How a physician writes for prescription refills can save that physician a lot of time. I have written tens of thousands of prescriptions over my career, a lot of those were handwritten on prescription pads. I am a member of an increasingly small minority of physicians – those that practiced medicine before the era of the electronic medical record (EMR). When our hospital first contracted with the electronic medical record company Epic, there were many tasks that became much easier and more efficient but there were other tasks that became more difficult and time consuming. The ability to send medication prescriptions electronically to pharmacies was the single greatest benefit.

Before the EMR, I would go through dozens of pads of paper prescriptions every year. I would generally write slowly with big block letters that could be easily read by the pharmacists. But many physicians had notoriously sloppy handwriting with the results that pharmacists would frequently call the physician’s office to clarify a prescription or make their best guess about what the written prescription actually meant (and sometimes got the medication or dose completely wrong). The EMR with its electronic prescription capability changed all of that and allowed physicians to do with a couple of mouse clicks what previously took 30 seconds of handwriting. For my outpatients who came in once a year for an annual visit, I would give them 30-day prescriptions with 11 refills. If they were on a 90-day prescription plan, then I would give them 3 refills.

Intuitively, that should have been enough to get them through the full year until they came in for their next annual visit. But a year after we implemented our electronic medical record, I started noticing that my in basket was regularly filling up with prescription refill requests from patients or their pharmacists.

Doing prescription drug refills outside of a regular office visit is inefficient. You have to do at least a minimum of medication reconciliation for each drug that involves verifying that you are actually the physician prescribing that medication, that the patient still actually needs the medication, making sure that no one else has prescribed another medication that either duplicates or interacts with that medication, and making sure that a new drug allergy has not been entered into the EMR since the patient’s last visit. This all takes time and that time is not reimbursable.

A second thing I began to notice after our EMR had been up and running for about a year was that when patients came in to see me for routine office visits for their pulmonary disease, they would sometime ask me to refill their non-pulmonary medications because they were going to run out of refills a few weeks before their next annual visit with their primary care physician. I found myself prescribing a month’s worth of everything from anti-hypertensives to heart failure medications to Viagra to get the patients through until their next office visit with their other physician. So, what was going on?

Prescribing either a 30-day prescription with 11 refills or a 90-day prescription with 3 refills is a total of 360 days of medication. That is 5 days short of a full year. Moreover, most patients do not come in for their annual visits at exactly 365 days from their previous visit. Most scheduling staff will look for open appointments after 365 days and that generally results in patients being scheduled several days or weeks after the exact 365 day number for their next annual visit. Furthermore, most people do not know their exact weekly schedule 365 days in advance – vacations, work conflicts, weddings, and the kid’s soccer tournament often necessitate re-scheduling the annual office visit. This causes that annual visit to be pushed back even further beyond 365 days. The bottom line is that patients were running out of their year’s worth of refills before their yearly office visit.

A simple solution

In most states, pharmacists are permitted to refill prescriptions for non-controlled medications for up to 12 months. Therefore, by writing a 30-day prescription with 12 refills, that last refill would theoretically be 5 days before the 12 month limit was reached. That would give you and the patient a 25-day window after 365 day mark for that annual visit. It is far more efficient to refill medications at the time that the patient is physically in the office for their regular visit. Moreover, the writing of a prescription (or refilling a previous prescription) can add to the complexity of that office visit, allowing the physician to bill a higher (and justifiable) level of service.

For 90-day prescriptions, if you write for 4 refills, that last refill will be at 360 days (five days before the 12-month refill limit). That gives you and your patient an 85-day window for that annual office visit after the 365-day, 1-year mark. In my own practice, I was almost always booking out more than a month for available return office visits and having that 85-day grace period for medication refills allowed my patients to re-schedule their annual appointments without running out of medications.

The result was that my in basket got a lot less congested with medication refill requests once I put that extra refill on long-term prescriptions. I was happier because my in basket was de-bulked, my patients were happier because they didn’t have to worry about running out of their inhalers, the pharmacists were happier because they didn’t have to take their valuable time calling my office for a refill request, and my office staff were happier because they didn’t have to deal with patients and pharmacists calling our office for refills.

But there is a downside. Anyone who has ever taken a prescription medication has had the experience of getting to the end of the month and finding that there are 3 or 4 pills left in the bottle. It is really, really easy to forget to take a dose, or two, or five each month. So, if left to the patient to go to the pharmacy every 30 days, the patient will invariably go at 32 or 33 days and by the end of the year, they will show up for their last refill a few days after their 12-month (365 day) refill limit. Therefore, whenever possible, get the patient on a 90-day prescription plan, preferably from a pharmacy that mails the the patient their medication refills automatically every 90 days.

The bottom line…

Always write long-term prescriptions as 30-days plus 12 refills. Or better yet, write 90-day prescriptions with 4 refills.

July 29, 2025

Tumor boards have been shown to improve cancer outcomes by incorporating the expertise of many specialists in order to formulate a personalized treatment plan for each patient. These interdisciplinary management plans can give patients the best chance of cancer control or cure. Tumor boards typically consist of a surgeon, a medical oncologist, and a radiation oncologist but may also include a pathologist and a radiologist. Organ-specific tumor boards may consist of other specialists. For example, a thoracic tumor board may include a pulmonologist or a GI tumor board may include a gastroenterologist. Tumor boards allow specialists to bring their own expertise to an individual patient’s cancer treatment plan in order to determine the timing of surgery, the use of adjuvant or neoadjuvant chemotherapy, and the use of radiation therapy.

 

Tumor boards have become even more important as advances in cancer genetics have resulted in many new treatments based on the molecular make-up of individual cancers. The advisability and timing of these newer treatments such as immunotherapy and driver-directed therapy can also be incorporated into the patient’s cancer treatment plan during tumor board discussions. Also, patients eligible for clinical trials of promising experimental treatments can be identified during tumor board discussions and enrolled in research studies.

In large medical centers, tumor boards typically meet once every week or two weeks. In smaller hospitals, tumor boards meet less frequently, often monthly. Each patient’s history, physical exam, radiologic staging study results, and tumor pathology results are reviewed. Specialists then develop a personalized cancer treatment plan tailored for that patient. A tumor board is far more efficient than having the patient see multiple physician specialists in their office for separate consultations and then having the physicians forward their individual recommendations to the primary care physician for coordination of care.

Survival of most cancers has improved significantly over the past several decades, largely due to development of new medications to treat cancers and to advances in cancer screening. But cancer is not one disease and cancer treatment has also become highly specialized. Oncologists used to be cancer generalists who were expert in the treatment of all forms of malignancy but now, medical and surgical oncologists specialize. The result is that there are different medical oncologists who treat lung cancer, gastrointestinal cancers, skin cancers, breast cancer, etc. As a consequence, tumor boards have also become specialized with different tumor boards for lung cancers, gynecologic cancers, and breast cancers. Large academic medical centers will often have 8-10 different tumor boards, each for a different type of cancer.

This specialization of oncologists and of tumor boards has posed a challenge for smaller hospitals and rural hospitals that do not have the luxury of multiple medical oncology specialists, surgical oncologists, or gynecologic oncologists. These hospitals either have to rely on general surgeons, general medical oncologists and general tumor boards or have to refer their newly diagnosed cancer patients to large medical centers for subspecialty evaluation that can sometimes be hundreds of miles away.

In the past, tumor boards were held in hospital conference rooms with physicians attending in-person. The COVID-19 pandemic showed us that multidisciplinary conferences could be just as effective when performed remotely. For more than 15 years, I led our medical center’s multidisciplinary interstitial lung disease conference which is the equivalent of a tumor board for non-cancer diseases such as pulmonary fibrosis. We found that our interdisciplinary discussions were just as easily done by a Zoom or Teams meeting as they were by in-person conferences. In fact, we had better attendance when the conferences went remote because physicians who practiced at off-site clinics could more easily attend.

A 2014 proof of concept study involving two Veterans Administration hospitals showed that virtual telemedicine tumor boards were both feasible and well-accepted by participants. The COVID-19 pandemic forced most hospital tumor boards to convert to virtual meetings. A study from the University of Pittsburgh demonstrated that virtual tumor boards during the COVID pandemic were very effective. But can we develop virtual tumor boards utilizing telemedicine technology to bring multidisciplinary expertise to smaller hospitals in order to improve cancer outcomes in rural and underserved areas of the country?

Lessons from institutional review boards

Institutional review boards (IRBs) are sometimes referred to as “human subjects committees” and are multidisciplinary groups that review clinical trials in medicine to ensure that medical experimentation involving humans is performed ethically and with appropriate study design. In the past, each hospital had its own IRB composed of volunteer reviewers. The volume of study proposals and the burden of IRB meetings by physicians, university faculty, and lay public members often resulted in long delays in getting clinical trial proposals approved.

In 1968, the Western Institutional Review Board was founded as an independent ethical review organization that allowed hospitals to outsource their clinical trial reviews for a fee. Hospitals no longer needed to rely on internal human subjects committees and Western was able to turn proposals over more quickly than the hospital IRBs. Our university outsources most of our clinical trial reviews to Western and this has greatly expedited research. Over time, more independent IRBs arose and consolidated. Now, most clinical trials undergo their ethics review by independent IRBs such as Western (now known as WCG IRB). These independent IRBs can match ethics and research specialists with specific clinical trials in order to provide superior reviews in a shorter period of time.

Our nation’s tumor boards can learn a lot from the independent IRBs. By assembling a large group of specialists in the treatment of each type of cancer, state-of-the-art recommendations individualized to each patient’s cancer can be made anywhere in the country, or for that matter, anywhere in the world. And those recommendations can be made faster, thus allowing patients to get started on optimal treatment as quickly as possible. A criticism of American cancer research is that racial and ethnic minorities are often underrepresented as subjects in clinical trials. By better reaching these minorities through telemedicine tumor boards and identifying clinical trial candidates, such disparities could be reduced.

Barriers that need to be overcome

There are several obstacles that need to be addressed before national telemedicine tumor boards can be implemented:

1. Medical licensure. In telemedicine, the medical encounter is legally considered to occur at the patient’s physical location and not the doctor’s location. As a consequence, physicians providing telemedicine must be licensed to practice medicine in the state that the patient is in at the time of the telemedicine encounter. A physician in Ohio cannot legally provide telemedicine care to a patient located in Florida unless that physician has a Florida medical license. For this reason, state-specific telemedicine tumor boards would be easy to implement from a medical licensure standpoint but a national telemedicine tumor board would require physician participants to have dozens of individual state medical licenses. The development of the Interstate Medical Licensure Compact may simplify the process of obtaining medical licenses in many states but not all states participate in the Compact. A national telemedicine tumor board could perhaps most easily be implemented in the Veterans Administration system since VA-employed physicians can practice in any state as long as they are licensed to practice in any one state.
2. Cost. Physicians participating in hospital tumor boards are generally not compensated for their time – they participate pro bono as part of their professional duties to the hospital. A 2021 study from a single academic medical center found that the total cost in physician time to participate in the hospital’s 9 separate tumor boards was $648,183 per year. Currently, there is not a mechanism to pay for national telemedicine tumor boards and this would need to be addressed by Medicare and commercial insurance policy changes. Alternatively, this could be financed by subscription fees charged to participating hospitals.
3. Radiographic and pathologic review. Like medical oncology and surgical oncology, radiologists have become subspecialized. Chest CT scans of patients with lung cancer are reviewed by a thoracic radiologist whereas brain MRIs of patients with brain tumors are reviewed by a neuroradiologist. Pathologists have become similarly subspecialized. Tumor boards at large academic medical centers are usually attended by the subspecialty radiologists and subspecialty pathologists who originally reviewed the patient’s materials. Smaller hospitals will typically only have general radiologists and general pathologists. A mechanism would need to be in place so that subspecialty radiologists could review original radiographic images and subspecialty pathologists could review full slides of tumor biopsy specimens. There are existing telemedicine solutions to both of these challenges but this could require smaller hospitals to purchase equipment and software to transmit radiographic and histologic images.
4. Malpractice insurance. When a physician’s name appears on a treatment recommendation, that physician can be named in event of a medical malpractice lawsuit. Several years ago, I was a defense expert witness in a malpractice case involving a patient with a rare eosinophilic lung disease. The pathologist reviewing the lung biopsy slides called a pathologist in a different city who was a national expert in pulmonary pathology and asked that pathologist over the phone about the diagnostic significance of all of the eosinophils that were present on the biopsy slides. The second pathologist was named in the suit, even though he had only spoken by phone with the initial pathologist and had not, himself, seen the actual biopsy slides or provided a formal pathology report. Malpractice insurance coverage would need to be worked out before implementing a national telemedicine tumor board. Board participants would either need to have immunity against civil litigation or would have to be provided telemedicine malpractice insurance.
5. Medical record access. Tumor board participants must have access to patients’ medical records. Many factors need to be considered when formulating a cancer treatment plan including laboratory test results, radiologic images, medication lists, drug allergies, past medical history, family history, social history, and the physical exam. All of these data must be available to tumor board specialists for them to provide the best recommendations for any given patient. Electronic medical records have improved physicians’ ability to access medical information at other hospitals, such as the ‘CareEverywhere’ app on Epic’s electronic medical record. Nevertheless, not all electronic medical record software are equally good at permitting cross-hospital patient information transfer. The success of a national telemedicine tumor board would be contingent on development of robust integrated electronic medical record networks.
6. Patient selection. Not every cancer patient needs to be presented at a tumor board. For example, the management of a patient with stage 1A non-small cell lung cancer is pretty straight-forward – they get a lung lobectomy. But cancer treatment guidelines change rapidly and it can be difficult for the general oncologist or the general surgeon in a small, rural hospital to keep up with these guidelines. Not too many years ago, the standard of care for stage 1B lung cancer was surgery alone but several years ago, adjuvant chemotherapy was added, followed more recently by neoadjuvant chemotherapy. Last month, a study showed that neoadjuvant chemotherapy plus immunotherapy was better still. There would need to be some process in place to identify those patients who would benefit most from a national telemedicine tumor board. One option could be to refer only those patients that general tumor boards identify as needing discussion at a subspecialty telemedicine tumor board.

Somebody is going to make a fortune

Successful entrepreneurs identify unmet consumer needs and then figure out a way to meet those needs. Those who are successful in a large consumer market become wealthy. Providing specialized cancer treatment recommendations is currently an unmet healthcare need in much of the United States and throughout most of the world. A national telemedicine tumor board has the potential to be an enormous commercial success and has the promise of making whoever can pull it off rich.

However, most physicians did not go into medicine just to be wealthy, we go into medicine so that we can improve people’s lives. I can think of few better ways of improving large numbers of people’s lives than by ensuring that every cancer patient in the U.S. has access to prompt treatment recommendations from specialists up to date on the latest in evidence-based oncology. It is time for national telemedicine tumor boards.

June 22, 2022

Hospitals have a love-hate relationship with verbal orders. On the one hand, they can expedite care to the patient and can save physicians time. On the other hand, they can increase medical errors. Some groups believe strongly that the goal should be to have zero verbal orders whereas others believe that there should be no barriers to verbal orders. Electronic medical records have reduced the use of verbal orders in some situations but promoted the use of verbal orders in others.

The Joint Commission, the Leapfrog Group, the Institute of Medicine, and the Institute for Safe Medical Practice have all called for reducing or eliminating verbal orders. Nursing groups often see verbal orders as dangerous because of the risk that a verbal order error will place nurses in a position of liability. The Health Systems Management Society that determines best practices in hospital medical record keeping has set a goal that verbal orders should be < 10% of a hospital’s total inpatient orders and < 5% of a hospital’s total outpatient orders.  The literature is rife with anecdotes of the nurse who thought a doctor said to give a patient 10 mg of Viagra when the doctor actually said to give 10 mg of Allegra. The reality is that verbal orders can both improve patient safety and worsen patient safety.

Electronic medical records have reduced verbal orders

Much of the literature on verbal orders is from a pre-electronic medical record era. 15 years ago, most hospital orders were written in the patient’s paper chart that was kept in a nursing station. For a physician to place an order, that physician had to go to the nursing station hand write the order. If the doctor was out of the hospital or was on a different floor of the hospital, then entering an order was not possible and verbal orders proliferated. A bad phone connection, a doctor with a foreign accent, or a lot of background noise in the nursing station helped to foster mistakes. Although physicians had to eventually sign those orders, signing often didn’t happen until weeks after the patient was discharged when the patient’s chart was flagged by the medical record department as containing an unsigned order. Every physician who practiced in the 1990’s can remember weekly trips to the medical record department where each physician would have a stack of discharged patient charts requiring signatures.

Pharmacy orders were a particular problem. In the by-gone era of the physician’s prescription pad, a hand written prescription was given to patients at the time of an office visit or when being discharged from the hospital. But if that patient called in with an acute illness or needed a prescription refill, then the doctor had to call the pharmacy to give the pharmacist a verbal order for a medication. On nights that I was on-call, I would almost always have to phone in a verbal prescription to a pharmacy for a patient needing an antibiotic or an asthma inhaler; the options were either a hand-written prescription or a verbal order.

With the advent of electronic medical records, a physician no longer had to be physically in a specific nursing station to place an order. Doctors could now access the patient’s chart from a computer located anywhere and can even place orders from an app on their phone. I have not hand-written a prescription on a prescription pad in years. Even when I am on call, I find it easier and faster to send in a prescription by computer or by an app on my phone than to call a pharmacy (and be put on hold for several minutes). It is now easier than ever before to place an order electronically and this has reduced the need for verbal orders.

When verbal orders are a good thing

There are times when a physician simply cannot safely place an order in the electronic medical record. For example, the surgeon who is scrubbed in the middle of an operation cannot break scrub to place an order for the nurse to give the patient a fluid bolus. The family physician who is at a restaurant having dinner and gets a call from a patient with bronchitis cannot easily walk away from the restaurant, drive home, get on a computer to access the electronic medical record, and then send an electronic order for an antibiotic to the patient’s pharmacy. When a physician is driving to work in the morning is called from the ICU about a patient who is seizing, that patient needs to receive a dose of lorazepam immediately and not 15 minutes later when the doctor has access to a computer to place the order.

The reality is that most hospital locations have to use verbal orders some of the time in order to ensure timely care of patients. But there are some areas where a higher percentage of verbal orders (> 10% of the total) is more necessary than other areas:

1. Operating rooms
2. Intensive care units
3. Cardiac catheterization labs
4. Endoscopy labs
5. Dialysis units
6. Cardiac echo labs
7. Emergency departments
8. Radiology areas
9. Patient emergencies anywhere in the hospital

When verbal orders are a bad thing

Although electronic medical records are ubiquitous today, most hospitals have only adopted them in the past 10 years. Consequently, there are many physicians who are still unfamiliar with the use of electronic medical records. Probably every hospital in the country has that doctor who still has not figured out how to place an order in the electronic medical record and gives all of his/her orders as verbal orders to a nurse. As younger, more computer literate physicians replace older, less computer literate physicians, this will be less of a problem in the future.

It can take time for a physician to enter orders in the computer and having someone else do it for you can improve your efficiency and allow you to spend more time actually talking to the patient. Consequently, many physicians like having a nurse that they can dictate orders to follow them around in the clinic or during hospital rounds, entering those orders into the computer as the doctor goes from one room to the next. This is an expensive use of a nurse and most physicians in small private group practices realize that it is financially untenable. However, hospitals have to court certain specialties, particularly surgical specialties, to keep them from moving their practice to another hospital in town. So, hospitals are often willing to provide an order scribe to the surgeon who brings a lot of high value surgical procedures to the hospital’s operating room. They know that they stand to make more from the surgeries than they will lose in the cost of the nurse to do order entry. The hospital can stand to ignore the hospitalist who says “Let me give verbal orders or I will leave” but cannot ignore the joint replacement surgeon or neurosurgeon who says the same thing.

There are situations when orders are generally not emergent and the risk of a medical error from an incorrect verbal order is just too great:

1. Chemotherapy orders
2. “Do not resuscitate” orders
3. Orders for narcotics when the nurse/pharmacist cannot confirm that the person calling in the order is actually the doctor

Minimizing the risks of verbal orders

Given that the use of verbal orders is beneficial to patient care in certain situations and essential to patient care in others, complete elimination of verbal orders is neither practical nor possible. However, there are certain steps that the hospital can take to reduce the chances of verbal order errors:

1. Use “read-back” of the order by the nurse or pharmacist so that the physician can confirm that what he/she actually said was what the nurse or pharmacist heard.
2. Avoid using abbreviations. “QID” can sound too much like “QD” on the phone. Saying “K” for potassium can be confused for vitamin K.
3. Beware of “sound alike” medications. It is easy to mistake “Tramadol” for “Toradol” or “clonidine” for “Klonopin”.
4. Keep the noise down. A lot of people talking loudly in the nursing station makes it harder for the nurse taking a verbal order to hear that order correctly.
5. Beware of accents. Regional American accents, foreign accents, and speech impediments can make it difficult for the nurse or pharmacist to understand the doctor accurately.
6. If it doesn’t make sense, confirm it. If the ER physician tells a nurse to do a pregnancy test on the patient in bay 5 and the nurse walks in to find that the patient in bay 5 is a 70-year old named Joesph Smith, then it is best to double check with the doctor before asking for a urine sample.

Despite what some would have us believe, verbal orders are not inherently evil. However, they can create vulnerability from both a patient safety and medical-legal standpoint. Hospitals do need to regularly monitor for judicious use of verbal orders.

February 22, 2020

There is a subtle difference between inpatient and outpatient medical practice that nobody ever talks about… time management. With inpatient practice, you see patients at your own pace during rounds and if you want to stop for a moment to have a cup of coffee or speak with a colleague, it doesn’t disrupt your workday. But with outpatient practice, you can work leisurely at your own pace before office hours and after office hours but during office hours, you are in a constant state of demand for time efficiency.

In my own practice, my office hours come in 4-hour blocks, either 8:00 AM to 12:00 noon or 1:00 PM to 5:00 PM. During those blocks, I schedule 15 minutes for return visits and 45 minutes for new patient visits – every minute is scheduled and the only way that there is a break is if one of the patients doesn’t show up for their appointment. During that 4-hour block, I have nurses, schedulers, and registration staff who all need to be working in order for the office to function in a financially viable way. But for them to stay constantly busy, I have to be constantly busy.

10 years ago, before we adopted an electronic medical record, each patient would have a paper chart and I would make a few shorthand comments on a piece of progress note paper and then at the end of office hours, dictate letters to the referring physician for each patient, clean up my orders for the day and fill out billing sheets. In other words, I “back-loaded” my work day with a couple of hours of charting after I was done seeing patents. Once we adopted an EMR, I tried to do a lot of that work while I was in the room with the patient. The result was that I didn’t have as much dictation and chart work after office hours but the EMR documentation encroached on the time that I was with the patients. I continued to allocate the same amount of office time per patient but I seemed to have fewer minutes just talking with my patients. And because the EMR results in the physician doing more of the work of documentation than in the past, I still was spending an hour or two at the end of the day finishing referral letters and closing encounters in the EMR.

This was reflected on my CGCAHPS patient satisfaction survey results. Patients were happy with the care that they got but they were not happy about the time they spent in the waiting room when I ran behind and they often commented that they didn’t get enough time to spend with the doctor once they were in the exam room.

So 5 months ago, I tried a different approach, pre-charting for my outpatient visits. The day before my office hours, I start my progress note for each patient by selecting the appropriate return visit note template (I have different templates for different diseases: one for interstitial lung disease, one for asthma, one for COPD, etc.). I pre-populate any new test results and pre-populate my final “impression” by pasting in the diagnoses that I manage for that particular patient from their previous note. For new patients, I insert the appropriate new patient template (again, I have different templates for different pulmonary conditions) and pre-populate the note with any test results, radiograph image review, pulmonary function tests, etc. that are available for that patient, either from our medical center or from other hospitals that I can access through the “CareEverywhere” function in our EMR (we use Epic). As a result, I spend about an hour prior to each 4-hour outpatient block pre-charting, sometimes longer if I have a new patient with a lot of records that require reviewing. After 5 months, I’ve found that there are advantages and disadvantages:

Advantages:

1. I am less likely to get behind on my schedule and so my patients are spending less time in the waiting room.
2. I have more time to spend just talking with my patients since I am not trying to furiously type into the EMR as much when I am in the exam room with the patient. As a consequence, I find that I actually enjoy my time in the outpatient clinic a lot more than I used to.
3. I anticipate improvement in two of the CGCAHPS survey questions: During this visit did this provider seem to know the important information about your medical history? and During this visit, did this provider have your medical records?
4. I finish the day’s work earlier because I do less charting at the end of the day by front-loading all of that charting before office hours.
5. I have now started billing CPT code 99358 about 2-4 times a week. This code pays you for review of medical records prior to seeing the patient in the office, as long as you spend at least 31 minutes doing the review. In my own outpatient practice, most of my patients have already had pretty extensive evaluations and in about half of the new patients, I spend > 30 minutes sifting through office notes, lab tests, cardiovascular tests, chest CT images, pulmonary function tests, etc. This pays 3.16 RVUs (about $114 in Medicare reimbursement) and I now find myself getting paid for the work that I was previously doing for free. And this adds up… I estimate that my clinical receipts will increase about $13,000 per year from this CPT, alone.
6. I have x-rays available when I see the patient. Most of my patients are sent to me from physicians at other hospital systems and so most of their chest x-rays and CT scan images are not in our hospital’s computer system. By pre-charting, I have been able to identify where those radiographs were done so that my office staff can contact that hospital’s radiology department and have the images sent over the internet before I see the patient – in the past, I often had to schedule a second visit with the patient just to go over x-ray images that I requested after I first saw the patient for an initial consultation.
7. I have been able to do a “huddle” with the nurses just before the start of office hours to let them know about anything special that they will need to do to prepare for each patient’s visit.

Disadvantages:

1. In the past, I defined my workday as being complete when I finished all of the work for the patients that I saw on that particular day and the administrative duties I had for that day. Because pre-charting is often relegated to the last thing that I do each day (since it is usually the least urgent), pre-charting becomes the task that keeps me at work an hour longer each day and so I now negatively associate it with being the thing that steals my time away from my family in the evening.
2. I often have residents and fellows in the office with me. I worry that by doing the pre-charting, I am detracting from their experience of independently analyzing the patient. Personally, I believe that the trainees learn a lot about how to comb through old records for diagnostic clues efficiently by actually doing it themselves and when I pre-chart, I am depriving them of this opportunity.
3. I’ve created this nagging sense that I am becoming obsessive-compulsive.

Every time management strategy in the outpatient clinic has a trade-off between advantages and disadvantages. I don’t think that pre-charting save me any of the total time I spend on any given week but I don’t think it requires any more of my time either – it just shifts some of the documentation time around from after the clinic hours to before the clinic hours. But I think that it makes both my patients’ experience and my experience with the time spent in the exam room a little better. So, for now, I’m going to keep pre-charting.

November 28, 2018