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Team Documentation Case Report: Cleveland Clinic

At the Cleveland Clinic, Kevin Hopkins, MD, 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, Dr. 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 upon finishing his residency. “My training program didn't have an electronic health record, so after my first two weeks here I wanted to dump the computers. It was so frustrating.” Even later, when the electronic health record (EHR) turned from obstacle to 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 was one of the biggest complaints we got from patients,” Dr. Hopkins remarks.

“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 a medical assistant (MA) visited another physician who was using a team care model in his practice. Returning to the Cleveland Clinic, 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. The team made modifications to their workspace to better suit their new team approach, including installing curtains to offer privacy to patients while the MA remains in the examining room and adding 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.” Through working together, the MAs have developed their multi-tasking skills so they can type, listen to the doctor and patient, and watch what parts of the exam the physician is doing—all at the same time. Shadowing and repetition are integral parts of this training.

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 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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