Efficiency, Flow, seeing 2-3 pph and getting documenting done

[Birdstrike]

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Thankfully just got a 5 year renewal, which should get me to financial independence! If the contract is lost at that point I'll have tons of options.

When can they terminate without cause?

 

[The White Coat Investor]

When can they terminate without cause?

I'd have to go look, but I imagine that's the 90 day out.

 

[Groove]

Fastest isn't always best. There's many contributions to "slow". Arthritis, inability to multitask, practicing defensive medicine, over treating, and other times, quite simply...treating appropriately. The rule of thumb is never to be an outlier. The fastest doc in the shop is rarely the best. The slowest doc (even if the smartest) is rarely the most valuable to the group. The key is to be somewhere in the middle or middle top. I feel productive anywhere between 2.0-2.5 but I feel dangerous over 3pph and I have no problem admitting that. I saw 3.5pph other night and I didn't like it one bit. I don't order POC troponins on pt's to rule out cardiac ischemia. The test was designed to rule "in" ischemia, not "out". Its analytical sensitivity and accuracy is abysmal when compared to a formal assay ran in the lab, just like any point of care test. If that management decision increases LOS and decreases my pph, then so be it. Luckily, I'm fast enough that I don't ever need to worry about it.

 

[BAM!]

I work at a busy, medium-acuity level 1, I'm the fastest doc with average 2.6 pph although many days it is closer to 3 pph. My dispo times average in the low 30 minutes. We have scribes but I don't use them as I realized that they just slow me down. I ALWAYS finish my notes before leaving. We have EPIC and Dragon. Here's my work flow.


1- Pick up several charts, 5 at most, go over all vitals/medical history/triage notes/past visits/etc, write in piece of scrap paper room number and chief complaint.

2- Get up and see all 5.

3- Come back to desk and write all orders.

4- Discharge those that aren't getting a workup and put them up in the rack.

5- NOW I document, patients already dispo'd I do the whole note in one sitting and those that are still cooking I do everything plus first half of MDM. Finish MDM after final dispo. I usually will not pick up any new ones until all 5 have been documented, unless something critical comes in.

6- Rinse and repeat, and I ALWAYS run my list before I pick up more patients to dispo as I go.

Avg dispo in 30 min/pt. Starting with 5 new pts per hour. rinse & repeat. that averages to 10pph x8 hrs/shift = 80 pts/shift! Your workflow kicks butt!

 

[BAM!]

This has been said numerous times, but the type of department makes a big difference. If you're running a single coverage dept you may not have the luxury of picking up patients at your own pace. It becomes very easy for an empty department to become a 10-15 new patient surge within 1 hour. And you're seeing all of them.

 

[UnderwaterDoc]

Avg dispo in 30 min/pt. Starting with 5 new pts per hour. rinse & repeat. that averages to 10pph x8 hrs/shift = 80 pts/shift! Your workflow kicks butt!

Well luckily the rate of patients coming in decreases throughout the shift, so I end up seeing on average 2.6 per hour.


To those talking about being "fastest". Time to dispo is a game and the only reason I am "fastest" is because I am playing the game a little better than everybody else at my shop. Let me give you some examples on how I do that.

A drunk guy comes in, no injuries, looks well, dude just needs to sleep it off. Instead of holding the guy for 6 hours in my tracker I will write a free text order and verbally communicate to his nurse to make sure that I can sober test the patient before he is physically released from the ED, then I will click discharge on the system and print out the paperwork, boom, dispo time 20 minutes as opposed to 6 hours, all the while the same thing is accomplished.

75 YO woman comes in with chest pain, h/o CAD with CABBG and multiple prior MIs. That is an admission every day of the week and twice on Sundays. I will see that patient, place orders, request a bed, and click on "pending admit" on dispo tab, time to dispo 5 minutes according to EPIC, however in reality it is much longer since I have to wait for labs, etc, before I can call upstairs. Think about how many patients you see that you immediately know they will be admitted.

A simple procedure (lac/paronychia/abscess) comes in, I will see the patient, place orders, discharge and print paperwork, and THEN do the procedure, nurses know not to discharge until I am done. Dispo time 10 minutes.

There's other examples but I will stop there.

Like everybody else, I have patients in whom I am not sure what the ultimate disposition is and those I will hold until I have the information I need. I do tend to discharge more than admit, and I do tend to order less tests than most, which also helps. But rest assured that number one priority for me is patient safety.

The numbers are all a game and we all just need to play it better 😀

 

[Cheese Whiz]

Do y'all prefer Dragon or scribes?

One of my shops got Dragon and I'm now a huge fan ... scribe turn over is quick and there's a lot of green ones that require too much editing out the "worst headache of their life" and pan-positive ROS notes.

 

[Arcan57]

Well luckily the rate of patients coming in decreases throughout the shift, so I end up seeing on average 2.6 per hour.


To those talking about being "fastest". Time to dispo is a game and the only reason I am "fastest" is because I am playing the game a little better than everybody else at my shop. Let me give you some examples on how I do that.

A drunk guy comes in, no injuries, looks well, dude just needs to sleep it off. Instead of holding the guy for 6 hours in my tracker I will write a free text order and verbally communicate to his nurse to make sure that I can sober test the patient before he is physically released from the ED, then I will click discharge on the system and print out the paperwork, boom, dispo time 20 minutes as opposed to 6 hours, all the while the same thing is accomplished.

75 YO woman comes in with chest pain, h/o CAD with CABBG and multiple prior MIs. That is an admission every day of the week and twice on Sundays. I will see that patient, place orders, request a bed, and click on "pending admit" on dispo tab, time to dispo 5 minutes according to EPIC, however in reality it is much longer since I have to wait for labs, etc, before I can call upstairs. Think about how many patients you see that you immediately know they will be admitted.

A simple procedure (lac/paronychia/abscess) comes in, I will see the patient, place orders, discharge and print paperwork, and THEN do the procedure, nurses know not to discharge until I am done. Dispo time 10 minutes.

There's other examples but I will stop there.

Like everybody else, I have patients in whom I am not sure what the ultimate disposition is and those I will hold until I have the information I need. I do tend to discharge more than admit, and I do tend to order less tests than most, which also helps. But rest assured that number one priority for me is patient safety.

The numbers are all a game and we all just need to play it better 😀

I'm surprised the nurses haven't lynched you for completely f%^&ing their discharge to depart metrics. You do hint at a big part of the discrepancies between pph and perceived busyness though. Most of the shops I've worked at have had very little to no immediate in-patient support. If you have a climate where you can admit a chest pain with an EKG that is non-ischemic and a neg POC troponin or have a moderately sick belly pain with other comorbidities where the inpatient doc will f/u on the scan, then it's much easier to see more high acuity patients. If you have to write admit orders, call every consultant on the case yourself, and package the patient to survive 12hrs without another physician seeing them then even 1.5 pph can feel like a slog.

 

[Hercules]

Do y'all prefer Dragon or scribes?

One of my shops got Dragon and I'm now a huge fan ... scribe turn over is quick and there's a lot of green ones that require too much editing out the "worst headache of their life" and pan-positive ROS notes.

I have used both and can say with absolutely no uncertainty that scribes trump dragon by a factor of 10. Dragon is not efficient even when tricked out and using macros. If dragon is working better for you than a scribe program, then your scribe program needs to be fired/outsourced. Just out of curiosity, is your scribe program internally run?

 

[coachB]

I have used both and can say with absolutely no uncertainty that scribes trump dragon by a factor of 10. Dragon is not efficient even when tricked out and using macros. If dragon is working better for you than a scribe program, then your scribe program needs to be fired/outsourced. Just out of curiosity, is your scribe program internally run?

If you care about the quality of your notes and documenting MDM appropriately when needed, I would strongly disagree.

 

[WilcoWorld]

If you care about the quality of your notes and documenting MDM appropriately when needed, I would strongly disagree.

Dragnet twerks a bot letter for you than it buzz for bee.

"correct that"

"spell that"

f^(k that, I'll just type it...

Dragon works a lot better for you than it does for me.

 

[Hercules]

If you care about the quality of your notes and documenting MDM appropriately when needed, I would strongly disagree.

Reasonable people can always disagree, but whenever I meet physicians who feel this way, it's tells me that they haven't worked with a good scribe program. I have worked with a bad one before and felt like you do. Now that I work with a high functioning one I have absolutely no doubts. I use a scribe to get all the HPI, physical exam, differential, importing labs, CT reads, etc. If your scribe can't do that then there's either a problem with them or a problem with your ability to effectively use scribes (which is a skill that you have to develop). Then I take a few seconds to jot down a quick blurb in the MDM.

 

[turkeyjerky]

I have used both and can say with absolutely no uncertainty that scribes trump dragon by a factor of 10. Dragon is not efficient even when tricked out and using macros. If dragon is working better for you than a scribe program, then your scribe program needs to be fired/outsourced. Just out of curiosity, is your scribe program internally run?

We have both dragon and scribes--combo kicks ass. Scribe documents while I'm in room and putting in orders, then I look over the note, use dragon to write my MDM and dc instructions, takes 1-2 min to document per pt if straightforward, 5 min if critical or complicated. When I walk out of the room, I tell scribe not to mention that headache was 'worst of life', child was "lethargic", etc.

I'm new, but fromwhatican tell, most docs in the group basically just use the scribes' documentation w/o adding any kind of addendum and I agree, their notes do not tell an intelligible story. Notes that are just prepopulated with macros are much the same and it's impossible to tell wtf happened.

 

[Birdstrike]

I'd have to go look, but I imagine that's the 90 day out.

Then it's a 90 day contract, not a 5 yr contract. You could be working for a CMG by October.

 

[RustedFox]

One of my job sites recent went to the Dragon/Cerner combo. Although Cerner 1.) is a wreck... and 2.) reads like a Chinese newspaper; everything really small and jammed in as closely as possible, Dragon is pretty amazing. I was initially very reluctant to work with it extensively, but now I freaking love it. Keystrokes seem so... pedestrian. Pshaw.

FWIW: There is a way to make the Cerner dashboard and text-entry windows "bigger" on the whole. I have limited idea how to do it, but it CAN be done. Makes it almost tolerable.

 

[fahimaz7]

Generally, while I am documenting on the last patient I saw who is admitted or discharged, I sign up for the next patient and put in orders but don't see them. If it's a RUQ abdominal pain I'll order CBC, CMP, Lipase, and US. That means the workup is in progress while I am documenting on the last patient. I'll see the next patient about 10-15 minutes later and often some of the labs are already back. Rinse, repeat. It really speeds up your efficiency if you put in orders before you see the patient. A 75 yo with CAD and chest pain will be an automatic admit. I order the EKG, CXR, POC Troponin and CBC before even seeing the patient. Often X-ray is waiting for me to leave the room. I can get a typical elderly CP admitted in about 35 minutes.

Wow. Automatic admit. I send home at least 1/2 of my chest pain patients. 25% of those that stay end up in our observation unit overnight with a r/o and stress. The other 1/2 either rule in or have a great story and get admitted.

So funny how regional variability plays a huge component in the game.

 

[coachB]

Then it's a 90 day contract, not a 5 yr contract. You could be working for a CMG by October.

Could be, but unlikely. There is almost zero CMG penetration in WCI's state from what I see. I have a theory as to why that is and why it is likely to stay that way but it's not too hard to figure out.

 

[coachB]

Reasonable people can always disagree, but whenever I meet physicians who feel this way, it's tells me that they haven't worked with a good scribe program. I have worked with a bad one before and felt like you do. Now that I work with a high functioning one I have absolutely no doubts. I use a scribe to get all the HPI, physical exam, differential, importing labs, CT reads, etc. If your scribe can't do that then there's either a problem with them or a problem with your ability to effectively use scribes (which is a skill that you have to develop). Then I take a few seconds to jot down a quick blurb in the MDM.

Agreed. I have had experiences with both. One was internally run and generally quite good. However, the group didn't really see an increase in productivity. The other was outsourced and generally poor. To add to the problem, most of the docs had no clue about how to effectively use a scribe and there was no education or training on that end. I still think with an up front investment in templates and macros and a good systematic way of documenting, you can produce a superior chart on your own in the time it takes to go over a scribe's work.

 

[Birdstrike]

Could be, but unlikely. There is almost zero CMG penetration in WCI's state from what I see. I have a theory as to why that is and why it is likely to stay that way but it's not too hard to figure out.

That may be. But my point remains the same. If a five year contract has a 90 day termination clause without cause, as many do, then there's no comfort in it being a "5 year" contract. That being said, if a lower bidder is no threat, CMG or otherwise, then there's not much reason to even have a contract. Yet, WCIs group has a contract. Why? Because Emergency Physicians that think they can't lose their contract, lose their contracts. Often. Either way, I hope it works out for him. I'm not coming to take his job and I'm sure he's well equipped to deal with whatever situation he faces.

 

[WilcoWorld]

Could be, but unlikely. There is almost zero CMG penetration in WCI's state from what I see. I have a theory as to why that is and why it is likely to stay that way but it's not too hard to figure out.

What's your theory?

 

[The White Coat Investor]

Then it's a 90 day contract, not a 5 yr contract. You could be working for a CMG by October.

I'm very much aware of that, although it seems to me less likely with a 5 year contract, even if said contract has a 90 day out, than a 90 day contract. At any rate, who wants to renegotiate a contract 4 times a year?

 

[The White Coat Investor]

What's your theory?

Yea, I'd like to know too. Because the CMGs are trying, I assure you.

 

[BAM!]

Well luckily the rate of patients coming in decreases throughout the shift, so I end up seeing on average 2.6 per hour.


To those talking about being "fastest". Time to dispo is a game and the only reason I am "fastest" is because I am playing the game a little better than everybody else at my shop. Let me give you some examples on how I do that.

A drunk guy comes in, no injuries, looks well, dude just needs to sleep it off. Instead of holding the guy for 6 hours in my tracker I will write a free text order and verbally communicate to his nurse to make sure that I can sober test the patient before he is physically released from the ED, then I will click discharge on the system and print out the paperwork, boom, dispo time 20 minutes as opposed to 6 hours, all the while the same thing is accomplished.

75 YO woman comes in with chest pain, h/o CAD with CABBG and multiple prior MIs. That is an admission every day of the week and twice on Sundays. I will see that patient, place orders, request a bed, and click on "pending admit" on dispo tab, time to dispo 5 minutes according to EPIC, however in reality it is much longer since I have to wait for labs, etc, before I can call upstairs. Think about how many patients you see that you immediately know they will be admitted.

A simple procedure (lac/paronychia/abscess) comes in, I will see the patient, place orders, discharge and print paperwork, and THEN do the procedure, nurses know not to discharge until I am done. Dispo time 10 minutes.

There's other examples but I will stop there.

Like everybody else, I have patients in whom I am not sure what the ultimate disposition is and those I will hold until I have the information I need. I do tend to discharge more than admit, and I do tend to order less tests than most, which also helps. But rest assured that number one priority for me is patient safety.

The numbers are all a game and we all just need to play it better 😀

My hospital looks past the numbers supplied by the ED group and looks at the actual numbers. Door to floor. These numbers have real meaning compared with fudged numbers.

Why not go a step further and put the slam-dunks in for admit before you see them? Time to dispo = -2 minutes.

 

[Birdstrike]

I'm very much aware of that, although it seems to me less likely with a 5 year contract, even if said contract has a 90 day out, than a 90 day contract. At any rate, who wants to renegotiate a contract 4 times a year?

Nobody does, obviously.


EM jobs are more like rivers than rocks. My reason for making the point is directed more towards young people get wise to the recruiting BS/lies that get told ad infinitum, like,

"We have a five year contract, therefore..." Here comes the lie, "...therefore, the terms of this job that I'm advertising to you can't change for five years. That's because we have a 'five year contract.'" {Well, yes, but not really. Can be tossed in garbage can on 90 days notice, no reason needed.} "And because..." Here comes lie #2, "...because we have several partners high up in administration, we're guaranteed to renew the contract as is or better in five years." That means little.

All are common recruiting lies and/or half truths. Every single term of a so-called "iron clad contract" can change in just a few months, on a whim if a hospital CEO wants, for any reason or no reason at all, if there is one of these 90 day, 120 day, termination-without-cause clauses.

Common scenario: ED group has great and seemingly secure contract. Lots of money, great hours, good support staffing. Hospital changes out CEO due to retirement/promotion/relocation, or whatever. New CEO comes in, desperate to make a mark, show his metal, whatever. Says, "This is crap. At my last shop, we had (insert contract clone group)________ that worked for dirt cheap and jumped when we said 'jump.' They were total lap dogs. These guys seem like ----s. What's the out clause on this contract?"

Pointdexter #2, "90 days, boss."

New CEO, "Get Jim ____ from (insert contract clone group)________ on the phone. I want them in here in 90 days. The existing ER doctors can join these guys..." (on completely new terms, new pay, new jobs, new director, new everything) "...or they can go _____themselves. Pointdexter, #2, do you see how it's done? This will increase my bonus by at least (insert dollar amount, could be $1, or $100,000, either way it's easy money to him)_______dollars." Big smile, half-belch and warm-fuzzy feeling ensue.

Point? Recruits, be wise to the recruiting BS that gets told to you. No ER contract is as secure as they make it sound. Don't put too much emphasis on finding the perfect job, or expect to keep the perfect job. The "perfect job" could vaporize on short notice, with no warning. You won't likely be out of a job, but the terms could change 180 and there's likely not much you can do about it. But you can make changes to remain mobile if a job changes in unacceptable ways, or at the least, have realistic expectations. EM jobs are more like rivers than rocks. They are rarely stable, and always changing.

 

[emergentmd]

Nobody does, obviously.


EM jobs are more like rivers than rocks. My reason for making the point is directed more towards young people get wise to the recruiting BS/lies that get told ad infinitum, like,

"We have a five year contract, therefore..." Here comes the lie, "...therefore, the terms of this job that I'm advertising to you can't change for five years. That's because we have a 'five year contract.'" {Well, yes, but not really. Can be tossed in garbage can on 90 days notice, no reason needed.} "And because..." Here comes lie #2, "...because we have several partners high up in administration, we're guaranteed to renew the contract as is or better in five years." That means little.

All are common recruiting lies and/or half truths. Every single term of a so-called "iron clad contract" can change in just a few months, on a whim if a hospital CEO wants, for any reason or no reason at all, if there is one of these 90 day, 120 day, termination-without-cause clauses.

Common scenario: ED group has great and seemingly secure contract. Lots of money, great hours, good support staffing. Hospital changes out CEO due to retirement/promotion/relocation, or whatever. New CEO comes in, desperate to make a mark, show his metal, whatever. Says, "This is crap. At my last shop, we had (insert contract clone group)________ that worked for dirt cheap and jumped when we said 'jump.' They were total lap dogs. These guys seem like ----s. What's the out clause on this contract?"

Pointdexter #2, "90 days, boss."

New CEO, "Get Jim ____ from (insert contract clone group)________ on the phone. I want them in here in 90 days. The existing ER doctors can join these guys..." (on completely new terms, new pay, new jobs, new director, new everything) "...or they can go _____themselves. Pointdexter, #2, do you see how it's done? This will increase my bonus by at least (insert dollar amount, could be $1, or $100,000, either way it's easy money to him)_______dollars." Big smile, half-belch and warm-fuzzy feeling ensue.

Point? Recruits, be wise to the recruiting BS that gets told to you. No ER contract is as secure as they make it sound. Don't put too much emphasis on finding the perfect job, or expect to keep the perfect job. The "perfect job" could vaporize on short notice, with no warning. You won't likely be out of a job, but the terms could change 180 and there's likely not much you can do about it. But you can make changes to remain mobile if a job changes in unacceptable ways, or at the least, have realistic expectations. EM jobs are more like rivers than rocks. They are rarely stable, and always changing.

I can't believe I agree with Birdstrike, but this is true about not only EM medicine, but Medicine in General, and LIFE in General. EM medicine is a business. We are part of the big cog to make money and thus a commodity in the hospital making money.

This goes with every hospital based practice. If you don't have your own practice, you will never have security. IF someone can offer you something just as good at a cheaper price/get kickbacks, you are gone.

If I owned a restaurant and could find a cook just as good at 1/2 the price, why not save the 30k? If I could find a good meat supplier at 15% discount, guess what, old meat supplier is gone.

ER, Anesth, Path, Rad, hospitalists are all in the same boat.

My mantra in life is don't stress out about what you have control over. Fix what can be fixed with what you have control over.

So I can care less if my great job has a 2 yr contract, b/c I know its as good as 90 dys termination clause. What I have control over now is how scarce ED docs are. We are valuable. So my 5 yr plan is

1. In talks about opening a FSED next yr
2. Do locums and get paid $500+/hr. I find great satisfaction getting paid 6K+ a shift knowing that I just took advantage of a CME.
3. Buy real estate properties with my excessive income. I made over 100K last yr doing 2 locums shifts a month. I will use that to buy 2 more rental properties this coming year. As of right now, I have 120K in passive rental income. I hope to get to 250K in 5 yrs.

At that time, I will work when I want, how much I want, where I want, what shift I want. I will not be beholdened to anyone.

Financial freedom is great.

I am already feeling so much better now than I was 3 years ago feeling I needed to keep my Job.

They could fire me tomorrow and I would be just as happy. I could work 5 more locums shifts and make the same amount working 10 less days

 

[xaelia]

Generally, while I am documenting on the last patient I saw who is admitted or discharged, I sign up for the next patient and put in orders but don't see them. If it's a RUQ abdominal pain I'll order CBC, CMP, Lipase, and US. That means the workup is in progress while I am documenting on the last patient. I'll see the next patient about 10-15 minutes later and often some of the labs are already back. Rinse, repeat. It really speeds up your efficiency if you put in orders before you see the patient. A 75 yo with CAD and chest pain will be an automatic admit. I order the EKG, CXR, POC Troponin and CBC before even seeing the patient. Often X-ray is waiting for me to leave the room. I can get a typical elderly CP admitted in about 35 minutes.

Wow. Automatic admit. I send home at least 1/2 of my chest pain patients. 25% of those that stay end up in our observation unit overnight with a r/o and stress. The other 1/2 either rule in or have a great story and get admitted.

So funny how regional variability plays a huge component in the game.

Much of this thread is prime example of the challenges associated with various pressures on EPs. What is "efficient"(lazy?) practice for the clinician under fire in the pit is not necessarily aligned with what is actually best for a patient. It's an adaptation to the rules of the perverse game the practice of medicine has partially become.

 

[Birdstrike]

It's an adaptation to the rules of the perverse game the practice of medicine has partially become.

Absolutely