Urgent Care EMR Implementation and Workflow Redesign

INTRODUCTION Without even looking at the clock, Tony Roland knew it must be close to seven; Closing time at his urgent care clinic in the heart of Santa Fe. The sun had been setting later as summer advanced, and children's "outdoor injuries" went hand-in-hand with the season. As a triage nurse, Tony imagined he'd see some stereotypical cases come through the clinic doors; sprained ankles from skateboarding, barbecue burns, and the robotic gait caused by full-body sunburns. He wasn't typically at the front desk, but tonight Tony was covering the job for a sick member of the clerical staff. It was selfish, but as he sat looking over notes from the day, he hoped for some yawn-worthy patients to close out the night. The clinic accepted patients until 7 P.M. exactly, but something like a fracture could add 20-30 minutes to the visit, due to x-rays. The automatic doors parted as Tony checked the clock. In walked a much less obvious scenario. At first glance, nothing appeared particularly wrong with the woman. "I told her she should've come in!" her apparent husband spat. His tone then turned more sedate, matter-of-fact. "She's been vomiting for two, almost three days. It's not the food, it's not anything." The patient was Martha Wright, 55 years old, a lifetime resident but first-time visitor. She looked halfway between a hangover and sleep deprivation. Fortunately the waiting room was mostly empty, so her wait time would be short. After just five minutes, a medical assistant showed the Wrights to an exam room, where they gathered some preliminary information. Martha had barely spoken during triage, but her movement and facial contortions triggered a question. "Are you experiencing any pain?" "My back," she exhaled and pointed towards her lower back, "right here." The assistant noted this on one of several forms in a manila folder, told the couple the doctor would be with them soon, and left. Outside, the Wrights' folder was placed in a "to be seen" rack, where it waited for the next available physician. Dr. Trevor Rohm was waiting for a CD of x-ray slides to arrive on his desk, so he took a look at the next patient, Mrs. Wright. After reviewing the notes and talking with her, Dr. Rohm suspected she might have had a heart attack. He ordered a blood test by placing a folder into the order rack, and returned to run an EKG. It showed an elevation in the ST period of her cardiac cycle. Not much time had passed since he placed the lab orders in their rack, but Dr. Rohm optimistically checked the provider rack for results. Nothing. He told the Wrights to expect a little wait, and requested patience as his mind shifted back to the x-rays from his previous case. He didn't usually track down the x-ray technicians, but this time it proved worthwhile; they'd just finished and run the CD by the radiologist on duty. A broken clavicle with a good prognosis; Dr. Rohm could have told them that without the additional time and cost. He heard the printer going and knew the labs were ready. Mrs. Wright's cardiac enzymes were abnormally high, supporting Dr. Rohm's initial thoughts. As he discussed recommendations with Mr. and Mrs. Wright, he caught a glimpse of his watch. 8:15 exactly. Mrs. Wright had been there over an hour. The words "urgent care" flashed into his head as he wrapped up, imagining all the little delays that kept him and others in the clinic well past closing. How could he keep those delays from consuming his life, little by little? BACKGROUND Urgent Care is a hybrid medical specialty covering a diverse scope of practice. The purpose of urgent care is to treat the immediate needs of patients. It offers walk-in scheduling, akin to a first-in first-out queue, thus making it easier for people who are unable to get a same-day visit for their primary care physician to be evaluated. Urgent Care treats all types of patients including infants, children, adults and pregnant women, and can handle minor emergencies like broken bones and lacerations. …