An excerpt from No Work After Hours: Tools to Maintain a Pleasant, Efficient, and Productive Clinic Without Work Before or After Hours.

The patient encounter is the core of clinical physician practices. That’s why we went to medical school from the very beginning. The excitement and passion for seeing sick patients and helping them on the path of healing was an ambition. One skill set is to be a good clinician, and another is to ensure an efficient workflow. I want to highlight some tips for documentation, placing orders, and optimizing the electronic health record (EHR) workflow.

Documentation

Different physicians can have many different approaches to documentation. Here are some of the many I saw:

• Sit in front of the computer in the patient’s exam room and look at the screen while talking to the patient. This type of physician is efficient, but many patients won’t be pleased. The satisfaction scores may need improvement, too. Continuous eye contact is critical.
• Talk to the patient throughout the visit and document afterward via typing or dictation. The patients here are frequently happier, but the physicians are usually behind with their documentation and sometimes postpone the notes till the end of the day on busy days when they’re already behind. They will reason that patient care is more important than documentation.
• I saw a physician dictating in the exam room in front of their patients. Although efficient, I see it as needing to be more professional and interfering with the basics of good communication.

If I don’t have all the details written right away, I’ll forget the details, which can be a big problem. I also like to have good communication with the patients. That’s why I love touch typing. I’ll talk to the patients and maintain eye contact while my hands are typing the notes. Sometimes, I need to look at my screen for a few seconds, like when placing orders or renewing medications. I’ll mention it, and I won’t be conversing then. I make my best effort to maintain continuous eye contact during active discussions.

I requested an adjustable cart and a laptop in each clinic to achieve that. Sitting comfortably or standing in the exam rooms and facing the patient during clinical encounters would be best. Many exam room designs need to have the computer set up that way. Commonly, you’ll have to rotate your neck 45 to 180 degrees to face the patient while typing on the pre-installed desktop; it’s unhealthy for your spine.

Orders

Endocrinology is a lab-heavy specialty; I can only adjust many medication doses I manage through the lab results. And frequently, they sway my questions during the clinical encounter. For example, if a patient had a recent TSH of 1.5, the visit would likely be straightforward, and I’d continue the present management. On the other hand, a previously controlled hypothyroid patient presenting with a TSH of 30 mcU/mL may drive me to ask many questions about supplements, compliance, tablet colors, way of taking it, weight changes, and last refill, among several others. That’s why I order all the needed future labs during the patient’s visit, set their time frame for the next planned visit, and clearly ask the patient to complete the labs before the visit. I provide specific instructions on fasting status, time of the day, and how many days before the visit to get them done based on what labs I’m getting. Collagen Type I C-Telopeptide and Procollagen 1 Intact N-Terminal Propeptide, bone turnover markers, can take up to 2 weeks to result at my institution, while TSH and free T4 will take less than 24 hours to be back. Most patients at my practice follow the instructions, and life is far easier for all parties. I’m happy to have all the needed data during the visit, ask all the relevant questions, and have a clear and detailed plan for the patient. The patient will be happy to have a clear plan when they leave the office.

EHR workflow during the encounter

By the time I enter the patient’s exam room, I would have the old note (for existing patients) copied to a new note, and I would have already selected the labs and parts of the imaging and pathology reports to include. I would also take snippets of the radiology images or insulin pump/continuous glucose monitor reports and include them in the note. As I talk to the patient, asking about the interim events and how they’re doing, I’ll fill that in the (interval history) under the HPI.

I’ll review the outside records for the new patients before the visit. This was a tricky issue; previously, it was scanned in the chart, and reviewing it was difficult. Imagine being only able to see a page at a time; I couldn’t scroll through the pages, and it wouldn’t be easy to go back and forth with your notes in the EHR. I worked hard to update the protocol, educate the staff, and have them attached as PDFs that I can have side-by-side with the EHR note. You can easily adjust your screen size by pulling the title bar down and using any corner to resize it. I can scroll through the PDF on one half of the screen while having my note on the other half and typing or dictating directly before the visit.

I’ll usually maintain eye contact with the patient while touch-typing whatever is relevant as we go through the history. I’ll go next to editing the physical exam based on my findings, and then I’d usually stand by the patient’s side and show them what I have in the labs, imaging studies (frequently pulling the pictures), or glucose reports. The patients are usually eager to be involved in my data assessment and actively participate in the analysis and arriving at conclusions. It also makes it easier to agree on a shared plan.

Afterward, I edit the assessment and plan accordingly, and I’ll type while saying it out loud to patients. I usually start by saying: Let me tell you what I’ll write down. You can access it through the portal; I’m not hiding anything. I usually write in the plan what I’ll copy and paste under patient instructions. I’ll order all the needed work-up to be done soon, if necessary, and before the upcoming follow-up visit, along with reconciling the medications. I’ll finalize the instructions afterward with all these details.

When the patient leaves the exam room, I’m ready to finalize the note, place the charge, and prepare for the next patient. This is the usual rule that I’ll do almost all the time. By the time the last patient leaves, I’m done with all the notes and charges for that day. In between the patients, I go through the inbox, messages, and results and aim to finish them by that time.

This workflow facilitates going to the clinic 5 to 10 minutes earlier and leaving when the last patient does. Isn’t it great? I almost always leave the office by that time with finished notes, charges, and a clean inbox. That’s why the clinic, especially an endocrinology clinic, is a beautiful practice with a low chance of burnout. Building an efficient practice is a learning curve, and it’s 100 percent worth it.

Michael Morkos is an endocrinologist and author of No Work After Hours: Tools to Maintain a Pleasant, Efficient, and Productive Clinic Without Work Before or After Hours.