Time on EHR/Computer

[HandFellow]

Walking out of clinic today at 530, having worked on charting for the last 15 minutes, I was thinking about the commonly quoted stat that doctors spend 2 hours of paperwork/computer work per hour spent on patient care.  I would say for a 10 minute visit, I average maybe a 2-3 minute note on my EMR.  My MA calls or texts me only for the most difficult questions and there are no emails to check.  Dictations after surgery take 4 minutes and the computer work 2 minutes.

So I am left wondering where the two hours per hour spent with patients come from.  I remember hearing 25% of a doctor's time is spend on paperwork or computer time.  That seems more like it.

How much time do you spend on the computer/paperwork?  Where did this 2 hour thing come from?

[gap55u]

You are not in primary care. Clinics tail from all the labs, workups, etc. patient expectations that you discuss these findings without a followup appointment. Tons of incoming notes from consultants, preop requests, home health, etc.

Follow ups handing 4-6 chronic conditions plus a few oh by the ways- doesn’t fit well in 15 minutes, so quite a bit of charting after.

I may sound bitter typing this up but I’m not - I wish the system was different- and especially that it was differently compensated — but I still like primary care.

(Example re compensation - “yup that’s an AK. Squirt of LN2.” In and out, 2 minutes. Earns you more than htn dm2 depression gerd Depression. So I got LN2 for the office. It’s still irritating.)

[HandFellow]

Sure, but how much time do you spend on these charts?  The 15 minute goes 5 minutes over, how long does it take to document it?

I'm not saying I don't believe there is a lot of work going on outside of direct patient care.  I'm only asking how much do y'all do?  I'm fortunate that I don't have much.

[StarTrekDoc]

cause that DM2, HTN, GERD and Depression 99214 - takes about 15min to document all the DM2 maintenance screening along with meds; then refills adjustment and the FU on the labs of that along with sending it out to the patient and adjustments accordingly.

Then there's the follow up 2 week mychart touch on the depression on the med adjustment that we did with them along with the bmp lab check and follow up on the lisinopril adjustment.

And that's the minimum.   If there's a question FU on this, that's another message to answer.     It all adds up.

Medicare completely made procedures a disproportionate advantage over brain power.   I really feel bad for our neurologists who don't do EMG/EEGs for their cash cows.

[HikingDO]

I miss paper charts

[Lordosis]

Quick issues it takes me 2-3 minutes to dragon dictate a note.

Complicated visits, Multiple problems, hosp fu, complex issues, can take up to 5 minutes.  I rarely spend more than that on a note.  I do my notes right after the visit which I feel speeds things up.  I do not know how people can remember can complete notes at the end of the day or later days.

But as mentioned above the note is not the issue.  It is all the date I get and need to deal with.  It is hard to put a number on that because it is literally hundreds of little actions throughout the day.  I come in 30-45 min before my first patient and clean out my box.  I clean it out before lunch and before I go home at 5.  That is at least an hour right there of computer nonsense.  If I added up all the other triages, labs, documents, etc that I do throughout the day I am sure it would be an hours worth.  Then add in 3 minutes a note X 20 = another hour.  So my "8 hour day" in the office is really from 7-5 (10 hours) and 3 are spent on computer work.  30%

[Allixi]

MPMD wrote:

What lots of docs seem not to understand is that chart #2 doesn’t give you anything that chart #1 doesn’t. The time differential between these 2 charts adds up.

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The problem is that insurance companies won't pay you the same for chart 1 vs chart 2. Those of us that are not procedure or visit-based, who bill purely for what we write, have to put in a lot extraneous info to make them happy.

It takes me 2-5 minutes to write a H&P or Discharge Summary, and 30 seconds to update a progress note. Multiply that by 15-20 pts a day and it's still 30-60 minutes a day purely spent writing notes.

[gap55u]

I am between chart 1 and 2- eg reasonably verbose.. I pull a lot of the necessary stuff from emr to reduce hunting around different tabs for data. I write more detail to help me remember circumstance for next time. Usually don’t dictate - fast typist - but I do dictate complicated hpi or incoming records that need a recap or I want to cut and paste into an upcoming TCM/visit.

I spend spend a solid 1.5 hours a day outside of face to face and I’m starting notes and entering all my orders in the exam room. Except for the talkers and recidivist 3-5 OBTW’ers - then I leave sooner as the longer I order in room the longer I stay.

[Lordosis]

MPMD wrote:

Chart 1 = 4 modifiers (more than enough for level 3)

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I thought all ER visits were supposed to be a level 5 visit

[childay]

I type while I am interviewing the patient.  Otherwise it would probably be 50% if you include reviewing charts, putting in orders, discharge summary etc.  Have been trying to be more efficient but still it takes a long time.

[Zaphod]

MPMD wrote:

As someone who is both clinically pretty fast and does expert review of charts I note that a ton of time is spent on completely wasted charting.

Here’s an example from EM, someone presents with wrist pain after a fall and you are writing the HPI. The exam is basically normal and you are planning to get a film.

Chart #1: “presents w/ foosh, pain is R wrist, non-rad, mod, no assoc sx.”

Chart #2: “30 f pmh dm, htn, depression presents 2 hours after fall. Pt slipped on ice walking to work today, she works as a pharmacist at CVS. She almost caught herself but fell and landed on wrist. Since that time she has had pain in the right wrist. She did not note deformity in the wrist at that time. The pain is moderate, alleviated with wrist, exacerbated by movement, she has limited range of motion. She took a tylenol but decided to come in after it was still hurting. She has never injured this wrist before. She is right hand dominant. There is no pain in the hand, arm, or elbow. She did not hit her head of lose consciousness, she did not injury her neck. No blood thinners. Pain was 8/10 at the time of the accident and is 6/10 now. An ice pack was applied in triage.”

What lots of docs seem not to understand is that chart #2 doesn’t give you anything that chart #1 doesn’t. The time differential between these 2 charts adds up.

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Lol. We used to make this joke about peds, "Well, it was during the second qtr of billys bball game, they were up 23 to 19 when connor set an illegal screen causing billy to...." you're like, get to the point!

I dont even think HPI is that bad an offender, though have seen some doozies, its when there is an excel book of labs and vitals stretching back to their communion that I absolutely glaze over, same with dx/plan. Usually all blah, no pertinent. Then they wonder why you can get a level five in 3 paragraphs.

[Zaphod]

Allixi wrote:

MPMD wrote:

What lots of docs seem not to understand is that chart #2 doesn’t give you anything that chart #1 doesn’t. The time differential between these 2 charts adds up.

Click to expand…

The problem is that insurance companies won’t pay you the same for chart 1 vs chart 2. Those of us that are not procedure or visit-based, who bill purely for what we write, have to put in a lot extraneous info to make them happy.

It takes me 2-5 minutes to write a H&P or Discharge Summary, and 30 seconds to update a progress note. Multiply that by 15-20 pts a day and it’s still 30-60 minutes a day purely spent writing notes.

Click to expand...

? What? I think that is the point. It is literally almost no work to get a level 4, even five. Gotta learn e/m, its so much easier than people make it. Though exam can be a pain if your institution focuses on 1997 only (which ours does and is very dumb).

[nephron]

I spend much more time on my patient notes then my partners do.  I used to always tell people that we chart for 1.  reimbursement  2.  communicate to other physicians  3.  medico-legal protection.  The 3rd one, medico-legal one, is the one most benefited by additional charting.  I've been through one lawsuit, I consider it a frivolous lawsuit, but by the time that went to trial, it was ~5 years after the incident and all anyone had to go on was what was written down.   It's very true when they say that if it wasn't written down, it didn't happen.  At my trial, they went note by note, projected them onto a projector screen, and asked the doctors to explain to the jury what they meant in each note.   A quick note may be sufficient for reimbursement or communication, but I think that a longer verbose note that explains your rationale and thought process goes a much longer way in a courtroom.  A good example would be like the patient who fell, if you just document patient fell, wrist hurt, but then felt better with ice, told her to come back if any increase in pain, loss of sensation, etc, and it turns out that the patient had a fracture that they didn't find on x-ray, you will do much better in court then if you just have a quick blurb stating patient fell, right wrist pain.   No one will believe you 5 years later in a courtroom if you say you remember the patient telling you that they thought that their wrist felt better and wanted to go home and you warned about the missing a fracture if you don't put in the chart.  A lot of wasted time charting for relatively rare events, but I think that people have to remember that a good chart can be the difference between a lawyer even filing a case vs passing up a case when they review the charts.

[wideopenspaces]

I used to type while I talked to patients and note was done when they left. But I spent a lot of time on mychart messages at my last job. So many messages! At the new job, I am only seeing a few patients a week but should increase to a couple a day, hopefully. Not a lot to do outside of notes, but the computers are so slow in the clinic rooms that I often write up the notes in my personal office after I talk to patients. Still not breaking the bank from a time perspective.

[Anne]

MPMD's comments might apply in the ER but the Chart 1 style of documention wouldn't work in my area--if you are in an area where continuity of care matters, thorough documentation helps with that. Although I agree, chart 2 is pretty crappy--while it has a few salient pieces of info the word efficiency is terrible.

I see a lot of patients with complex chronic conditions who have had numerous treatment trials with variable success. If their treatment course isn't well documented a lot of time can be wasted considering the same things over again.

Also, there is interesting research in predictive factors for what acute pain will turn into chronic pain. A review of those risk factors at the time of intitial fracture treatment could help identify who needs closer f/u, etc. and might prevent that patient from being in my clinic 5 years later with chronic intractable wrist pain

That being said, there is a way to be efficiently detailed. I see a lot of resident notes that take 3-4x the words/space that I would use to convey the same info. That makes f/u more difficult, as you are scanning a book of fluff trying to find the salient points.