 (iOS) – 29 ratings

Description – “Join over 22,000 of your colleagues and subscribe to the #1 Emergency Medicine show in the world. For over 14 years, Mel Herbert and our team of EM experts have been sharing their “Reviews and Perspectives”, bringing you the most up-to-date and relevant topics in emergency medicine, every month. It’s funny, it’s smart and it’s truly irresistible medical education.”


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Miscellaneous

Deployed Medicine

AvailabilityAndroid and iOS

Price – Free

Rating4.9 (Android) – 46 ratings.  4.0 (iOS) – 17 ratings

Description – “Deployed Medicine is an innovative learning service developed to supplement the medical education and training of U.S. military personnel, although some of the medical content could be broadly applied for use by civilian medical providers. The information contained in this app is designed to serve as a supplementary resource to reinforce prior training, and to help you deliver high quality trauma care in deployed settings.”


M*Modal Mobile Microphone

AvailabilityAndroid and iOS

Price – Free

Rating3.8 (Android) – 21 ratings.  3.2 (iOS) – 19 ratings

Description – “The M*Modal Fluency Direct™ Mobile Microphone is a mobile application that allows clinicians to dictate using the M*Modal Fluency Direct Desktop Application without the need for a physical microphone attached to the PC. Once the mobile application is paired onetime with a M*Modal Fluency Direct User ID, the user of the application can dictate using M*Modal Fluency Direct running on any physical desktop or virtual device without a need for docking, Bluetooth or physical connections. The Application uses secure data transmission to stream audio from the mobile device directly to M*Modal Fluency Direct running elsewhere. It builds on the same cloud-based M*Modal Speech Understanding™ technology powering all M*Modal solutions, so existing clinician voice profiles can be used easily and instantly for optimal accuracy.”


Nuance PowerMic Mobile

AvailabilityAndroid and iOS

Price – Free

Rating1.9 (Android) – 60 ratings.  3.6 (iOS) – 23 ratings

Description – “PowerMic Mobile turns your smartphone into a secure wireless microphone for use with Windows-based desktop clinical speech recognition solutions. Optimized for use with Dragon Medical One and Dragon Medical Direct, PowerMic Mobile gives clinicians the freedom to roam from workstation-to-workstation, room-to-room, and location-to-location to complete clinical documentation using their smartphone as a wireless microphone at the desktop.”


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-Efficient MD

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A Simplified Explanation of Emergency Department E/M Coding https://efficientmd.com/a-simplified-explanation-of-emergency-department-e-m-coding/ Mon, 17 Dec 2018 15:33:57 +0000 https://efficientmd.com/?p=119

The way medical charts are coded and billed is unnecessarily convoluted, and you have the Centers for Medicare & Medicaid (CMS) to thank for that.  They are the ones who created the coding system that is used to assign an Evaluation & Management (E/M) level to our charts. Each chart is billed using a Current Procedure Terminology (CPT) code based on E/M levels 1-5.

Billing and coding is an extraordinarily boring topic.  I’m actually impressed that you’ve read this far. But I think it’s worth taking a little time to understand the basics in order to chart as efficiently as possible.  A level 5 chart does not necessarily require that you write a novel to meet the coding criteria. It is also possible to write a very long, thorough chart and still only get credit for a level 3 or 4 chart.  Unless you know the elements of the chart that count towards that level of coding, you may end up doing a lot of unnecessary work.

Rather than review the criteria for every component of each of the 5 CPT codes, which would be time-consuming and painful for you to read, I thought it would be most beneficial to go through a sample level 5 (CPT code 99285) ED visit, pointing out the potential pitfalls where your chart could possibly be down-coded to a level 4.

There are only 3 components that determine the E/M level:

1. HISTORY

2. PHYSICAL EXAM

3. MEDICAL DECISION MAKING

As I go through this sample case I will demonstrate the minimum amount of documentation needed for the chart to be coded as a level 5 chart.  I’m certainly not telling you to only document the minimum just to hit the level 5 criteria, as you should thoroughly chart  everything that is necessary for each patient. This is simply an exercise to illustrate the minimum documentation that would be needed solely for coding purposes.  Next to each of these 3 components, I will list in parentheses the minimum criteria required for that particular component. Keep in mind that the lowest scoring of the 3 components will determine the E/M level for the entire chart.

 

HISTORY (HPI: Chief Complaint, 4+ elements, ROS: 10+ elements, PFSH: 2 of 3 elements)

The history component consists of 4 elements: chief complaint (CC), History of present illness (HPI), Review of systems (ROS), and Past medical, family and social history (PFSH).  A level 5 chart is designated “comprehensive” and includes 4+ HPI elements, 10+ ROS elements, and 2 of the 3 PFSH elements. What do you do if the patient is unable to provide a history because they are altered or intubated?  Or what if the patient refuses to give a history? Add a qualifier describing the reason for the limitation, such as “patient is unable to provide history secondary to…”. This will apply to all elements of the history component.

  • CC – This is a mandatory element for all charts, regardless of CPT level.
  • HPI – A level 5 chart requires a minimum of 4 HPI elements*.  You can include more, but you need at least 4.  The HPI elements include
    • Location
    • Duration
    • Timing
    • Severity
    • Quality
    • Context
    • Modifying Factors
    • Associated Signs/Symptoms

*In lieu of the HPI elements you could also document the status of 3 chronic or inactive conditions.

  • ROS – There are 14 organ systems recognized by CMS
    • Constitutional
    • Eyes
    • Ears, Nose, Mouth, Throat
    • Cardiovascular
    • Respiratory
    • Gastrointestinal
    • Genitourinary
    • Musculoskeletal
    • Integumentary (skin and/or breast)
    • Neurological
    • Psychiatric
    • Endocrine
    • Hematologic/Lymphatic
    • Allergic/Immunologic

A level 5 chart must document at least 10 organ systems.  Your EMR may have a button you can click that states something to the effect “all other systems reviewed and are negative.”  Clicking this button will technically satisfy the 10+ organ system ROS criteria, but doing so attests that you actually reviewed every organ system with the patient.  A word of caution: don’t document something that you didn’t do!

  • PFSH – This consists of 3 distinct components:
    • Past Medical History (PMH) – Includes experiences with illnesses, operations, injuries, and treatments.
    • Family History (FH) – Review of medical events, diseases, and hereditary conditions that may place the patient at risk.
    • Social History (SH) – Includes sexual history, alcohol/drug use, employment, and education.

A level 5 chart must include at least one item each from 2 of the 3 components.  These are often documented by another staff member, such as the triage nurse.  If these are documented by another staff member they still counts toward your coding as long as you attest that their notes were “reviewed and verified by me.”

Let’s get to the sample case:

John Doe is a 60yo male with a history of hypertension and diabetes who presents to the emergency department complaining of chest pain.  He describes the pain as a “pressure” sensation in his left chest that began at 4pm today while walking.   He notes that his father died of an MI at age 65.

This brief paragraph includes the chief complaint (chest pain), 4 HPI elements: quality (“pressure”), location (left chest), duration (began at 4pm), and context (while walking);  past medical history (history of hypertension and diabetes) and family history (father died of an MI at age 65). As long as you include your 10 ROS elements, you’ve met the minimum level 5 criteria for the HISTORY component of the chart!  If this were a real patient you would clearly want to include more details regarding his presentation, but again, I’m using this example just to illustrate that you don’t need to write a novel for your chart to be coded at a level 5.

Pitfall – Keep in mind that the PFSH consists of 3 distinct components: PMH, FH and SH.  You could list 10 medical conditions that the patient is suffering from but these all only count for 1 of these elements, the PMH.  If the entire chart meets criteria for a level 5 chart but only 1 of these 3 elements is documented, such as failing to document that the patient is a smoker or has a significant FH of heart disease, the HISTORY component of the chart will be downcoded to a level 4, which means the entire chart is downcoded to a level 4.

 

PHYSICAL EXAM (9 systems, with 2 bullets per system)

A level 5 chart requires a “comprehensive” physical exam, which consists of 9 systems, with 2 bullets per system.  CMS recognizes the following 14 systems as part of the physical exam:

  • Constitutional
  • Eyes
  • Ears, Nose, Mouth and Throat
  • Neck
  • Respiratory
  • Cardiovascular
  • Chest (Breasts)
  • Gastrointestinal
  • Genitourinary
  • Lymphatic
  • Musculoskeletal
  • Skin
  • Neurologic
  • Psychiatric

If you’d like to see the bullets that are within each of these systems, they can be found at the CMS website here.  I’ve found that the most efficient way to ensure that your chart meets level 5 coding criteria is to create a “normal” templated exam that includes the minimum 9 systems with 2 bullets per system and modifying it as needed.  However, if you choose to do this, be cautious! You need to know exactly what is in your templated exam and you must review it for each patient to ensure that you have not documented something that you did not actually do.  Again, don’t document something that you didn’t do.

 

MEDICAL DECISION MAKING (High)

The MDM section of your note is the most nebulous of the 3 components when it comes to understanding how it is coded.  There are 3 elements that are considered here, with the final code being based upon the highest 2 of the 3 following elements:

  • The number of possible diagnoses and/or the number of management options that must be considered (I will refer to this as DIAGNOSES)
  • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed (I will refer to this as DATA)
  • The risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options (I will refer to this as RISK)

DIAGNOSES – The highest score for this category is “extensive,” which is needed to bill as a level 5 chart.  If you are seeing a patient who is presenting with a problem that is new to you, the provider, and you are pursuing a workup of the presenting problem, this fulfills the “extensive” criteria.  If you are seeing the same patient, but not pursuing any workup, this component would be categorized as “multiple” rather than “extensive” and coded as a level 4 rather than a level 5.  As an emergency provider, nearly every patient you treat will be presenting with a problem that is new to you. A rare exception to this may be someone who is returning for a scheduled re-check.  

DATA – Again, the highest score for this category is “extensive,” which corresponds to a level 5 chart.  This section is calculated using a scoring system, with a score of 4 or greater needed to be considered “extensive.”  Here is the breakdown of the scoring :

  • Review and/or order of clinical lab tests – (1 point)
  • Review and/or order of radiology tests (excluding cardiac cath and echo) – (1 point)
  • Review and/or order of medical tests (PFTs, colonoscopy, cath, echo) – (1 point)
  • Discuss tests with performing physician (e.g., You discussed a colonoscopy result with the gastroenterologist.  You must document this discussion in your note.) – (1 point)
  • Independent review of image, tracing, specimen* – (2 points)
  • Reviewed and summarized old records or history from a person other than the patient (e.g., If you spoke with a consultant, even informally, this counts!  Just be sure to document the conversation in your note.) – (2 points)

*If documenting an ECG, your interpretation must include at least 3 of the 6 elements: rate/rhythm, axis, intervals, ST-segment changes, comparison to prior, summary of the patient’s clinical condition

RISK – Level of risk is scored from “minimal” to “high,” with a score of “high” needed to bill as a level 5 chart.  The risk score is calculated using a risk table, which is unwieldy and probably not worth your time to study. For our purposes, to understand what qualifies as a level 5 chart in the ED, suffice it to say that a patient who is sick and requires urgent intervention typically qualifies as a “high” level of risk.  Conditions that fall under this category include acute MI, pulmonary embolism, severe COPD exacerbation, multiple trauma, seizure, CVA, and psychiatric patients who are a threat to themselves or others.  Also note that any patient who receives a parenteral-controlled substance qualifies as “high” risk.  

Let’s revisit our patient who is presenting to the ED with chest pain.  His chief complaint is a problem that is new to us.  If we decide to pursue a workup for his chest pain (e.g., labs, ekg, cxr, etc.), the DIAGNOSES component of the MDM would meet the “extensive” criteria.  Now, in order for the MEDICAL DECISION MAKING element of the chart to qualify for level 5 billing, we just need either the DATA or RISK component to also meet the threshold for a level 5 chart.  Remember, you need 2 of the 3 components of the MDM (DIAGNOSES, DATA and RISK) to satisfy the highest level of billing in order for the MDM element to be billed as a level 5 chart.

Remember, the DATA component of the MDM is calculated based on points derived from various elements of the workup.  We need at least 4 points to satisfy the “extensive” level of billing required for a level 5 chart.  For this patient, if we order labs (1 point), a chest x-ray (1 point), and then document our interpretation of the chest x-ray (2 points) we have a total of 4 points, which is sufficient to reach the “extensive” level of billing for the DATA component.

At this point the MDM element of the chart satisfies the billing criteria for a level 5 E/M code because 2 of the 3 elements of the MDM, the DIAGNOSES and DATA components, meet the maximum level of billing.  The RISK component of the MDM does not even need to be considered because the MDM can be billed as a level 5 chart without it.  However, if you had treated your patient’s chest pain with morphine during the encounter, this would have automatically bumped the RISK component to the maximum level, “high.”  If this were the case, all 3 of the MDM elements would satisfy the criteria for a level 5 chart, though only 2 of these 3 are needed.

 

SUMMARY

To recap, a level 5 E/M chart requires that all 3 components of the chart, the HISTORY, PHYSICAL EXAM, and MDM, meet their respective maximum coding criteria.  Here are the 3 components with their respective level 5 billing criteria and the items from the chart that fulfill them:

 

CRITICAL CARE TIME

Critical care documentation is a special snowflake that warrants its own section.  CMS defines critical care as a medical condition that “impairs one or more vital organ systems” and is one in which “there is a high probability of imminent or life-threatening deterioration in the patient’s condition.”  They further note that the physician should provide “frequent personal assessment and manipulation” of the patient’s condition.

Here is a list of diagnoses that suggest critical care billing may be appropriate:

  • Active seizures
  • Acute altered mental status
  • Acute GI bleed
  • Acute psychosis with agitation
  • Acute stroke
  • Cardiac arrest
  • Delirium tremens
  • DKA
  • Ectopic pregnancy
  • Hyperkalemia requiring treatment
  • Hypovolemic shock
  • Intracerebral hemorrhage
  • Moderate to severe asthma
  • Moderate to severe CHF
  • Overdose requiring antidotes or reversal agents
  • Pneumothorax
  • Pulmonary embolus
  • Rapid atrial fibrillation
  • Respiratory distress requiring non-invasive positive pressure ventilation
  • Respiratory distress requiring intubation
  • Sepsis
  • Severe anemia requiring blood transfusion
  • STEMI
  • Suicidal ideation immediate threat
  • SVT
  • Unstable angina

In addition to the patient having a critical condition, in order to bill for critical care time, you need to have spent 30 minutes or more on patient care.  This includes time spent on direct patient care, as well as time spent on indirect patient care.  Indirect patient care may include documentation, reviewing prior records, and speaking with consultants, paramedics, and family members.  It is important to note that critical care time does not include time spent on procedures that are billed separately, such as intubations and central lines.

Some critically-ill patients may not qualify for critical care billing.  If a patient with a STEMI is brought in by ambulance and then whisked off to the cath lab within 10 minutes of arrival, they would typically not qualify for critical care billing, regardless of how unstable they were.  At least 30 minutes of time must be spent on patient care to bill for critical care.

If you care for a patient who meets the criteria for critical care billing and document it as such, these CPT codes (99291 for the first 30-74 minutes, 99292 for each additional 30 minutes beyond the first 74 minutes) supercede all of the elements discussed above for coding a E/M level 5 chart.  Meaning, if you didn’t document a social history and your ROS only includes 8 organ systems instead of the 10 required for a level 5 chart, it will still be billed as a critical care chart.

Keep in mind that some patients may appear clinically stable but still qualify for critical care billing.  The hyperkalemic patient who requires treatment, monitoring and frequent reassessments may qualify. As may the asthmatic who requires BiPAP and frequent reassessments.  

Congrats on making it to the end!  I hope this has been helpful. If you have any feedback for me regarding this article please contact me at theefficientmd@gmail.com.

Efficient MD

Disclaimer: This article was written for informational purposes only.  I cannot guarantee the accuracy of the information provided. Payment policies can vary from payer to payer.  I assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of, or relating to, the use, non-use, interpretation of, or reliance on information contained here.  Specific coding or payment related issues should be directed to the payer.

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Are Scribes The Solution To Our Documentation Woes? https://efficientmd.com/are-scribes-the-solution-to-our-documentation-woes/ Mon, 10 Dec 2018 17:03:55 +0000 https://efficientmd.com/?p=113

In response to the increasing burdens of administrative work and cumbersome charting levied upon healthcare providers in recent years, medical scribes have been touted as a potential solution for streamlining the documentation process.  Interest in the use of scribes has certainly been increasing, with the American College of Medical Scribe Specialists estimating that the number of medical scribes nationally will increase from 15,000 in 2014 to more than 100,000 by 2020.

Who are medical scribes?

Medical scribes are often college students looking to gain exposure to the medical field, many of whom are planning on applying to medical or PA school in the future.  There are also those who work full-time as medical scribes. The salary of a medical scribe ranges from $13-18 per hour and the cost to hire a scribe is around $20 per hour.  While there are courses and certifications dedicated to medical scribing, medical scribes are not required to go through a certification process.

The precise role of the medical scribe will vary by institution, but they generally perform a variety of tasks with the goal of maximizing the provider’s workflow efficiency.  In addition to transcribing the medical chart, scribes may also obtain prior records, notify the provider of lab and imaging studies once resulted, and prepare discharge instructions.

A new twist to the medical scribe paradigm is the implementation of virtual scribes.  A virtual medical scribe remotely accompanies the physician during a patient interaction, documenting the encounter in the electronic medical records off-site.

Benefits

The most apparent purported benefit to having a scribe is increased productivity by minimizing the time spent on documentation and other secretarial tasks.  One retrospective study found that the use of scribes by emergency physicians was associated with improved overall productivity as measured by patients treated per hour and RVUs generated per hour.  A prospective cohort study at a tertiary academic ED, published in 2017, found that scribes enabled attending physicians to see more patients per hour, though they did not improve overall patient throughput.  In the primary care setting, the use of medical scribes has been associated with significant reductions in electronic health record documentation time and significant improvements in productivity.

Other  benefits to using scribes, as reported by physicians who have worked with them, include better patient interactions, improved physician satisfaction, and potential mitigation of physician burnout.  Some feel that the quality of the patient encounter is improved by allowing the provider to focus more on the patient interaction than data entry.

The costs associated with the implementation of a scribe program or hiring an independent scribe are significant.  In addition to the salary of the scribe, other expenses may include costs associated with training, hardware and tech support.  Proponents of medical scribes argue that the increased productivity that results from the use of scribes offsets these costs.

Downsides

From my personal experience working with scribes, the biggest downsides are the variability in the quality of the scribes and their rapid turnover.  I found that it would take some time for a particular scribe to understand how I structure my workflow and document my charts. Our working dynamic would steadily improve, right up until they left for medical school.  A new batch of scribes would come in and the process would have to start all over again. When working with an inexperienced scribe, I would often have to spend so much time modifying the chart to fit my documentation style or to make corrections, that I would have been better off documenting the chart on my own from the beginning.

Moreover, having an additional person in the room during the H&P also has the potential to negatively impact the provider-patient interaction.  It may even affect the accuracy of the history being obtained. I can certainly imagine a scenario where a young male would be less willing to discuss his penile discharge when a college-aged female is at the bedside transcribing the history, than if only the physician were present.  Patients are often in a very vulnerable state when presenting to an emergency department or clinic. It’s imperative that we try our best to create an environment that allows patients to speak comfortably about the most intimate details of their lives. Adding another person to the mix may hinder this.  While I have had patients tell me that they would prefer to be seen without the scribe present, some patients may not be as comfortable making such a request.

The Upshot

To answer the question, whether scribes are the solution to our documentation woes, I would have to say “no.”  I’ve had great experiences working with scribes and have seen first-hand their ability to save documentation time and streamline the charting process.  However, a solution that requires every physician to have another person following them on their shift, whether it’s in-person or remotely, is not truly a solution.  Rather, it is a stop-gap measure that does nothing to address the underlying problems, inefficient EMRs and burdensome compliance measures. The real solution will be the development of an EMR that is built with the focus on clinician usability, without sacrificing the ability to capture revenue.  With the advent of advanced speech recognition technology and artificial intelligence, which promise to simplify the way we will interact with our devices, I’m hopeful that such a system is on the horizon.

What are your thoughts on medical scribes?  Comment below or head to the Facebook group to let us know.

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Speech Recognition Software Will Change Your Life https://efficientmd.com/speech-recognition-software-will-change-your-life/ https://efficientmd.com/speech-recognition-software-will-change-your-life/#comments Wed, 28 Nov 2018 18:33:59 +0000 https://efficientmd.com/?p=105

Over the past few years I’ve noticed more and more of my colleagues in the emergency department using speech recognition (SR) software to dictate their notes rather than type them.  Although I consider myself a technophile and I love experimenting with new technologies that could allow me to work more effectively, I resisted jumping on the SR bandwagon for a couple of reasons.  

 

Firstly, I had convinced myself that I was proficient enough at typing that SR software was simply unnecessary.  I can type at approximately 80 words-per-minute (wpm) with a high degree of accuracy and didn’t think that SR software would provide much of an advantage beyond what I was already doing.  (If you’re curious to check your own typing speed you can test it here: https://www.typingtest.com/test.html)

 

The other major reason I was reluctant to try it out, as silly as this may sound, is that I was self-conscious about having other people overhear me dictating.  I can’t explain exactly why I felt this way. Was I worried that others would judge how I worded my HPI and MDM? Was I concerned that someone would overhear my plan and disagree with it?  I can’t tell you for sure but there was something off-putting about verbalizing my documentation out loud.

 

I regret allowing these hangups to put me off of trying SR software for as long as I did because it has truly been a game-changer for me.  Little did I realize that today’s SR software can accurately dictate twice as fast as I can type. According to Nuance Communications Inc., a manufacturer of Dragon Medical software, voice dictation averages 150 words-per-minute.1  Regarding the concern about other people overhearing me while I dictate, I initially dealt with this by seeking out secluded locations where I could dictate in private.  After a while, though, I realized that dictating in a room with others doesn’t really bother me like I thought it would. When I finally fully embraced SR dictation software I found that I was completing my charts in a fraction of the time that I had previously.  Since integrating it into my practice I can’t imagine working without it.

 

HOW ACCURATE IS SR SOFTWARE?

I haven’t been able to find much literature looking at the accuracy of SR software in an emergency department setting.  A study done by Goss et al2 reviewed a random sample of 100 notes dictated by attending emergency physicians using SR software.  They found that 71% of notes contained errors or some sort. 15% of the charts contained one or more critical errors, meaning they could have affected providers’ decisions about patient care.  It’s important to point out that the notes that were analyzed in this study were from 2012. I imagine that SR technology has evolved significantly since this study took place.

 

NUANCE DRAGON MEDICAL VS M*MODAL

There seem to be 2 market leaders in the medical SR software industry: Nuance Dragon Medical and M*Modal.  I’ve had the opportunity to use the SR software made by each company while on shifts in the emergency department.  While they have both have created remarkable products that will dramatically improve the efficiency of your workflow, if I had to choose one to work with on a daily basis it would be the software made by M*Modal.  Their software seemed to have an edge when it came to accuracy, especially when it came to recognizing obscure medical terminology.

 

TIPS FOR USING SR SOFTWARE

  1. Enunciate clearly — While SR software has become remarkably good at deciphering my mumblings that tend to occur towards the end of my shift, there’s only so much you can expect from it.  Enunciate clearly to minimize the number of times that you’ll have to go back to correct misspellings.
  2. Don’t speak too quickly — Another limitation of any SR software is the speed at which it can accurately detect your speech.  As long as you speak at a normal conversational speed, or even slightly faster, the software will have no trouble following along.   If you start speak like the Micro Machines guy the software will likely struggle to keep up.
  3. Minimize ambient noise — Another thing that really impresses me with the current SR technology is the ability of it to filter out ambient noise.  That being said, it will occasionally pick up surrounding voices, so the less ambient noise, the better.

 

START USING ASAP

If you have access to SR software and aren’t already using it, try it out on your next shift.  If your department hasn’t integrated it into your EMR, talk to your administrators about doing so.  It’s well worth the investment and will improve the productivity and well-being for everyone in the department.

 

Do you already use SR software?  Do you find it as helpful as I do?  Let me know at theefficientmd@gmail.com

 

  1. https://www.nuance.com/content/dam/nuance/en_us/collateral/healthcare/demo/dmo-nuance-dragon-medical-infographic-en-us.pdf
  2. https://www.ncbi.nlm.nih.gov/pubmed/27435949
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Dramatically Speed Up Your Charting Using The Autocorrect Dictionary https://efficientmd.com/dramatically-speed-up-your-charting-using-the-autocorrect-dictionary/ Sat, 10 Nov 2018 23:43:46 +0000 https://efficientmd.com/?p=61

The autocorrect dictionary in your EMR can be used to significantly increase the speed of your documentation. This is the tool that corrects inadvertent mis-spellings.  For example, “paitent” would be automatically corrected to “patient.”  However, this tool can also be used to change letters into words and short phrases.  This can allow you to create a type of shorthand which minimizes the number of keystrokes needed when documenting.  Common examples of this include “pt” becoming “patient” and “hx” becoming “history.”  If there are multiple two-letter abbreviations that you commonly use, you can distinguish them by making one lower-case and the other in CAPS.  For example, “pt = patient” and “PT = physical therapy.”

The autocorrect dictionary can also be used to create entire phrases from just a few keystrokes.  For example, I found that I was constantly typing the phrase “…who presents to the emergency department for the evaluation of…”  Using the autocorrect dictionary I can turn this into the  3-letter shorthand “wpt.”  The current build of Epic that I use allows me to create phrases up to 64 characters in length.

Using some of the autocorrect shorthands that I’ve created, here is a demonstration of how powerful this feature can be:

 

Mr. Smith is a 46yo m waho htn, cad, dm, and chf, wpt cp.  Hdp as a “pres” sen that does not rad.  Pt rtp as 7/10 in sev.  The pain is exac w exer.  He den f, c, n, v, or sob.  Pt den hhs.” (188 keystrokes)

becomes

Mr. Smith is a 46 year-old male with a history of hypertension, coronary artery disease, diabetes mellitus, and congestive heart failure who presents to the emergency department for evaluation of chest pain.  He describes the pain as a “pressure” sensation that does not radiate.  Patient rates the pain as 7/10 in severity.  The pain is exacerbated with exertion.  He denies fever, chills, nausea, vomiting or shortness of breath.  Patient denies having had symptoms like this in the past.” (481 keystrokes)

 

In this brief example the autocorrect dictionary decreases the number of keystrokes from 481 to 188 keystrokes.  This is a 61% decrease in the number of keystrokes used to create the same document.  How does this translate to real world benefit?  If it takes you 10 minutes to complete a typical chart, implementing this single change to your documentation would save you 4 minutes per chart.  If you see 20 patients on a given shift this would free up 80 minutes!  How would you spend those additional 80 minutes that you gained?

If you decide to implement a shorthand system such as this using the autocorrect dictionary you will find that your charting will actually be slower than usual when you start using it.  This is because you will frequently have to stop and recall the shorthand abbreviations that you had created. Before long, though, the muscle memory will kick in and you will start using the abbreviations automatically.

Do you already use your autocorrect dictionary to speed up your documentation?  Have you found it to be helpful?  If you have any additional autocorrect tips and tricks to add I’d love to hear them.

If you’d like a spreadsheet with the autocorrect abbreviations that I use in my own documentation just email me at theefficientmd@gmail.com and I will send you a copy.  Please write “autocorrect dictionary spreadsheet” in the subject line.

(note that the specific functionality of your autocorrect dictionary will differ depending on the particular EMR that you are using.  The examples that I provide here are specific to Epic)

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8 Strategies To Help You Leave Your Shift On Time https://efficientmd.com/8-strategies-to-help-you-leave-your-shift-on-time/ Fri, 02 Nov 2018 23:37:49 +0000 https://efficientmd.com/?p=59 It’s 1am.  My 12-hour shift ended an hour ago but I’m still in the hospital working on my incomplete charts.  I’m exhausted and my brain is fried.  I desperately want to go home and get a good night of sleep before returning for my shift tomorrow. However, leaving now means I will have to come back early tomorrow to finish my documentation before the start of my next shift.  I take a deep breath and power through until the last chart is finally complete.

 

The early stages of burnout

I had only been out of residency for a few years but I was already starting to feel the effects of burnout.  I found that I was beginning to feel cranky and agitated all the time.  I would get depressed at the thought of having to go back to work.  I would routinely spend an hour or more after each shift, or occasionally on my days off, completing my charts.  I knew that this extra time spent on documentation was contributing to feelings of burnout that I was experiencing.  “If I’m feeling like this after working for just a few years, how could I possibly sustain this for the next few decades?” I’d routinely ask myself.  Realizing that this was absolutely not sustainable I committed to figuring out strategies that would allow me to leave my shifts on time with my charts completed.

 

Some things are out of your control

There are numerous factors affecting the throughput of patients in the emergency department but it is important to realize that many of these factors are out of your control.  These include things like department space, staffing, sick calls, lab processing time, delays for imaging studies, etc. Todd Beel, MD, FACEP, notes that “fifty percent of efficiency is a systems issue.”1 While there’s always the option of joining the administrative team to effect change on an operations level, most of us would be best served to focus on the things that are within our immediate control.

 

Focus on the things you can control

I try to adopt this as a life philosophy but it certainly applies to the work environment. After accepting the fact that there will always be systemic issues related to department flow that I won’t be able to change I decided to figure out what I could do to improve my own efficiency and allow me to leave my shifts on time.  Here are some of the things that I have found to be helpful in my own practice.

  1. Adopt a “pre-shifting” strategy – When I did my internal medicine rotation in medical school I was introduced to the concept of pre-rounding. This involves checking the newest test results, reading the most recent progress notes, and assessing your patients before rounding with your team.  This allows you to be as prepared as possible for your presentation and help to streamline the rounding process.  The better prepared you were, the smoother the rounds would go.

I refer to “pre-shifting” as the period of time just prior to the start of my shift that similarly allows me to mentally prepare for the work day.  I allow around 15-20 minutes for this process.  I use this time to grab some coffee and a snack, review the final results and studies from my previous shift, do follow-up calls with patients, clear my inbox, and take care of other tasks that I would otherwise try to squeeze in during the course of my shift.

Before adopting this strategy I noticed that the start of my shifts often followed a similar pattern.  I would walk in several minutes before my scheduled shift and would immediately be pulled in multiple directions: the outgoing doc looking to sign out, the ED tech asking to get some EKGs signed, the charge RN notifying me of the cardiac arrest that is 5 minutes out, etc.  The hunger pangs would start to kick in about 2 hours into my shift and make me deeply regret not arriving early enough to grab a bite before the shift began.  Meanwhile, I’m ruminating about a patient I had seen the day prior and trying to figure out when I can find a few minutes to make a follow-up call.

As a medical student I was advised by one of my attendings to start each shift with “a full stomach and an empty bladder.”  I think this is great advice but I would expand it and recommend that each shift should also begin with a clean mental slate.  Minimizing the number of tasks that you need to complete and the number of times that you task-switch during your shift will allow you to better focus on the patients in front of you.  Pre-shifting helps you accomplish this and ultimately leads to more efficient charting, quicker dispositions, and ultimately more effective use of your time.

 

  1. Minimize distractions and interruptions – Easier said than done, I know. A study by Chisholm et al2 found that physicians working in an emergency department were interrupted a mean of 31 times in 180 minutes. While it is impossible to eliminate all distractions and interruptions while on your shift there are steps you can take to minimize them.  Do you typically do your charting in a workroom and find yourself getting sucked into work gossip? Find a more secluded place to escape to focus on your charting.  Getting frequent calls from nurses to find out what the plan is for your patients?  Speak with your nurses at the beginning of each patient encounter to discuss the plan up front.  Pay attention to the most common distractions that you encounter on a typical shift and figure out ways to minimize or eliminate them.

 

  1. Delegate when possible – There are certain tasks that only you, as the provider, can do.  I consider these to be the essential tasks. These include things like charting, placing orders and discussing patients with consultants.  The greater the percentage of your shift that you spend on these tasks the more efficient your work will be.  This is something that I have struggled with in the past. With the intention of trying to expedite patient care I would often find myself transporting my patients to X-ray, putting in IV’s, etc.  While performing these tasks on your own may speed up the throughput for that particular patient, keep in mind that every minute spent on a task that could be done by another staff member translates into another minute that could otherwise have been spent completing your essential tasks.

 

  1. Chart more efficiently – Of all the factors that can impact your work efficiency this is the one that will likely be the most impactful for the majority of providers.   Whether you love or hate them, electronic medical records (EMRs) are here to stay. While it’s easy to get bogged down in the endless number of checkboxes and compliance regulations that accompany EMRs there are numerous ways to harness the power of these systems to not only make your charting faster but more accurate as well.  From utilizing autocorrect dictionaries and building macros to using scribes or voice dictation to speed up your charting, there are numerous tools and strategies you can take advantage of to not only lessen the burden of EMRs but to also actually use them to your advantage.

 

  1. Complete charts in real-time – You just finished seeing a patient and would like to sit down to write your HPI while it’s fresh in your memory but you see that there are 10 new patients waiting to be seen.  Do you begin charting on the patient you just saw or start seeing new patients and postpone the charting until later?

While everyone needs to determine the workflow that best suites them I’d argue that in most cases you are better off writing the chart as soon as possible after having seen the patient.  Have you ever left your charting until the end of your shift and then found yourself mixing up the details of different patients you had seen that day who had presented with the same chief complaint?  I would guess that my charts take 50% longer to complete when I leave them until the end of my shift because of this extra time spent trying to recall the details of each case.

By doing your charting in real time, immediately after seeing the patient, not only do you save the time that would later be spent trying to recall the details of the case but you will likely include important details that may have been forgotten completely.  Charting as soon as possible after a patient encounter not only results in faster documentation but it also results in the most accurate documentation.

 

  1. Batch tasks – Before getting up to go reassess your patient, ask yourself, “what else can I do while I’m walking through the department?”  Are there other patients you could reassess as well? Do you need to speak with a nurse about repeat labs that need to be done?  Frequent laps around the department may allow you to burn more calories but it certainly doesn’t help with your work efficiency.

 

  1. Minimize “multitasking – As much as we like to pride ourselves on our ability to juggle multiple tasks simultaneously while on shifts, a study by Skaugset et al3 shows us that we often aren’t multitasking after all, but rather task-switching.  Cognitive load theory tells us that you have a limited amount of working memory available at any given time and that the less cognition that is required for a given task, the more things you can fit into your working memory.  Be conscious of the interruptions in your tasks that take place while on shift and think of ways to minimize them. These strategies may include creating lists of tasks that need to be completed in the future, following checklists when performing procedures, and finding a place to document where interruptions will be less likely.

 

  1. Initiate dispos ASAP – As soon as you have seen a new patient you should be immediately thinking about their ultimate disposition and determining the information that you will need to make that disposition.  To borrow advice from the efficiency master Stephen Covey, “begin with the end in mind.”4 Order all necessary studies up front.  If you know that a consultant will need to be involved, contact them early.  If there are pending studies for a patient who you know will need to be admitted to a particular service regardless of the test result, contact your inpatient colleagues to let them know about the admission and the pending studies.  The cognitive unloading that occurs with each disposition allows us to more effectively use the limited working memory that we have available at any given moment, allowing us to work more efficiently.

 

Start working more efficiently

My purpose for writing this post is not to help you find ways to cut corners at work or to sacrifice patient care in order to leave your shift on time.  The goal is to provide the excellent patient care and documentation that you normally would but in a way that is as efficient as possible.  I challenge you on your next shift to begin implementing some, or all, of these strategies.  Which do you find the most helpful?  Which strategies of effective working have I left out?

 

  1. http://www.epnotoledo.com/wp-content/uploads/2015/08/June-2012-Efficiency-in-the-EmergencyDepartment.pdf
  2. Chisholm CD, Collison EK, Nelson DR, et al. Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”? Acad Emerg Med. 2000;7:1239-1243. 4. France DJ, Levin S, Hemphill R, et al. Emergency physicians’ beh
  3. Skaugset, LM et al. Can you multitask? Evidence and limitations of task switching and multitasking in emergency medicine. Ann Emerg Med. 2016  Aug;68(2):189-95. PMID: 26585046
  4. Covey, Stephen R. The 7 Habits of Highly Effective People: Restoring the Character Ethic. New York: Free Press, 2004. Print.
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