CanadianEMR: EMR Comparisons, Ratings, Directory Services and Expert Discussions

Powering Primary Care - New BC Initiative

Technology (including EMR) is an important enabler as we strive to improve patient care and reduce waste within the healthcare system. However, if isolated from policy, legislation and compensation, EMRs alone cannot solve the problem of limited access to care. 'A GP for Me' is a joint program between the Government of BC and the BC Medical Association, created through the General Practice Services Committee (GPSC) which has been put in place to assist approximately 176,000 patients who cannot find a family doctor.

A February 23rd article in the Vancouver Sun provides further details on the $132 Million program. One of the stand out features is the designation of funding for telephone consultations with patients in order to more efficiently manage care without needing to bring that patient into the office for a face-to-face consultation in order to be compensated. (Until now this was the only way a fee-for-service physician could be paid to manage a patient unless they were covered under a different program e.g. chronic disease). What this equates to is up to 500 telephone consultations with patients per year at $15 per consultation (with critera that will need to be followed). However, it is an important recognition of the capability to manage patients effectively using the most basic form of telemedicine, the telephone.

I believe that there is one element of this strategy that has not been addressed. After a number of years of working as a part-time family physician in a walk-in clinic, I am convinced that convenience will continue to win over quality 9 times out of 10. What I mean by this is that even with a family physician, unless there is a mechanism to link a patient to a doctor or practice and place some accountability on patients to attend their 'new' family physician for the majority of care, we will not really solve this problem. Granted, the +/-176,000 patients may find a family physician, but if patterns of access to healthcare do not change, their new family physician will be utilized just like the 'old' family physicians and become the repository for copies of lab results ordered by walk-in clinics, visits to Emergency Departments and requests from 3rd parties for documents or from lawyers for medical legal reports.

Don't get me wrong. I believe this is an excellent step in the right direction. My only concern is that people do not change their behaviour patterns very easily. I believe that patients will continue to attend any walk-in clinic that is convenient for the majority of their episodic care. With all of the additional primary care capacity being created within the healthcare system, effective utilization is a necessity.

Do you have any thoughts or experiences you would like to share? Click on the 'Comments' link below.

How to Maximize the Use of Your EMR

Imagine a future state in which you can use your EMR to look at a population of your patients in such a way that you can determine whether you may be misdiagnosing patients with certain diseases. If you could compare your practice to other practices of a similar size and demographic makeup in order to determine whether prevalence of certain diseases was similar, you would be able to identify cohorts of patients at risk. Take rheumatoid arthritis as an example. If you only had two diagnosed rheumatoid patients in your practice, and other equivalent practices had three times that number, you may be missing someone with this debilitating disease amongst your patients with arthralgias or osteoarthritis. This would be a strong indicator to look harder for rheumatoid arthritis. While this is a theoretical example, it is certainly quite possible if we had the data and analytical tools and we knew how to use them. At the moment, it is a future state. What can you do to optimally use your EMR?

The following are some tips and recommendations:

• Set goals, personally and at the practice level. Identify something that you would like to accomplish with your EMR, such as improving diabetic monitoring in order to get all HBA1C levels below 7.0. You can use notification messages, reminders for staff and patients, and reports to identify patients out of target range, and work harder with those patients to improve outcomes. Similarly, establish one or more practice goals. These can be clinical or operational. For example, standardizing templates amongst all physicians so that everyone uses the same templates for similar patients. This will assist in making clinical data more consistent so that is more effectively reportable across the practice.
• Get complete buy-in from physicians and staff. This may seem mundane, but if you cannot get everyone in the practice to commit to using the EMR effectively, it will be impossible to derive maximum value. Identify the barriers and then try to address them. It may be a lack of keyboarding skills for a colleague. Some physicians use speech recognition software very effectively, or dictate and have the notes transcribed into the EMR. This works best if the system is optimized for recording narrative notes. Another alternative is to set up a comprehensive set of templates that allow for options to be selected from pick-lists or drop-down menus.
• Optimize your internal practice environment. There are certain things that you do not have control over. While it may be ideal to have an interface with your local hospital for diagnostic imaging, this is a complex goal that requires both your EMR vendor and hospital IT department to work together. It is far better to spend the time and energy optimizing processes and workflows in the practice before taking on more complex projects.
• Hold regular practice meetings. Many practices operate year after year without the physicians and staff getting together to discuss problems, suggest solutions, assign tasks, and set goals. Think of your own practice and the last time you got together as a team to discuss your EMR and what you would like to do in order to optimize its use in your practice. The only time everyone got together in the last year could have been the office Christmas dinner. Not a great time to discuss strategy.
• Trust your gut. The EMR is a tool. Use clinical judgment when making decisions. Your EMR vendor is not infallible and needs your support and feedback
• Keep an open mind. What can your EMR do for you that you were never able to do before?

Following these basic principles, while not a guarantee of success, will help keep you focused on setting achievable goals. If you have any tips you would like to share, click on the “Comments” link below.

Use of Email to Communicate with Patients

I have recently presented a number of sessions for physicians on the use of patient portals and personal health records in order to more effectively engage patients in managing their own care. There is a great deal of evidence that providing patients with access to their medical information promotes better care and is associated with improved outcomes. So why are we not all doing this in our practices? The simple (and practical) truth is that there are still a number of barriers to simply making these tools available. The tools are not ready for seamless integration and physicians are also anxious that they would create an administrative headache for practices and potentially negatively impact patients.

However, the following study provides strong evidence that the anxieties and concerns may be unwarranted. An October 2, 2012, article published in Annals of Internal Medicine by principle investigators Jan Walker, RN, MBA and Tom Delbanco, MD titled “Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead,” examined the interaction between primary care physicians and their patients after providing access to clinical notes via a patient portal and electronic messaging. The study involved 105 primary care physicians and 13,564 patients at three institutions: Beth Israel Deaconess Medical Center (BIDMC) in Massachusetts, Geisinger Health System (GHS) in Pennsylvania, and Harborview Medical Center (HMC) in Washington. An earlier article was published in December 2011.

Findings were based on patient and physician post-intervention surveys:

86% of patients with visit notes available opened at least one note and 5,391 patients who opened at least one note completed a post-intervention survey:

• 77% to 87% across the three sites reported that open notes helped them feel more in control of their care.
• 60% to 78% of those taking medications reported increased medication adherence.
• 26% to 36% had privacy concerns.
• 1% to 8% reported that the notes caused confusion, worry, or offence.
• 20% to 42% reported sharing notes with others.
• The volume of electronic messages from patients did not change.

After the intervention:

• 0% to 5% of doctors reported longer visits or more time addressing patients’ questions outside of visits (0% to 8%).
• 3% to 36% of doctors reported changing documentation content.
• 0% to 21% reported taking more time writing notes.

At the end of the experimental period, 99% of patients wanted open notes to continue and no doctor elected to stop. 59% to 62% of patients believed that they should be able to add comments to a doctor’s note and one in three patients believed that they should be able to approve the note’s contents. This was met by resistance, as 85% to 96% of doctors did not agree.

A number of years ago, I implemented an email policy in my practice and shared my regular (non-secure) email address via the practice website and appointment cards. My patients never abused the email address and during a busy week I may have received 4–5 emails. What helped was printing the email on the back of the appointment cards as well as publishing it prominently on the medical practice website.

An example of the (appointment card) email policy is provided below:

 

If you have any thoughts or comments regarding communication with patients via email, patient portals, or personal health records, please click on the “Comments” link below.

EMR Strategies When Planning Retirement

If you are planning for retirement, the last question you may be asking yourself is whether you should implement an EMR system before you close or pass on your practice. In some cases it may not be practical to implement an EMR. Your decision may also depend on whether you are a specialist or family physician, in a solo practice or a larger group. If in a larger group, the decision may already have been made for you. In some cases, physicians who plan to retire and do not want to adopt an EMR being implemented by a group decide to use the opportunity to opt out and move on to other activities. Specialists, particularly those who do not have long-term relationships with patients and provide episodic care typical of specialty practice, can have tens of thousands of charts with some patients having been seen only once. The practicality of re-digitizing all of those records and entering them into an EMR is daunting and in most cases unnecessary for specialists. The following article in the Ontario Medical Review is worth reading: “EMRs and the Late Career Physician”.

One of the big challenges that physicians face when closing a medical practice is developing a succession strategy. Is it possible to find someone who will take over an existing practice? In most cases, for family physicians, particularly those in solo practices, this is no longer an option. There is such great demand for family doctors that simply hanging up a shingle plus advertisements in the local newspaper is enough to bring a steady stream of patients. For female doctors, the demand is even greater.

An earlier article that I wrote on this topic received the following comment: “I think you are missing the fact that many established practices have either a) significant goodwill, and b) an established community presence. I would have thought that these play a far more important role in purchase considerations. The incoming doctor would, in most of my experience, usher in their own changes to the admin anyway.”

Transferring a practice to another physician (versus selling it for real money) is unfortunately the most likely transition if you can find someone to take over your practice. The motivator for the outgoing doctor is generally to maintain continuity of patient care for all the patients that have been treated over the years. However, even this is unusual if the outgoing physician is still running a paper-based practice. With 50–60% of Canadian doctors now using EMRs, I am not aware of a single new graduate who would consider going into a practice with paper charts.

Consider the following:

1. If you plan to work as a locum after retirement or do a shift on a regular basis in a walk-in clinic, you will likely be working with an EMR. As a result, it is good practice to hone your computer skills and get up to speed on electronic medical records. You may be fearful of computers and feel that they will interfere with the patient encounter; however, many patients now expect your practice to be computerized and are surprised when you are still using paper charts.
2. Continuity of care for your patients is an incrementally greater problem If you do not have an EMR. Even if you cannot transfer your patients, it is easier to generate pdf files for each, store them on a number of discs for security purposes, and transfer digital copies of patient records that can be attached to a patient’s file in a new physician’s EMR. If are unable to find someone to take over your practice, you should get ready to try and transfer as many patients as possible and accept that a significant number are not going to find a new physician.
3. Chart storage is expensive and it is a significant amount of effort to find, package, and send out charts as they are requested. If you decide to go down this pathway, there are a number of companies that provide chart storage and will scan your paper records for easier retrieval. Click here for the list of companies in the CanadianEMR Resource Directory.
4. Patient safety: over many years, one accumulates a great deal of information, reports, lab results, etc. Implementing an EMR is a very good opportunity to summarize the face sheet in your charts and do a careful review of your patients before entering the data into the EMR. While this process generally happens during the yearly physical, there are patients that fall through the cracks and implementing an EMR provides a good opportunity to get current with your patient's problem lists and medications.
5. If your practice has aged with you, you likely have a predominance of older patients with concomitant co-morbid disease. EMRs are great for the management of chronic diseases. If you are not taking advantage of incentive payments for Diabetes and other chronic conditions, you should seriously consider an EMR — if only to optimize your payments in the last few years of practice. If you have a slick system in place for reminders — ensuring you do not miss your chronic disease payments — it will also make your practice more attractive to a new physician.

There are still a number of are good reasons to implement an EMR in your pre-retirement years. There is nothing better than being able to leave your practice in the capable hands of a physician who will look after your patients with good quality information at their fingertips.

Add your feedback by clicking on the “Comments” link below.

Surviving as a Solo Practitioner

Over the past 5–10 years, I have read a number of articles that describe solo practitioners as a dying breed. In primary care, the transition to shared care by teams of providers (including physicians) and the development of primary care networks have accelerated this change. I have not come across any new family medicine graduates in the last few years who plan to enter solo practice. The concept of setting up and running a practice is too daunting, particularly if that physician wants to start off their practice with an EMR. This is not the case with specialists. Even though many may wish to work in either a single specialty group setting or multi-specialty practice, there are a number of specialists who continue to work in solo practices.

The benefits of solo practice are well recognized. These include the ability to:

• Make your own policy and financial decisions about how you want to run your practice
• Spend as much time as you feel is appropriate with your patients
• Create stronger, more personal bonds with patients
• Employ the staff of your choosing and control your own schedule

In 2013, in the face of financial, administrative, and oversight pressures, can a solo practitioner survive? If so, what strategies should be considered in order to do so? The answer is yes, but physicians wanting to retain their independence and continue to practice solo need to be creative in order for their practices to remain viable. It is important to keep your overhead costs down and to run as efficient a practice as possible.

Some suggested strategies include the following:

• Take advantage of provincial EMR incentive programs and implement an EMR that is appropriate for your practice setting. In small practices, ASP- or cloud-based EMRs are a good choice because they do not require a local server or expensive hardware. Frequently these EMRs will run on low cost desktops or tablets, as most of the intensive computing takes place in the cloud. Backups are also handled centrally by the vendor, reducing the need to keep local copies of data in case a server fails. However, do your research, conduct site visits, and speak to colleagues before selecting a system.
• At the present time, EMRs in most settings have yet to achieve true interoperability with other systems. The advantage of the Electronic Medical Record is the ability to share information efficiently electronically with other clinicians and ancillary care providers. Once we have widespread interoperability between systems, the ability to practice in a solo setting but still function as part of a virtual group will become a strong facilitator for those who want to work solo. I am often asked by colleagues whether they should wait for interoperability before implementing an EMR. My advice is to choose a system that will best match their needs and get on with adoption. Over time, once a critical mass of EMR users exists, the interoperability will take place more quickly.
• A concierge practice is another viable option. Patients are charged an annual fee to belong to the practice. As a result, a physician can care for a smaller number of patients and provide a concierge level of care with the annual fee offsetting associated reductions in revenue. For example, a concierge practice of 500 patients in which each patient pays an annual fee of $300 generates a baseline revenue of $150,000/yr. Some physicians are integrating remote consultations, tele-consults, and using other tools such as text messaging to provide a level of care that differentiates them from a more traditional family practice. It is important to ensure that any practice following this model does not contravene the Canada Health Act and that patients are not charged for services covered under their provincial payment system. It may be necessary to completely opt-out of the provincial payment program. In addition, a number of provincial licensing bodies publish guidelines on the use of Annual Fees.

Are you in solo practice? Do you intend to join a larger group or have you found a way to maintain your independence? Share your experiences by clicking on the “Comments” link below.

Who is the Most Responsible Physician?

The December 2012 CMPA Perspective included a very interesting and relevant article on the importance of identifying the 'most responsible physician' in the management of patients that require concurrent care from multiple care providers at the same point in time. The most responsible physician in a primary care setting has traditionally been the family doctor who (by default) has assumed the role of care coordinator, ordering preliminary investigations, referring patients to specialists, interpreting consultant findings and determining the most applicable care options. However, in predominantly EMR-based clinical care settings in which shared and collaborative care are becoming the norm, determining the most responsible physician can be difficult depending on where the patient is being managed and who has primary decision making responsibility.

In a dominantly paper world, grey areas still existed, however the directionality of reports and the carbon copies generally provided a guide to who was the most responsible physician. For example, if a family physician referred a patient to a cardiologist who then ordered additional investigations, admitted the patient for monitoring and requested opinions from a neurologist and a psychiatrist, the cardiologist could be deemed to be the most responsible physician as he/she was directing the care of the patient and managing appropriate consultations from other specialists. Once the patient's care was passed over to the specialist, the family physician was essentially off the hook in terms of being the most responsible physician, particularly when the patient was managed in an inpatient setting. Care tended to be provided in blocks with each episode being directed by a specific clinician. The designation of the most responsible physician has medical legal implications in terms of on-call coverage and reliance on other providers as well as compliance with hospital policies.

In an EMR/IT-based setting, responsibility is no longer so clear cut. Consider the concept of a shared-care record that is shared amongst multiple providers including physicians and ancillary caregivers. In this setting, a care plan is created and made available to other providers using some form of shared EMR or a portal that all designated providers can access. In the course of management of a patient, the shared care record is updated as the patient navigates through the system and receives care. The concept is that a designated physician or other practitioner should take initial responsibility for the patient and for creation of the plan, which is then shared. In patients with multi-system co-morbid disease, it is not always appropriate or practical for the initial creator of the shared record to be the most responsibly physician when changes are made. Further complexity is introduced when specialists are added to the care team. If a specialist makes a change to the patient's care plan, there are implications for all other providers involved in the care of that patient and a need to be notified that a change has taken place. Following the change, does the specialist become the most responsible physician or does this role revert back to the family physician and if so, how long after the change in care plan? What if a decision of a specialist is nullified by a different specialist or the patient's primary care physician? Who in this situation is the most responsible physician?

Technology can enable information sharing more effectively, but in doing so can also introduce complex legal and ethical issues that need to be addressed. As the health care system evolves towards greater collaborative care, expect these types of issues to become more prevalent.

Have you had any experiences in which shared care and the most responsible physician designation have created challenges? Add your thoughts below.

Creating Online Communities of Practice to Support EMR Use

A number of years ago, while working with Vancouver Coastal Health on a primary care health IT strategy, I had the opportunity to lead a project to develop local peer support networks or physician user groups (PUGs). The principle behind the groups was to find a way to bring together clinicians with a wide range of skill sets ranging from none to highly skillful in relation to EMR use and health IT. However, as with many of these types of strategies, programs such as this are difficult to sustain over the long term.

The following summarizes lessons learned after 20 months of facilitating and supporting physician engagement through the Physician User Group strategy (2005 and 2007). Many of these learning points remain applicable in 2012, further supported by social media and mobile communication tools. It is important to note that the creation of these groups entailed both face-to-face meetings and online communication, leveraging local relationships and strengthening mechanisms to facilitate collaboration:

• There are multiple levels of engagement of clinicians. Physician User Groups are an entry-level engagement strategy to facilitate communication, build trust and credibility, and provide feedback into eHealth projects to ensure relevance of the projects to end users and to facilitate and organize thinking within a community.
• Time is one of the scarcest commodities that we have in the healthcare system today. Physicians work in a highly time pressured environment.
• It is not necessary to reach every clinician face to face. A very effective communication system exists amongst physicians in a community and the message will be disseminated informally and via email.
• It is important to initially understand the needs of the local group and allow concerns, issues, and desires to be openly discussed and documented. From the physician’s perspective: “What is in it for me and my local community?”
• The context then needs to be established in order to define what is doable and what is not and to seek involvement of clinicians in those areas.
• Once the group is established, the majority of communication takes place electronically.
• Leaders do not all need to be tech savvy. Strong clinical leaders who are respected by their colleagues and are seen as “more like me” are highly effective group leaders.
• Leveraging existing groups, e.g. departments of family medicine, and medical staff groups, is a very effective way to build your clinician member base quickly.
• One of the roles of groups is to facilitate communication amongst physicians in a peer-to-peer communications network.
• Leaders must have an easy mechanism to generate communications and distribute those communications to their members.
• Wherever possible in communication with physicians one should not use acronyms, as this creates confusion.
• The importance of accountability. It takes approximately two “cycles” to get buy-in and support from your members. It is necessary to prove to the members that you are responding to their needs and feedback, and that this is being integrated into the solutions and processes that are being developed.
• As face-to-face meetings are scheduled approximately every six months, it takes about one year to effectively establish a group.
• Meetings amongst group leaders are a critical part of sharing the lessons learned and providing timely and useful information and feedback to the IT resources and sponsors plus executive team members.
• Groups will evolve and change over time based on environment and needs.
• User groups enable physicians to organize themselves and structure their thinking within communities. Whether related to connectivity, eHealth information such as DI, Labs, Medications, or Electronic Medical Records, a standardized approach and fewer variables is easier to manage and more effective in achieving adoption and improved clinical outcomes.

I am currently reviewing a book titled Technology Enabled Knowledge Translation for eHealth. One of the chapters is focused on the building of electronic communities of practice. I will share observations and insights at a later date.

To add your thoughts or experiences with physician online communities, click on “Comments” below.

Does Access to Online Information Increase the Cost of Care?

Last week I wrote an editorial about the potential benefits of patient access to clinical information titled, “Consumer Oriented Care — So Near, Yet So Far”. The premise behind much of the work that has been done to enable consumer (patient or caregiver) access to online information through patient portals and personal health records has been the potential to improve patient satisfaction while at the same time reduce unnecessary clinic or hospital visits with a corresponding reduction in the cost of care. Initial studies conducted by Kaiser Permanente were able to demonstrate a reduction in caregiver visits; however, a recent article raises some important questions and suggests that our initial assumptions may be incorrect. What if the exact opposite is true? With all the best intentions, there may be unintended consequences that we do not fully understand. By providing access to online health information, we may be increasing the overall costs of care.

A Nov 21, 2012, article in JAMA, “Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services” by Palen et al, describes a retrospective cohort study for the period March 2005 through June 2010 at Kaiser Permanente Colorado. The study was designed to assess utilization of the health system by both users and nonusers of online access to health records before and after initiation of a patient patient portal. Researchers studied 44,321 members who signed up for the the online access system (MyHealthManager) and remained active users of the system for at least one year. MyHealthManager provides the ability for members to access their medical records, communicate with their physicians via email, and request appointments and prescription renewals online.

The authors found that contrary to the findings of this study (amongst others), which demonstrated a reduction in total office visits, “patients with online access to their medical records, including secure e-mail communication with clinicians, had a subsequent increase in use of most in-person and telephone clinical services”. The authors could not explain these findings and suggested that influences such as the decision to sign up for online access to their electronic records, may pre-select individuals who have a higher propensity to seek face-to-face care with a provider. By extrapolating their results to a small group practice, the authors suggest that “a primary care physician with 1,000 adult patients who have online access would need to provide for almost 10 more clinic visits per week and over 5.5 more telephone calls per week”.

This is clearly not the type of result that we are seeking by making electronic health records available to patients and their caregivers through portals or integrated personal health records; however, as these tools become more integrated with the care delivery process, we should continuously measure their impact to ensure that we are managing resources responsibly.

If you have any thoughts or feedback on this topic, please click on the “Comments” link below.

MyHealthManager allows members to email their physicians, as well as access their health records, request prescription renewals and schedule appointments online.

Read more: http://www.ihealthbeat.org/articles/2012/11/21/access-to-online-health-records-linked-with-more-patient-visits.aspx#ixzz2D0cAWzRY asdas

esearchers from Kaiser Permanente Colorado studied 44,321 health plan members who signed up for the MyHealthManager system between 2006 and 2009 and remained active users of the system for at least one year.

Read more: http://www.ihealthbeat.org/articles/2012/11/21/access-to-online-health-records-linked-with-more-patient-visits.aspx#ixzz2D0bZHyCz

esearchers from Kaiser Permanente Colorado studied 44,321 health plan members who signed up for the MyHealthManager system between 2006 and 2009 and remained active users of the system for at least one year.

Read more: http://www.ihealthbeat.org/articles/2012/11/21/access-to-online-health-records-linked-with-more-patient-visits.aspx#ixzz2D0bZHyCz

 

 

Sacrificing Humanism — The Downside of EMRs?

One of the most frequent concerns that physicians have about using EMRs is the potential for the technology to get in the way of the physician-patient relationship. This concern is influenced by many contributing factors: the ergonomics and layout of examination rooms, the form factor of the hardware being used to document information, the keyboarding or data-input skills of clinicians, and the usability of the EMR software.

A recent article in JAMA by Elizabeth Toll legitimizes these concerns. The article includes a drawing by a seven-year old patient of her visit to the doctor. The patient is sitting on the examination table with her mother and sister nearby. The doctor is shown sitting at his computer in the corner of the room with his back towards the patient and her family.

An excellent article was written for the Atlantic by David A. Shaywitz (co-founder of the Center for Assessment Technology and Continuous Health (CATCH), titled “Humanism in Digital Health: Do We Have to Sacrifice Personal Connections as We Improve Efficiency?” He writes, “The electronic medical record has been a particular nidus of tension, as it seems to perfectly capture the transformation of medicine from a day when it was -- choose your descriptor -- [more personal/less robust] to a future when it will be [less human/more effective].” He also states, “I deeply believe medicine’s value far transcends data collection and evidence-based decision making; there is a vital human connection that is threatened because it's so difficult to reduce to zeros and ones.” Shaywitz eloquently captures the essence of the problem and identifies the disconnect between the technologists who see the benefits of “discrete data” while others fear that something important will be lost if we dehumanize healthcare information into pieces of sortable data. What I take from this is that the art of medicine is losing ground to the science.

As a clinician with over 25 years of clinical experience, I can recall numerous instances where the “Art” served me better the “Science”. In the presence of normal laboratory tests, normal diagnostic investigations, and a normal physical examination, there was something that was just not right. Call it intuition or pure gut sense, but in most cases the inner voice was correct. I do not know how this gets translated into a world in which the new generation of doctors will depend more on analysis and discrete data than on clinical acumen and intuition.

What do you think? Have we de-humanized medicine by applying increasing amounts of technology to the care process? Where does one draw the line? Add your thoughts by clicking on the “Comments” link below.

Job Descriptions Remain Important in an EMR-Based Practice

By Don Price: Many staff learn their jobs from their predecessors or through trial and error. Many more get by on common sense and an innate knowledge of how to get things done; yet stress levels rise if the objectives of the job are not clear. As a practice transitions to an EMR, roles can change significantly, necessitating the need to review and update job descriptions. For example, filing responsibilities can change to scanning once the EMR has been implemented.

A job description is not only a good teaching tool, or a yardstick by which performance can be judged — it is also a good way to motivate staff.

If staff are unsure of their responsibilities, negative impacts can be felt throughout the office. First of all, there is the individual who not only exceeds his/her responsibilities but may also overstep the boundaries. This can have disastrous medico-legal consequences if it involves an unqualified staff member giving medical advice to patients. Secondly, there is the person who, unsure of what he/she is meant to achieve, timidly does the very least to get by. This means that other staff have to work harder to tie up the loose ends, and productivity generally will be lower. The majority of staff will probably fall somewhere between these two extremes, with greater or lesser degrees of zeal and inefficiency.

What a good job description does is set down the minimum standards that you want your staff to achieve. It offers guidelines for reaching these expectations, and ensures an acceptable level of efficiency in the job if the staff follow it diligently. A good job description will also outline where certain tasks should be handled by other people, such as in the case of a medical receptionist who is uncertain what to do when a patient asks for advice about his prescription. By stating at what point a patient request should be handled by the doctor or registered nurse, an overly enthusiastic receptionist can be guided effectively by the job description.

Even the most autonomous staff person needs a job description, if only to provide clear direction for the staff member. A job description should never restrict a person to achieving the bare minimum, but should encourage initiative within set guidelines. To work as effectively as possible, people need to know what they are expected to achieve and how much responsibility they can take themselves.

If you don’t already have job descriptions in place, ask your staff to write their own, particularly if staff roles have changed with the adoption of an EMR. Once this is done, sit down with the individual staff member and go over each task listed in the job description to fine tune it to your own expectations.

Never simply state the task. “Handle the mail” doesn’t provide any direction for the person whose job it is to sort the mail, review, and deliver it, especially if this person is new to the job with little training. Provide thorough guidelines that show when the job has been satisfactorily performed, such as: “Mail should be opened no later than 10:30 am. All reports should be sorted, scanned, and placed in each doctor’s inbox by 2:00 pm each day or as soon as possible. Give cheques and invoices to bookkeeper. Review junk mail and discard or handle as per individual doctor’s requests.” This leaves no room for doubt in a staff person’s mind as to how and when to perform the task.

Comprehensive job descriptions are also useful when doing annual staff appraisals. It is much easier for the manager/supervisor and employee to assess how competently each staff member does his or her job if performance can be tied into the job description. In the mail handling example, if the staff member responsible for this doesn’t get the mail opened until noon and the doctors do not have their scanned documents available in their inbox until end of day, it will be obvious immediately that the staff person’s performance is not up to set standards. It may be that the job guidelines are unrealistic for the amount of other work the staff member has to accomplish before he/she can get to the mail, or it may be that performance is unsatisfactory. Steps can then be taken to correct the problem, either by changing the job description to more attainable standards, if the job description is at fault, or by offering more training to the staff person involved.

A job description should be more than a list of all tasks that have to be done. It should provide guidelines for staff so that they know what is expected of them. If they know this, they will work more confidently. Confident staff suffer from less stress and are happier in their work.

(Don Price is an Ottawa-based practice management consultant and financial advisor.)