How to avoid charting after hours

In the Medical Post 2022 annual physician survey, almost 20% of respondents said they spent 14 to 20 hours per week on paperwork; 30% spent nine to 13 hours; about 12% spent between 21 and 31 hours or more. They also reported much of this work was being done outside of clinical hours. Some of that work is filling out forms but much, doctors said, is patient charting. In fact, about 60% of physicians who responded said they either agreed or strongly agreed that “Charting is a significant source of stress for me.” Dr. Sarah Smith, a rural family physician in Edson, Alta., has been there. She loved her patients and loved medicine, but was spending her evenings charting and began hating her job. She felt she was missing out on important aspects of her personal life. Dr. Smith searched for answers, eventually teaming up with a life coach who helped give her back her life. “There was finally the distinction between working and not working. I wasn’t constantly thinking, ‘I can’t because I have paperwork.’ I don’t have to delay joy until this insurmountable task is finally over.” Dr. Smith then became a life coach herself, and in turn became a charting coach, and started the Charting Champions Program (chartingcoach.ca), a program and ongoing community for doctors who want to “get home with today’s work done.” Though the charting solution for each physician is different, generally the goal is the same: “We want you to be able to see patients and close chart,” said Dr. Smith. “That’s the foundational step because that’s going to help your brain be at its freshest all day, and get you home with today’s work done.” Dr. Smith takes a holistic approach to coaching doctors and says there is no quick fix for the charting woes facing physicians today, and the process and solutions will be different for each one. But there are some key concepts: Ready for change: Physicians need to be “ready for different. They need to be done with evening work. They need to be at the point of, ‘I don’t want this anymore,’ and they’re determined that they want it different. Because it’s going to be uncomfortable. Doing new things is not the easy part. It’s hard.” Ready to take control: “I spent 15 years kind of stuck in this ‘It’s-all-happening-to-me’ frame of mind. I have no control over when patients are booked in, how long they’re booked for, interruptions, or other jobs I have to do. It takes a lot of courage to turn up differently in your encounters . . . and think about it from the point of view of being the executive decision-maker in what can be achieved today and what can’t be and then helping the patient, for example, understand that.” Becoming a curious observer: “We want you to be able to see patients then close chart, but then that brings up a whole other set of concerns, doesn’t it?” Finishing charting with each patient can mean being late for the next appointment. “I’m running 45 minutes behind. I’ve got three patients waiting. They’ve just fit in another patient. The patient’s got five problems,” Dr. Smith says. “So if you’re half an hour behind at 11:30, it’s stepping back in curiosity and saying, “OK, why am I behind? Let’s go back and revisit what happened in the day. What time did I start my rounds? What time did the patient arrive? What time were they put in the room?” Dr. Smith says to bring a kind, curious eye to the day and then ask, “What am I noticing about my day? How else could I set this up? I have choices here.” Smart charting Vancouver family physician Dr. Eric Cadesky is an advocate for sustainable healthcare for patients and for doctors, and has written and spoken about the impact of paperwork on doctor burnout. He offers this practical advice for smart charting: Templates: “Use templates and other predictive text for common histories, examinations and plans.” Up your skills: “Invest in a typing course to get your stroke speed up.” Speak up: “Invest in specialized medical dictation software. Or just use your smartphone, which is often remarkably accurate.” Copy and paste: “For complicated reassessment visits, copy and paste the previous visit and edit the changes. This will save time and allow you to compare the progress.” Choose a good EMR. “Or at least a less bad one.” Dr. Noah Crampton is a family physician with the Toronto Western Family Health Team and peer leader with OntarioMD, which supports physicians in adopting digital health technology. He is also a strong advocate of templates and dictation tools, as well as using pre-visit questionnaires (which patients fill out before the visit and which are automatically entered into the EMR). “Having a nurse or physician assistant do a pre-visit history and physical exam, where they write an initial note before the physician sees the patient” can help, said Dr. Crampton, while noting that all the offered suggestions depend on a physicians’ preferred approach to patient interactions and their comfort with technologies and multitasking. “I also suggest using other EMR user-assistance tools (examples of companies in this space include Suki, Phelix, Tali.AI, Caddie Health), some of which are powered by AI. These tools try to auto-prepare EMR actions thereby minimizing the number of clicks by the clinician.” Speaking of AI, Dr. Crampton is also founder and CEO of Toronto-based Mutuo Health Solutions, which has developed an AI tool called AutoScribe. “We’re not quite there yet,” he said, but as technology evolves, machine learning AI could be part of the solution for overburdened human physicians. “One of the nice advantages of our tools is that we do have a personalization algorithm built in. Each doctor likes to chart in their own specific way, stylistically. And so the way our system works is: Upfront the doctor provides a template of how they like to do their charting. A human scribe is then made aware of that and is able to make the notes according to that template. Then with time, the more a doctor uses it, the AI is able to predict that for this doctor they want it in this format and will output directly in that format. And that will never be lost like with human scribe turnover because that (AI) guy never forgets.” Human scribes One of the advantages of AI scribes is that the cost of their service is much lower than that of their IRL counterparts. Dr. Peter Graves is an emergency physician at Ottawa’s Queensway Carleton Hospital and co-founder of Medical Scribes of Canada, a company that runs medical scribe programs in ERs and to a lesser extent in other healthcare settings. Most of the scribes are pre-med students who are eager to learn and undergo extensive training. “Scribes allow physicians to completely engage with patients, and then later completely recharge when they leave work,” said Dr. Graves. “Physicians who have scribes talk about getting to do the work they love rather than paperwork, and no longer feeling beaten up at the end of the day.” But he acknowledges that even though scribes usually cost only about minimum wage, that is still costly for many doctors and they can take months of training. “The goal is that governments or institutions chip in for the cost of scribes, but we are not there yet,” he said. Still, many physicians swear by scribes, he said, especially because not only do they do real-time transcription of doctor-patient interactions, they record patient history and updates, exam results or follow-up appointment details. They have no direct interaction with patients. For doctors who want to hire their own scribe, Dr. Graves says they should expect to pay minimum wage, invest in training and talk to the colleges or the CMPA about insurance required, confidentiality agreements and other legalities.

How to avoid charting after hours

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