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Workflow and Process Case Report

Implementing Team Documentation in Strongsville, OH: A Case Study

STEPS in Practice

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Kevin Hopkins, MD, family physician at the Cleveland Clinic, recalls overhearing triage nurses just outside his office tell patient after patient, “I’m sorry, we can’t see you today, you’ll have to go to Urgent Care.” As a family physician trained in the importance of the ongoing doctor-patient relationship, Hopkins strove for continuity in his practice, yet he was spending so much of his day documenting care that many of his patients were being turned away.

Dr. Hopkins joined the Cleveland Clinic after finishing his residency in 2005. “My training program didn’t have an EHR, so after my first two weeks here I wanted to dump the computers. It was so frustrating.” Even later, when the EHR “became my friend” and was indispensable, Dr. Hopkins felt he was putting his focus in the wrong place. “I was staring at the computer screen rather than looking at the patient. I was spending more time on documentation than on the patients.” He wasn’t the only one to notice. “This is one of the biggest complaints we get from patients.”

“One day I realized if I didn’t have to do this documentation I would really like my work.” Slowly he resolved to make changes. He and one of his MAs visited another physician who was using a team care model in his practice. Returning home, Dr. Hopkins and his colleague used this physician’s model as a guide to develop templates specific to their practice and patients. Dr. Hopkins taught his staff how to use the health maintenance reminders in the practice’s EHR to place orders for mammography screening, labs and immunizations. Workspace modifications were made, such as installing curtains to offer privacy to patients while the MA remains in the examining room and a computer workstation in the hallway to allow Dr. Hopkins to do minor note editing between patients.

“One of the challenges for me was letting go of some of the control, especially control over the computer. We also had to figure out ways for the MA to pull up information that I wanted on the screen when I wanted it. We have worked with the MAs to develop their multi-tasking skills. They need to be typing, listening to me, and watching what parts of the exam I am doing all at the same time. We trained them with shadowing and repetition.”

Dr. Hopkins and his team are continually refining their processes. “We set aside one hour every Friday morning to go over the week: what worked well, what didn’t and what changes do we need to make. We edit our note templates during those meetings as well. We do some education, for example, why we do microalbumin testing on diabetic patients and other important clinical items. Learning why we do certain things gains buy-in. The new model has not only been good for patients and the physician, it has also been good for the MAs. The MAs are more fully engaged in patient care than they have ever been and they enjoy their work. They have increased knowledge about medical care in general and about their individual patients in particular.”

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