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Experts highlight ways for urologists to improve clinical efficiency


"Another thing is to customize your EHR with favorite orders and grouped orders, and these things can be standardized across a practice," says Sarah Hecht, MD.

In this interview, Jyoti Chouhan, DO, PharmD, FACS, and Sarah Hecht, MD, discuss ways to improve clinical efficiency based on their course, “Work Smarter, Not Harder– Improving Clinical Efficiency,” which was delivered during the 2023 American Urological Association (AUA) Annual Meeting in Chicago, Illinois. Dr. Chouhan is an assistant professor of urology at Oregon Health & Science University (OHSU), and Dr. Hecht is an assistant professor of pediatric urology at Doernbecher Children’s Hospital, OHSU in Portland.

Could you provide an overview of your AUA course, “Work smarter, not harder– improving clinical efficiency”?

Jyoti Chouhan, DO, PharmD, FACS

Jyoti Chouhan, DO, PharmD, FACS

Chouhan: This course was born out of our own personal struggles with efficiency and feeling like there wasn't a lot of high-level guidance as to how to improve our practice. So, this course aims to identify areas where we often struggle with efficiency on a day-to-day basis in clinic and provide solutions to those issues. We don't talk about clinical efficiency on a high level very much so this course provides a platform for that. We can share our struggles and find ways to improve.

What are some reasons that urologists might struggle with efficiency?

Sarah Hecht, MD

Sarah Hecht, MD

Hecht: One major reason is the status quo bias. We don't know what we don't know; we haven't seen a different way. We do what we've always done or what we've seen done. As surgeons and urologists, systems engineering and efficiency improvement is not necessarily where our curiosities lie. It's not what we spend time thinking about. One of the challenges is that support staff has less and less autonomy, so delegating becomes a challenge as more work is falling to the physician. Certainly, the [electronic medical record] (EMR) is a major contributor—it's not designed for the end user—and becoming more efficient takes quite an investment, so we feel we don't have time to invest, which becomes a little bit of a catch-22.

Could you speak to the importance of improving efficiency?

Chouhan: Efficiency is maintaining or improving output without excessive input. Excessive input oftentimes leads to fatigue, that leads to professional dissatisfaction, and eventually it leads to burnout. [Although] I think a common goal is trying to improve our own personal day-to-day efficiency, I feel like the ultimate goal is improving overall practice level efficiency, because at that point, not only are we improving and increasing patient education, we're decreasing the amount of extraneous work on both our providers and our ancillary staff.

What are some of the first steps to overcoming barriers to efficiency?

Hecht: The first step is to decide that you care about efficiency. I'll start with some encouragement: It is worth it. The investments in the systems pay off. As Dr. Chouhan was saying, it does help fight burnout. It can lead to better patient care. Once you've decided that this is important to you, a good place to start is to identify your pain points; pay attention to what annoys you and don't be complacent about it. Also, pay attention to things that you find yourself doing over and over. Repeatable tasks are the best targets for automation. This is a high-yield target for efficiency improvement.

There's no need to reinvent the wheel. So, if you see somebody else who seems to have it together, who seems to be moving through their day efficiently, mimic them. They've already figured something out, and there's no shame in standing on their shoulders. Standardization is a big opportunity for efficiency improvement. That means personally standardizing how you care for particular problems. Do it the same way every time. Standardizing within a practice means between physicians, but also having shared pathways within a team. This minimizes your low-level decision making and minimizes confusion, which generates more work: more decisions, more questions, [and] more back-and-forth communications.

Don't attempt to multitask or switch between different types of tasks. Just get 1 thing done and then move along. Recognize that cognitive energy is a finite resource. We can't waste our time doing busy work. Even though as surgeons, we're very good at task completion and sometimes checking little boxes feels like we're doing something productive, we want to focus on the high-level stuff at the top of our scope.

In the course, you touched on issues regarding billing and coding. Could you highlight some of the discussions surrounding that?

Chouhan: For many years, prior to 2021, providers were asked and basically forced to add information in the chart for billing purposes that wasn't always relevant to what the patient was coming in that day to talk about. Some examples of that would be a 14-point review of system and a family history. Since 2021, there have been significant changes made to documentation and billing, where now our documentation can be more focused. Billing from a clinic or outpatient standpoint is determined by the time we spend on patient care that day, or our medical decision-making. That allows 2 things with shorter notes. One is there's less time charting, hopefully, and the second one is that it takes less time to find information in a note because it's not as long anymore.

The course also highlighted some ways to optimize EHR utilization. Could you touch on ways that urologists might do that?

Hecht: The electronic health record is the most cited source of increased administrative burden for physicians, and we spend most of our time doing documentation. Just like Dr. Chouhan mentioned, the new coding guidelines will help you make your notes more concise. Certainly, [it helps to] invest in and develop lots of note templates so you're not starting with a blank screen every time. No matter how fast you type, it is probably faster to click or tap through things or dictate; particularly dictating is quicker than typing. There's voice recognition software that integrates within the EHR to help write notes more quickly.

Another thing is to customize your EHR with favorite orders and grouped orders, and these things can be standardized across a practice. If you don't want to be the one to do that, find someone in your practice who has an interest, and they can be the champion who sets up these favorites.

In terms of EHR education, there are opportunities for further education. I think all of us hate those modules that are required, but there are tip sheets that are very helpful. There are modules that help you fine tune your ability to take advantage of the EHR functionality, including high-level training. It's important to build a relationship with your informatics team to solve problems that you may not be able to solve as an end user. You can forge those relationships, come to them with problems, and very frequently, you'll be able to forge a solution or a new build that makes your life easier.

Is there anything else you’d like to add?

Chouhan: I think it's important as a specialty that we try to promote and bring a bigger voice to this topic. It's one that I think we all think about periodically, but we don't really talk about. Some of our greatest efficiency practices are often siloed within our own practice and not shared amongst other people. I think effective promotion of what you're doing and what's working well for you can be done through instructional courses like ours, publications that describe your technique, or even social media. Other specialties are doing a great job promoting this in a lot of different ways, and I think we could use them as an example moving forward.

Hecht: I would just add that as much as we might hate to accept this, the administrative burdens that are new on our plate, the EHR, these things are here to stay. So, we have to figure out how to work within the system we have. You are not too busy to invest in efficiency; you're too busy not to. You can't afford not to. I do think that there's hope on the horizon. I think that AI might change things, so stay tuned. I'm hoping that things get better.

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