One of the things that can cause physician burnout is the arcane way information flows in medical offices. In essence, due to EMRs we are the recipients of increasing amounts of unfiltered data without context.
Pre-EMR, team members sorted incoming data, which allowed us to deal with it more efficiently. We would have piles of things that needed a signature just as a formality, other piles for normal reports, smaller piles for abnormal reports, or whatever system worked best for us and our practices.
Because EMRs were created by people who never imagined that doctors themselves knew anything about how to maximize their own efficiency, results and reports now fill our inboxes in random order and demand our attention and our electronic signatures more or less immediately.
There is a better way. It is standard practice in manufacturing. They call it “Just in Time”.
First, let me describe the way it works now:
I saw Mrs. Keller three months ago for her diabetes. Next week, she will be back for her three month followup appointment. In the next few days, I will get her blood test results, each requiring my electronic signature. This time that might be her HbA1c and her annual urine microalbumin and a chemistry profile. I might also have received an eye doctor report from last week and a progress report from her podiatrist, neither one of which requires any action on my part. That means I must “steal” time from this week’s patients to peruse and electronically sign off five items, which I will have to review again when I see her next week. I also have to remember to flag the eye doctor report for my medical assistant to enter in the flowsheet so we can keep up our quality reports.
In my mind, I multiply Mrs. Keller’s five sign-offs by the number of followup visits I have every week. Even CT scans, MRIs and other imaging could be reviewed and signed off at the time of the followup visit; the radiology departments at all my area hospitals have routines in place to flag critical results.
Why should I look at everything twice? Why are physicians, the highest paid members of the health care team, essentially opening and sorting the mail?
I imagine how my day would flow if none of those five items cluttered my inbox, but popped up when I sat down with Mrs. Keller to talk about her diabetes or with Bill Watterson to talk about his partially torn meniscus.
In the lean, “Just in Time” manufacturing paradigm, factories don’t store parts and raw materials needed for production. They save space, time and money by planning for what they will need and having these supplies arrive just before they are needed.
In medicine, information like test results and outside reports are the parts we need in order to produce treatment plans, which is the output in our “industry “.
Most of the time today, we get paid only for face-to-face visits, and not for “managing” patients’ care. Even in the future, when Medicare starts paying us for outcomes, efficient information flow is essential. Imagine getting important information in random order versus delivered in context, when it is time to assess a patient’s or an entire population’s health status.
Between the skill and experience of our team members and the vast untapped potential of the expensive information systems we have, we could get to where we touch most incoming information only once, just when we need it. Imagine how much time, energy, frustration and money that could save us all.
A Country Doctor Writes: 
This post is so interesting! I never knew about the “just in time” principle in manufacturing. It makes a lot of sense. Thank you once again for helping to improve current medical practices!
This brings up so many issues in my medical care, and makes me, as a patient, feel that I’m lost. The complaint of redundency-unfiltered data flooding my PCP and other care givers-lack of communication is well explained by you in this post.
My system has a person call and I get an Email about what I expect to happen in the upcoming visit. They didn’t know that I had been contacted at all. Now, I think that they avoid looking at anything-and now I’m worried and I don’t think that I’ll fill out the electronicsurvey anymore.
I’m used to managing my own health–calling the labs to make sure that the lab orders are in so my results are for my visit. If the order isn’t in, I call the doctor’s office-which upsets most nurses and sometimes the doctor.
I had trouble with this very recently. State law requires an annual TSH-hypothyroidism. My PCP took maternity leave, and I was assured there wouldn’t be any problems. Her leave had to be extended. That happens-she’s a nice competent human being. It was time for my annual TSH, and I was having trouble with beaucoup boils, weight change, eye problems, etc. According to the nurse-as i’m not sure she had any understanding of this request for a state mandated test- the doctor refused to order a TSH or to give me an appt. I took the electronic message to UC, and that doctor felt there was sufficient reason to order a TSH. My eye doctor appreciated having the results, when she saw me a few days later. It saved her lots of hassle and it expidited my eye care.
My PCP already put in the order for my May 2017 TSH, so this doesn’t happen again. I filed complaints about the nurses and covering doctors, and I asked they get educated about thyroid, since it can cause heart conditions, etc.. I don’t have a record of going in or calling up complaining about thyroid. I told the nurse that I didn’t expect a doctor to treat me, but my eye doctor needed to know, etc.
i was looking over my chart- and it doesn’t list a TSH as being due or when-but it lists mammograms, bone density, etc. It list what shots are due and when on another tab, but it doesn’t list my TSH. I think that I need to get in ontact with my network and talk to them about this.
I was diagnosed with hypothyroidism, when the state ordered TSH for adult females in my part of Uranium Country. Women seemed to complain of odd things-fatigue, irritability, aches, boils, mense problems, etc. Then 5 went to bed and died in 6 weeks or less in a cluster-this was in about a 4 week time. The state sent the medical examiner down, and Hispanic, white, and Native American women died from hypothyroidism. So, I was put on thyroid hormone suppliment.
I really hope that the nurses that answer the phone and relay messages to doctors do a better job. My TSH was in range-something was going on in my body. I just got scared after 6 weeks of boils and problems. My eyes?
‘inversion of eyelashes’ They were super fine and clear, and I couldn’t see them to pluck.
i can really see how garbage in- lots of garbage in-gave me problems. Thank you for enlightening me. It’s worse than I thought.