Accomplish more by delegating in the medical office: SEED initiative

Despite the arrival of AI scribes in their offices, many doctors find they still have too much to do – they’re swamped by a never-ending stream of results to review and an overabundance of paperwork. AI scribes are assisting with some of the load, as these computerized systems can automate a lot of documentation during patient encounters.

Still, there are many other tasks to be done, and one person can only accomplish so much.

To the rescue, with a strategy for reducing the load, is Kitchener family doctor Rebecca Lubitz. She is championing a system called SEED – short for Stop, Eliminate, Educate and Delegate.

It’s a framework for reducing a physician’s workload by eliminating redundant and unnecessary reports and tasks. Moreover, it also trains office staff to take care of low-risk tasks that were traditionally done by a doctor.

Dr. Lubitz gave a fast-paced presentation at the OntarioMD conference in September where she summarized SEED.

“I’m going to go through how to stop and eliminate certain types of data that you don’t need. Some of the data doesn’t need to be in your EMR, and that’s what we’re going to help you eliminate,” she said.

She added, “Education and delegation is a much bigger piece that I’m really passionate about, and I’m going to help you leverage some tech tools to improve.”

Dr. Lubitz mentioned that there is a substantial body of literature about cognitive overload and having too much to do. Much of it originated in the aviation sector. It was found that when pilots have too many tasks and alarms in the cockpit, it actually makes it harder to fly the plane.

On a personal note, she said she prided herself as a medical resident on being thorough; however, she eventually realized – on the advice of colleagues – that by being too detail-oriented, she was sometimes missing the forest for the trees.

By better managing data, she could perform more effectively and also find more time for family and friends.

She cited studies which found that 40 percent of the administrative burden in a medical practice could be reduced through elimination and delegation.

For example, a couple years ago she received an echocardiogram result four times in her inbox. “Every time you get the result again you think, is this new? Is there an addendum? And after reviewing it four times, I just started to cry and I called OntarioMD. They explained to me that I could just shut off duplicates!”

That helped germinate the idea for SEED.

As a first step, Dr. Lubitz said doctors must learn what to stop receiving or reviewing. “We’re going to stop items of low clinical value from being sent to you.”

She said physicians should eliminate data that has almost zero clinical value if it’s in the chart in another format, and they don’t need a second, third or fourth version.

As well, “things you can eliminate are things that don’t actually need to be in the EMR because they’re not actionable for the patient – what I would call virtually zero risk.”

She gave the example of urgent results. “You may get 300 urgent results a week, but there’s only a few that actually need to be dealt with in a very timely manner.”

She said an audit of her own practice found that in the past two years, she once received 500 urgent results in a week, but only five of them really needed urgent attention.

“Five to five hundred, right? Something has to be done,” she asserted.

Another example of duplicates, at least in the province of Ontario, comes in the form of Hospital Report Manager (HRM). Referring physicians often receive multiple copies, and the reports can be exceedingly long.

Family physicians may also receive the patient’s lab report, which is also contained in the HRM report.

So, it’s important to filter out multiple copies of Hospital Report Manager, if they’re coming into the office. And separate lab reports may not be needed, either.

Dr. Lubitz said these are examples of things that can be stopped or eliminated. The next step is to stop looking at documents that someone else in the practice can review.

“What you might want to consider are things that are not actionable for you as a practitioner for the patient, where there is no follow up or communication needed for the chart.”

Examples in her own practice include items such as massage notes and physiotherapy notes, and requests for orthotics. “Staff intercept them, and staff does not send me a message about it,” she said.

Consult requests and referral redirects are also handled by staff – in cases where the specialist responds that they can’t see the patient quickly enough and to refer elsewhere.

“I was being my own secretary for many years and copying and pasting that referral, reattaching all of the things and sending it on to another specialist only to have it declined again,” said Dr. Lubitz.

Finally, she decided to create a protocol for staff to intercept and handle those declined referrals. They’re routed to her if they’re urgent or semi-urgent, but otherwise, staff take care of them.

She said that items which staff can safely handle have protocols. They’re tied to buttons in the EMR, which lead to e-forms and templates for the staff.

“Many of you order MRIs, and the creatinine is out of date and you get a fax from the hospital saying please update the creatinine. I’m never going to say no to that, and it needs to get done, but I don’t need to see it. So, we’ve developed a protocol for it,” said Dr. Lubitz. “It never goes through me.”

She asserted that once you’ve looked at how many things are coming in that do not require a physician’s attention, and that can be done by the receptionist or another member of the office, you can develop protocols that are tied to helpers like buttons, templates and stamps.

The next step is to review a higher level of data that could potentially be handled by staff. In this case, you go on to create an educational program to train staff members.

“Education is huge for everybody, because it just makes the environment so much more interesting. It empowers your staff. You can delegate more, and it makes the culture better,” she said.

That in turn reduces staff turnover, as people become more interested in their jobs.

However, educating staff is not easy; it’s time consuming. “I found I was running into problems educating my staff because they were working when I was working. So, I redid all their workflows to allow them to have some protected time, when I’m not seeing patients.”

Dr. Lubitz can then meet with staff for training. “That has changed my life,” she said, “and it’s changed our clinic dramatically.” Staff are so much more engaged, and Dr. Lubitz spends far less time on paperwork.

How do you train staff? The best place to start, she said, is to educate people about the difference between common results and urgent results.

She said that lab orders are often pretty much the same, and educating staff about results is not difficult.

“Any hemoglobin less than 100, I want to know about it. Any creatinine less than 45. A white count over 13.

“Last night, I had 75 things in my inbox,” she said. “My nurse went through it all and all I had to deal with was one issue. So, I didn’t have to spend three hours mining all of that.”

A nurse in Dr. Lubitz’s office has also learned to read consult notes that come back to the office from specialists, and to annotate the patient charts. At first, Dr. Lubitz would read the charts to make sure the annotations were done properly.

“As she got really good at annotating things, I stopped opening the PDF for most consults,” said Dr. Lubitz.

“When the allergist sends a three-page consult note and what I need to know is whether the patient was allergic to anything on testing, whether there is an anaphylactic issue I need to know about, and if so, I need the problem list detailed – such as a peanut allergy. So, she learned all that.”

Dr. Lubitz said there’s a lot of information available on how to delegate and how to do it safely. A major factor is to ensure a lot of documentation is readily available to the person performing various tasks, so they can review it when needed.

But the bottom line is that if physicians don’t delegate, and try to do everything themselves, it creates an inefficient or unsafe environment.