Gaming the system looks good, but ultimately creates more problems than it solves.
Dear Director,
Our chair has instructed the group to “click” on the patients’ box indicating that we’re with them as soon as they get to the ER. Sometimes, this is a long time before I actually see the patients. It seems fraudulent to me and I don’t want to do it but then I’m penalized by my director for long arrival to provider times. What should I do?
I have among the worst handwriting of anyone working in the ED and I love the fact that my EMR allows me to type or dictate my note. Besides scribbling my signature on a few prescriptions and work notes a day, I barely have to use a pen. The down side is that every click we make translates into a time stamp.
Potential ED metrics, particularly door to provider (D2P) time, are at the top of list of importance to most CEOs. And as a medical director, an accurate D2P is critically important to me, too. It helps me understand our operational flow, left without being seen rate, patient experience, and can be tied to quality (or how delays in care occur).
What’s the Definition?
The Emergency Department Benchmarking Alliance defines arrival to provider as “the time from a patient’s ED arrival to their first contact with a provider who can initiate their ED evaluation plan.” This is typically reported as a median. I’ve seen EDs have APPs “greet” patients, typically at triage, to stop the clock and I’ve seen docs click the button and then intentionally not see the patient for an hour. My own practice is that I click the “time in with the patient” button when I’m ready to go see the patient.
I use Epic, so that button is on the triage screen. I’ll take a few seconds to review the triage note and past medical history. I walk to the room and am probably at the bedside within a minute of clicking the button. I think it’s okay to review the pertinent past medical records, but if the patient is so complicated it takes more than five minutes, I think I’m better off at the bedside making sure they’re okay and then letting them know I’m going back to the computer to order tests and review their records. After all, I’m not a medicine intern and don’t need a chart autopsy on every patient before I see them.
Follow the Money
It’s human nature that we focus on things that are incentivized. It’s particularly true when money is attached. That’s why productivity based compensation models are so prevalent throughout all of medicine (and law and accounting and other professional fee for service industries). Managers have targets set by their bosses and these drive the areas of focus. CEOs are no different. The board delivers targets, typically attaches bonus compensation requirements, and the CEO designs targets for ED medical directors. If you live in a region of the country where billboards post real-time ED Wait Times, this metric may be critical to your CEO to help drive volume. But focusing on improving a metric is very different than fraudulently capturing a time stamp.
Gaming the System
Let’s be honest, at one point or another, everyone has fudged the “time into the room” metric. I know people who used to make up times when charts were hand written, and now you may click on the “provider with patient” box long before you’re actually with the patient. I’ve heard all the reasons. Some are legit, but ultimately it depends on the time difference between clicking on the EMR when you a) see them walk into the room b) review the old records and are therefore engaged in patient care c) stop in to say hi and tell them you’ll be back in 20 minutes and when you actually start taking the history and then initiate their work up.
This metric can be so important for department or hospital metrics, it’s not uncommon to put a provider in triage. While sometimes a provider in triage can make a dramatic improvement in flow, it’s not proven to improve overall flow as much as it is to decrease arrival to provider time. Perhaps this is the ultimate in gaming the system. We’ve all been tracking OP-20, a CMS out-patient core measure that publicly reports the median time from patient arrival until seen by a provider, but this measure is in the process of being removed from public reporting. As it turns out, CMS realized there is limited evidence that a shorter D2P time improves patient outcomes and they also recognized that the time stamps weren’t necessarily accurate.
Why Clicks Matter
Historically, we’ve been pretty limited in what data we could gather. We generally focused on arrival or bed to provider time, left without being seen rate, and length of stay (discharge, admission, overall). But with the transition from paper to electronic medical record, it’s easier than ever to break down the ER process into numerous steps. However, I have a sense of most of my ED metrics simply based on my LWBS rate. If this goes up, I’m pretty sure my D2P and LOS stays are high and patient sat will be low. Yes, it could be related to boarding or volume surges, but you get the idea.
However, the clicks really matter when I’m evaluating our department flow and when I’m in the weeds comparing provider performance. I’m particularly interested in provider to disposition time. I typically separate this into admits and discharges, and sometimes by ESI score. It’s almost like Newton’s Laws of Motion—for every action there’s an equal and opposite reaction. If you fudge your time into the room and don’t see the patient for an hour, you’ve just increased your provider to dispo time, and likely increased your overall length of stay, which ends up hurting your metrics.
Checks and Balances
Dr. R worked in my ED years ago. He would see a patient with pharyngitis, click discharge since he knew the patient was ultimately going home, and then order 2 liters of IV fluids and Toradol for the patient. Two hours later the patient would leave, but his provider to dispo time was short. Nurses owned the “dispo to discharge” time. How many times do you think this happened before nursing approached me saying their metrics were unfairly impacted by his rapid decision making? Just like docs are worried about D2D times, with EMRs, nurses are now seeing their own “dispo to discharge” time.
Nurses are well aware of who doesn’t follow the rules when it comes to appropriate clicking and which docs click on the patient and then don’t see them in a timely fashion. And yes, this makes its way to nursing and physician leadership. In most EDs I’ve worked in, some version of this conversation among the ED physician and nurse leadership team has taken place. We actually have some basic rules of the road in my current ED that are discussed in physician orientation and then turn up at our staff meetings once or twice a year. At my site, nursing generally keeps us honest as they have concerns when patients have long waits for orders once the doc supposedly saw them.
Reviewing complaints that come to patient relations provides further oversight. Timelines are created and complaints about wait time and LOS are commonplace. It’s definitely hard to explain a short D2P provider, but delays in orders, pain meds, or other patient related interventions. I can’t imagine having to explain the discrepancy between a short D2P time and a complaint where the patient states they waited in a room for an hour before someone came in. It’s even worse when a pattern of such complaints occurs, highlighting the false documentation.
LWBS rates will be another check on the accuracy of the D2P times. It’s hard to justify almost any LWBS rate above 1 or 2% if you’re average D2P time is just minutes. Diving into the data to better understand why the LWBS rate is so high will only highlight the inconsistent documentation.
Fair and Accurate Clicking
Metrics are important. Good metrics are even better if you’re an administrator or medical director. But metrics are a reflection of the department’s status and contributes to the road map the director needs to work on. Long waits can compromise patient safety and quality of care so I really am interested in honest metrics so I can figure out what areas need to be our focus. If I’m unaware that the department’s arrival to provider time is falsely short, and therefore the provider to disposition time is artificially inflated, I may be focusing my administrative time on issues that are not real rather than on front end or back end flow issues.
Take the High Road
Our job is to follow our boss’s direction and make them look good, but this should not come at the cost of acting in a fraudulent or unscrupulous manner. My wife is constantly reminding our kids (and me) to take the high road and do what’s right. It’s extremely unethical for the chair to ask people to falsify medical records. And while I might not recommend that exact wording when you meet with him or her, I do believe you need to meet directly with your boss to start this discussion. I would not go over your boss’s head to begin with, but it may be a necessity to talk to others in your group if you don’t make headway with your director.
Conclusion
I’m a pragmatist. Metrics aren’t going away in my lifetime and I can’t change that. If anything, metrics are likely to increase in numbers since EMRs allow us to track pretty much any click that is made. Although CMS may not require publicly reporting of door to provider going forward, for many hospitals, this remains a critical metric. But if you’re trying to find bottlenecks and work to improve metrics, it’s also critical to have reliable data so establishing department rules around critical time stamps is also valuable.
We don’t have RF chips implanted in us (yet) that know our precise location and when we’re shaking hands with the patient, so there’s always going to be a bit of discrepancy in metrics that require a click on a computer and then walking to the bedside, but we also shouldn’t knowingly say we’re with a patient when we’re not starting their care in any manner.
