Dr. Sarah Smith sits down this episode with Jordan to dig into how to get that critical time back in your day so that you aren't spending your nights charting. Dr. Smith has helped hundreds of Physicians make sustainable changes in their practices and we will share some of her most valuable insights and recommendations that can help you.
Sarah Smith is the Charting Coach for Physicians and a practicing Rural Family Physician in Alberta. Sarah is the founder of the Charting Champions Program helping more than 150 physicians in the specific area of getting home with their charting done.Sarah has a passion for reducing burnout and overwhelm resulting from the administrative burden of Clinical Medicine. Using evidence based coaching to help Physicians find their most simple solutions within the clinical environments that they work in.Sarah is a Physician Champion in her Primary Care Network and strives to build robust systems within her clinical environment to create a strong patient medical home.Sarah is married to her husband of 21 years and has two sons and lives on her small farm. Evenings and weekends are for enjoying pursuits such as farming, exploring, reading and coaching
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[Host]: Dr Jordan Vollrath
[Speaker]: Sarah Smith
Jordan (00:02.006)
All right, so Dr. Sarah Smith is the charting coach for physicians and a practicing rural family physician right here in Alberta. She's the founder of Charting Champions program, helping more than 150 doctors in the specific area of getting home with their charting for the day already done. Dr. Smith has a passion for reducing burnout and the overwhelm resulting from the administrative burden of clinical medicine, which is a huge topic of debate amongst the medical oversight bodies right now.
Sarah's married to her husband of 21 years and has two sons and lives on a small farm. Evenings and weekends are spent pursuing enjoyments like farming, exploring, and reading. Dr. Smith, thank you so much for joining us on the podcast today.
Sarah Smith I Charting Coach (00:41.014)
Thanks so much for having me here.
Jordan (00:44.998)
So why don't we start with, you know, what is charting champions? Where did this come from? How did you get the inspiration to actually dive into it?
Sarah Smith I Charting Coach (00:53.006)
Perfect. Yeah. So Charting Champions is a lifetime access program for physicians where we really want to help physicians with how do we redesign the clinical day to help them contain the clinical data, the clinical hours and get home to have a life outside of medicine. So that looks like foundational modules, community of their peers and lots of opportunity to come in for that specific help with their expert peers who are trained as executive coaches.
or with our guest coaches every month that we bring in to have a different perspective. I'm not the expert in every topic about the clinical day. So we bring in people who do leadership training, access improvement, ADD, and executive functioning management. Anything about the clinical day that physicians are struggling with, that's what we do at Charting Champions. So how did it come about? It came about because...
I personally had an issue with charting paperwork, getting home on time. And I was 15 years in this role as a family doctor and still unable to tell husband when I'd be home. I still wouldn't be done at the end of the day. I'd have lots and lots of evening weekend work that was using up my time. And I did not know there was a solution. So the only help I got from my...
mentors and colleagues was you just do it when you can, you come in on weekends. And that wasn't the answer I wanted. And it wasn't until I kind of discovered coaching and what coaching could do in regards to helping me be the owner of my day to find a different experience of clinical medicine in my day and to help me really dive into the redesign of the day so I could get the work done, that I could make a difference for myself.
And then when you get bucket loads of time, suddenly you just want to share this with the world. So I started coaching one-on-one family doctors and then specialists would come to me and then other allied health professionals would come to me asking for help in that exact same area. So after I got kind of fully loaded up with one-to-one clients, we then said, okay, we now understand the problem. We understand the.
Sarah Smith I Charting Coach (03:13.058)
the framework of how to get people out the other side feeling better. That's when Charting Champions was put together and launched three years ago.
Jordan (03:22.858)
So it truly evolved out of a problem that you yourself were experiencing and had to come up with solutions for.
Sarah Smith I Charting Coach (03:29.054)
Exactly. So I did, I thought it was the impossible unsolvable problem.
Jordan (03:34.958)
And how much time in your day did you save yourself? Because I'm sure this was something that evolved over years and you've honed your craft of having your workflow and your processes dialed in. How many charting hours or administrative hours and non-patient care interaction time were you spending in an average week?
Sarah Smith I Charting Coach (03:54.262)
That's a great question. So after the last patient left, it would be two hours before I would get the text from husband reminding me it's time to come home. That I'd kind of, it was dinner time. So I would pack up knowing that I wasn't done. So that was two hours. Then when the kids were in bed, I'd be back on the computer for around about two to four hours a weekday. And then I had this wonderful experience where patients hand you a form at the end of the visit and they say, oh, you can get that done when you have time.
And that those, you know, go away.
Jordan (04:24.242)
By the way, I have this EI form I'd love for you to fill out, you know, when you have a minute, no big deal.
Sarah Smith I Charting Coach (04:29.686)
when you have a minute. So what I would do, I would take those, you know, three, five, eight forms home on a Friday, expecting to try and get to it on the weekend. And then I would spend all weekend telling family I couldn't because I had paperwork and then go back to work Monday with them still not done. And so it would actually use up the entire weekend of mental load, but not doing paperwork. Or I would get up early in the morning, or I would spend.
you know, all of a sudden they're doing paperwork. So this was a, I'm going to say I was one of those 18 to 20 hour physicians, pajama time. It was, it was very overwhelming.
Jordan (05:09.534)
Well, and so recently there've been some studies across the country here showing that there's about 80 million hours every year of physician time spent just doing administrative work, paper tasks, a big chunk of that being what's viewed by the doctors in the surveys as unnecessary work, just frivolous stuff that either doesn't need to be done, could be delegated to a team member, or just otherwise shouldn't be plugging them up from actually treating patients. Like, is that,
Sarah Smith I Charting Coach (05:37.452)
Yes.
Jordan (05:38.642)
Does that sound realistic to you? Does that sound like a huge number or does that sound like an undershoot even in your opinion?
Sarah Smith I Charting Coach (05:43.178)
Yeah. Oh no, I think the administrative burden, if anything, since I started in my career is bigger. Certainly COVID created a whole lot of worklists and inboxes we never had previously. We currently have the amazing experience in Alberta for the Alberta physicians listening of ConnectCare. And so if you happen to have ConnectCare access, you now have this siloed worklist of things to go and mark completed, which doesn't...
interact with your EMR. So now you have double workload of things. So all of this is creating increased non-physician work, especially when you've already seen something, now we're duplicating it, now we might be triplicating it when it's in this siloed system. So yes, if we don't take some major changes, we're going to run out of minutes available. So they say with adult...
primary medicine care, if you were doing good care for your panel, it would take 27 hours a day. Well, there isn't 27 hours in a day. And that was one of the studies that came out last year. And I'm like, yes, I hear a lot of physicians say for every hour in front of a patient, I have an hour of paperwork or not patient time. And so that becomes part of the work of the day is, okay, how do we empty these work lists in the most effective way for where you are, right?
now with the stuff you have with the EMI you're using, how do we get out of this as fast as possible? Yeah.
Jordan (07:17.49)
Well, and it sounds like there's a lot going on behind the scenes here, right? So it says charting right in the name of the venture, obviously, but clearly there's more going on in terms of leadership skills and practice management. Let's chat a little bit more about the charting side of things. Like what are some strategies that a physician or even another healthcare practitioner could implement so that this isn't dragging into their evenings needing to be done on the weekends? Like, are there some high level, just general tips you'd have?
Sarah Smith I Charting Coach (07:47.178)
Yeah, so the framework that we use for physicians are kind of four steps. First step is to get our charting done after every patient. And that's kind of the foundational step because even though it feels impossible, if we're carrying those patient encounters with us through the day, we're adding to the working memory of the day and we're crowding our brain, right? So what are often...
Jordan (08:12.372)
it out there while it's fresh.
Sarah Smith I Charting Coach (08:13.93)
Yeah, exactly. So while it's fresh and it's current, like it's fresh in your mind, so you're gonna collect accurate information. And as we complete that encounter, there's no homework from that encounter, yay. So we wanna ensure that encounter is done. All of the aspects of that encounter complete before we move to the next patient. And that takes a minute for a physician to kind of get their head around. And then the implementation of that could take a while.
there could be a significant difference between what you do now and what you might end up doing if you decide that this would be something you'd like to implement. Step two is the clinical encounter. Like physicians have a set number of minutes with a patient if they're in that appointment book style or they have a waiting room full of patients if they're in the emergency department. Like we don't have all day with a patient. So we have...
Jordan (09:08.07)
It doesn't end though. There's always more. There's more work to be done. I mean with a physician shortage, right? And that like sense of duty, it's just, it doesn't stop unless you have some sort of barrier boundaries you start setting up.
Sarah Smith I Charting Coach (09:14.657)
Yeah.
Sarah Smith I Charting Coach (09:21.314)
Yeah. So the clinical encounter, we hear physicians saying, my patients are demanding, entitled, they bring a list in, they have multiple issues in the room. But the boss of the encounter is the decision maker in the room. So that's your physician or a clinician is the expert decision maker in the room and understanding that you have the ability with the language you use with the way you're setting up your appointments.
to be able to start to contain what you will say yes to today. And when you say yes to something, you say yes to all of the aspects of that. So if you say yes to 30 second shoulder, added on problem in this encounter, you still have to assess it, document it, and arrange anything about it that you needed to arrange. So the patient never understands how long it's gonna take to do a puzzle, like.
Hey, just a quick question about my headaches. I'm like, that's not a quick question. We know how long it takes to do a good headache workup. That's your job. And all the minutes and seconds count. So what are they leaving the room for? Are they being interrupted doing that high level work? What do they spend their time on in the room? That step, step two, can be a big, there's a big amount of things inside a clinical encounter and how you do your work of the day.
So that's kind of step two is trying to help them lead their encounters in a way that feels good for them and helps them keep that relationship with their patient and doing their highest level work. Step three is everything else.
Jordan (10:58.218)
So saying no to some things, I guess, right, is key there. Like, you know, phrasing it, yeah, like, you know, this is a, you know, big problem or maybe not a problem, but this is a serious issue that, you know, we really should give it the time it deserves, make sure that we fully unpack this, right? Cause it is in the interest of the patient and the benefit to them, right? Like if you're gonna, you know, kind of half do a lazy job with it in 30 seconds, I mean, you're not doing a service to them or yourself.
Sarah Smith I Charting Coach (11:01.874)
It could be saying no. Yeah.
Sarah Smith I Charting Coach (11:15.392)
Yeah.
Sarah Smith I Charting Coach (11:19.284)
Yeah.
Sarah Smith I Charting Coach (11:26.37)
That's right, exactly. And it is about that quality of patient care. So that's really important that we have the language we're gonna use with our patients for how do we defer this to next time, or what are we saying yes to and why in the room, and how do we start to negotiate that. Even how we start and end an encounter can add minutes to the encounter, right? So it's noticing all of it.
Jordan (11:50.034)
Wha- and then I imagine that agenda setting up front is key.
Sarah Smith I Charting Coach (11:54.462)
It can be, but for some physicians that really get some bogged down. So it's not just a gender setting. Sometimes we have to just put that down because it's too hard. It creates more problems, but we do need to give them an approach for how they're going to address this encounter. And it's not one problem per visit because a lot of physicians won't do that. Cause they know that access is a problem and getting the back is a problem. And some things are fast. So they do want to be the owner of that appointment.
the boss, the one who's deciding what will and won't be done. Yeah.
Jordan (12:26.77)
Well, it's tough, right? Because patients have booked a day off work or a half day off work, you know, they're taking time out of their busy schedules to come see you. And so if you're just kind of superficially cutting it short based on a general rule there, you know, you're not really, you know, is that fair to them?
Sarah Smith I Charting Coach (12:33.142)
Yeah.
Sarah Smith I Charting Coach (12:41.742)
I'm going to go ahead and turn it off.
Sarah Smith I Charting Coach (12:45.354)
Yeah, so it's that knowing which patients are needing that time now and which ones are we going to bring back quicker because they aren't having to have a whole half day off or whatever. So yeah, all of that's part of the clinical encounter. Absolutely, yes.
Jordan (13:03.046)
And then, so how would you phrase that to a patient? Let's say you're seeing somebody, they look like there's a few different things to be addressed. What would that first encounter couple sentences out of your mouth even be?
Sarah Smith I Charting Coach (13:09.901)
Hmm.
Sarah Smith I Charting Coach (13:15.882)
Yeah, so one is guarding what you're saying as you walk in the room. So the, how are you today is about a three minute cost versus what are we doing today? It gets us kind of closer to the mark of what's of importance to you today. And it can be that question of what is important about the things you're bringing in today and what are we going to put into next time? Or they might say, hey, just a one more quick question. I'd like to, you know, talk to you about my headaches. We can do that.
general inquiry around triaging the problem just so we understand, you know, is this a, I'm going to stop and do this right now or am I, okay, that sounds important. Let's get you back in so we can dive into that. So we'll book that in for next time. So it is that deferring of, but it's using the language that feels comfortable for you. And you need to practice it because it doesn't come out naturally the first time you use it.
Jordan (14:10.662)
Now, how do you build that patient rapport, you know, that human aspect of the interaction? Cause I'm a sucker for this one, like, hey, how's it going? And then you get a grandpa Simpson story, which just goes on and on and on. And then just like you're saying, yeah, next thing you know, three, four, eight minutes have elapsed. And like, they'll talk about something very personal, which is, you don't want to cut that off if there's been health problems in the family or something else related. Like, how do you, how do you...
Sarah Smith I Charting Coach (14:23.852)
Yes.
Sarah Smith I Charting Coach (14:29.45)
Yes. Thank you.
Yes.
Jordan (14:39.338)
capture that kind of like personal connection versus the utilitarian aspect of like, we have a limited amount of time and a job to do here.
Sarah Smith I Charting Coach (14:48.382)
Yeah. So it's the, when, when can we do this? Do we have to do it every single time with our patients? So we can, what are we up to today? We can get into the meat of the problem. And then I might be doing a referral letter and the way my brain works, I'm quite happy if they're nattering on while I'm doing something in the room. So I'll be doing that referral letter that they want done. And I'll, I'm like, how are the grandkids? And they can chatter and natter as I'm doing my thing.
Jordan (15:14.986)
That's genius, okay.
Sarah Smith I Charting Coach (15:15.062)
We have a great interaction. I love my patients. I love having that understanding of who they are and what they're up to in their world. I'm in a small town. They know what I'm up to. And they ask about how the farm is, how the kids are, how the everything is, but we need to remember it takes up a lot of time. So we want to do that when we have.
Jordan (15:36.134)
Yeah, while you're filling out a prescription or something else. And then you've got that other half of your brain actually on social mode, listening and nodding and smiling and asking questions.
Sarah Smith I Charting Coach (15:44.735)
Yeah, and not, yeah. And not every physician can do it that way. And that's okay. But for my brain, it's fine to do that. Yeah.
Jordan (15:53.966)
And so, okay, so we've talked a little bit about how to manage the encounter in terms of the charting itself. What kind of strategies do you employ to actually get the charting done as you go? Is it as simple as extending your appointment visits, or is it cutting the appointment with the patient short and giving yourself time to chart? Are you using scribe tools as you're going, a combination of everything? How do you get the charting done so it's not...
this monkey on your back all day.
Sarah Smith I Charting Coach (16:24.546)
So most physicians have a set appointment schedule set up for the next eight weeks. So we're gonna go with exactly what you have right now. We're not gonna take out patients, we're not gonna extend appointments. None of that's actually gonna be helpful in the longterm. But the doing of new things is hard and it will be slowed up by the trying of new things. So just know that it's supposed to be messy in the middle as you're trying to figure it out.
Step two is what are you already doing? Cause that's familiar to you. So how do we kind of enhance what you're already doing? And I think that's important that you're not always trying to just do the newer thing because it could work for you. It's really about what's in our notes and why. And if we wanted to get this done, how and where would we do it? And we're just looking at what's available to you right now. What's getting in the way of the charting. Cause often
You come out of the room, you might have a spot where you can finish that note, but instead you check the work list or you answer a phone call or you get interrupted. So it's like, what is getting in the way? And then of course, if, for instance, templates help you, if dictation helps you, if some of the newer AI scribes help you, anything that makes this simpler, easier and done, we're all for it. But we don't have to go looking for fancy to start with. We're just saying, if you wanted to.
not do this later, how and where could you start? And just making it as simple as possible. And all of the physicians inside the program will be doing it in their own way. I tend to not use templates. Yeah, I don't use templates particularly. I think I have three different types of chart note that I can use. I use one template only and that's because the college requires a lot of
Jordan (17:51.838)
Back to basics. Yeah.
Jordan (18:00.31)
What are you personally using in terms of fancy tools? What do you got on the go? Drop some names for us here.
Sarah Smith I Charting Coach (18:15.978)
you know, must do's for opiate prescribing. So if I'm doing an opiate prescription encounter, I'll use my template for that so I can remember to tick off all the must do's. But otherwise I'm just using a general note myself. I'm typing mostly in the room and then immediately after, I do have pre-filled in forms for lab requisitions because that makes life easier and saves some seconds there. So that's me personally.
That's how I've attacked it from my point of view.
Jordan (18:47.174)
No templates, you're just out there, do it. How many words a minute are you typing?
Sarah Smith I Charting Coach (18:49.578)
I didn't. I can type at talking speed. Um, so I don't know my actual type, but I'm pretty okay with what. And, and it's not, I'm not recording word for word. This is the, so what I heard you say was concise summary, write it down. So as I talk it out to the patient, I read it.
Jordan (19:14.066)
Pertinent positives, pertinent negatives.
Sarah Smith I Charting Coach (19:15.902)
Permanent positives, pertinent negatives. What happened? What do I need for billing and insurance purposes? Why do I think this is my working diagnosis? What was my supporting to and fro data? And then what's the plan?
Jordan (19:29.058)
What's your typical patient appointment visit duration?
Sarah Smith I Charting Coach (19:32.946)
Mine at the moment are 15 and I have over the course of the 18 months it took me to figure it out and through COVID and through the changes that the Alberta government were planning to implement and with virtual kind of appointment styles available, I have pivoted and changed up everything and I'm not afraid to do so. So right now I'm on 15 minute appointments, I've done 10 minutes, I've done, I've not done any less than...
So I haven't gone less than for an hour ever, except for the occasional like longer visit that I might have intentionally planned for one of those undifferentiated patients that you really just wanna dive into that meaty detective work.
Jordan (20:18.634)
The hearing Alberta 15 minutes, I would say, is probably the most common thing we see. Like it seems to be, you know, kind of a nice balance between time and efficiency and you know, the billing code time modifier lines up with it. So the actual like business logic behind the scenes. So I think the vast majority of doctors are probably on that 15 minute schedule. I locum'd once for a doctor and his whole patient panel was trained.
Sarah Smith I Charting Coach (20:22.615)
Most common.
We'll see you later.
Complete.
Sarah Smith I Charting Coach (20:32.43)
Mm-hmm.
Sarah Smith I Charting Coach (20:38.76)
Hmm. Yeah.
Jordan (20:44.03)
for years or maybe even decades for these 10 minute appointments. And the band did that ever give me anxiety, but we got it done, but it was a lot.
Sarah Smith I Charting Coach (20:52.526)
Yeah. We've had physicians that join the program who want to keep their 40 a day and they do, and they still get their charting done as they go. So it's possible, whatever of the environments you work in, the key is that if you want it sustainable, we need to be doing the work of the day within the day. So it's figuring out how and where we're going to get that done. Yeah.
Jordan (21:14.118)
Well, while it's fresh, you know, before it starts, because the details get fuzzier, the longer the duration elapses between when you see the encounter, you start, you know, was that a positive sign on the abdominal exam or was it kind of iffy? And so, you know, medically speaking is probably going to be more accurate too, as well as more effective.
Sarah Smith I Charting Coach (21:18.19)
Mm-hmm. 100%.
Sarah Smith I Charting Coach (21:32.286)
Yeah, correct. If informational continuity, it's perfect because then if you've got like the U S physicians will have an MA coming behind them to carry out the orders. If those orders aren't in, they don't know how to do their job and the patients waiting on the orders and you're in the next room and then you're getting buzzed, what were the orders and the whole thing becomes very messy. Um, so there's a lot of liberation for the team, as well as the physician or the clinician, as we start to do this work in real time.
Jordan (22:00.042)
Tell me a little bit more about your team. How do you actually set up the workflow with the other people in your practice?
Sarah Smith I Charting Coach (22:05.374)
Yeah. So not every physician or clinician is higher in fire in their clinic. And so we are looking at, um, who is available, what are they mandated or able to do for you? And that's part of that next step is the worklists and other, the other work of the day. So everything else, um, and part of the interruptions. So that's kind of the managing the rest of the clinical day. So who's interrupting you?
What are they asking you? How do we start to batch some of those interruptions so that we're not having that constant interruption? The sum of the physicians I've worked with are not every single patient encounter. Can you imagine? So that high level work, you're doing your expert level work and suddenly there's a knock, knock on the door. They're like, so and so is late. Will you still see them? And you're just.
sucked out of that patient encounter and you're thinking, what do I got to do this afternoon? Do I have time to stay if this person's late and what are they coming for anyway? And then you got to go back and reorientate yourself to the patient in the room. It is so adding to our decision fatigue and so interrupting that executive level work is so important to protect your time and no one else will do that. That is your job. All of the things in your inbox eventually get out of your inbox.
but how are we getting it out? And how can we get it out as fast as possible? So for our clinic with the EMR we're using, which most EMRs are kind of, you know, not set up for us to have great workflows. It was working with the team to say, okay, you know, how do I bring a patient back in three years for a pap smear without me having to remember that they need one? Like the next time I wanna know that they're ready for one, they're in my room because it's time.
And it takes all of the work off the physician. That was the very first puzzle I had to deal with when I got here from Australia. Um, because there that recall system has been established over the last 20 years because it's our responsibility says the college to remind the patient that they do for something. So we had to figure it out here. There wasn't that same emphasis. So now I'm like, because when I first arrived here in Canada, I was supposed to be here for a year.
Sarah Smith I Charting Coach (24:27.726)
So I'm like, well, how do I tell a patient they're supposed to be come back in three years if I won't be here? So I had to start talking to the team. Okay, who would call a patient and tell them it's time to come back? How do I tell you what if you aren't here in three years? How do we make it so that it's not person dependent and it becomes a system level change? And started to implement that so that it's not me in my work list annoying myself with, you know, bring Sally because it perhaps may as do.
Jordan (24:32.89)
Yeah.
Sarah Smith I Charting Coach (24:57.058)
That's not physician work. So it's really.
Jordan (24:59.786)
Yeah, a little bit of health literacy and, you know, kind of taking ownership of the care on the patient side or having these external supports to actually do these reminders. Like for anyone not in Alberta, you know, we have these kind of guidelines and practice frameworks in place, provincially implemented programs just to like create these return cycles and get those adequately done. But then some of the EMR vendors are addressing and starting to
Sarah Smith I Charting Coach (25:13.963)
Mm-hmm.
Jordan (25:26.77)
build those into the workflow. But again, it's not done on a more coordinated level. It's more of just like here's best practice guidelines. And then it's still up to the individual team to figure out how to manage these.
Sarah Smith I Charting Coach (25:28.078)
Mm-hmm.
Sarah Smith I Charting Coach (25:39.286)
Yeah. And it was no good when Sally's in front of me telling me she had a pap smear do a year ago. That's opportunistic and that's not what we wanted to create. We wanted to create the two and a half years later, she gets a call saying, Hey, it's time to book you in when we book you in. That safety net was important to us as physicians and we were able to create it, but we had to do some kind of.
creative things with the EMR as it existed in order to make that happen and then to onboard the staff so that they could carry it out for us. Because if we don't trust it, we won't use it as physicians and clinicians. Yeah.
Jordan (26:16.03)
There exactly. Which EMR are you using? Can I ask?
Sarah Smith I Charting Coach (26:20.034)
So we're using HealthQuest and MicroQuest and they have been excellent with regards to talking to programmers, listening to the things that we want done about the program, adapting it for us. I think I'm their biggest, like, I'll email Janet almost on the weekly, hey Janet, blah, blah. She'll be like, oh, well, that's a good idea. We'll get busy with it. Yeah.
Jordan (26:44.054)
How many of the different EMRs have you tried?
Sarah Smith I Charting Coach (26:47.806)
Oh, that's a great question. So in Australia, we were using Medical Director and Best Practice, which were developed by a physician for physicians. So it was really quite a nice, robust, and quite easy user-friendly platform. Then I came to Canada, they were already on HealthQuest here. And then the Connect Care is coming, so I'm in there. So they're the three, the four that I have been kind of part of.
as I used on a daily basis. I think there were some other ones I might've used temporarily.
Jordan (27:18.922)
Okay, you heard it. Dr. Smith, the charting coach herself, HealthQuest is the EMR of choice. What are your thoughts on NetCare? Like just in general, you know, is this the miracle, or not NetCare, ConnectCare. Is this the miracle solution to start reducing burden? I mean, I have not had the pleasantry of experiencing it firsthand myself. I just see all the commentary happening through Facebook.
Sarah Smith I Charting Coach (27:26.38)
I'm sorry.
Oh, so neck here. Yeah.
Sarah Smith I Charting Coach (27:35.784)
Oh!
Jordan (27:48.776)
What do you think?
Sarah Smith I Charting Coach (27:50.126)
Okay, so we'll talk quickly about Netcare. So in Australia, there was no Netcare. So Netcare for those of you who are not in Alberta is the one-stop shop if you're looking for any diagnostic imaging pathology results, anything like that, and consultations, visits to hospital for the last 10 plus years for all of our patients in Alberta. Anyone with an Alberta Health Care card, you can go into this portal and you'll have access to this patient's entirety. It's amazing.
When I was in Australia, we would have to say to the patient, did you go to the pathology department with the red or the blue door? Because there were two different pathology service providers and I'd have to call them and say, can you send the last lab report for? It would take up so much time. So now this one stop shop is like a miracle.
Jordan (28:35.826)
If you had a colorblind patient, they'd be sending you on a goose chase to the wrong lab.
Sarah Smith I Charting Coach (28:40.526)
Yeah. Even finding out what medications they had last filled, you couldn't find in the central database as I was leaving Australia. I believe that is now exceptionally better, but still not as good as Netcare, which can find the scripts as well. Connect care is the hospital based electronic medical record. And it is the same essentially as Epic for those of you who are in like the US or it's called something different in Ontario.
because they do have it in some of their hospitals there as well, I believe. And so Connectcare or Epic is a very big program designed to hold a lot of information and to have everybody being able to document in real time. So you're a nurses, you're allied health, you're physicians. Um, so it contains a lot, a lot of data and it is not intuitive. So you're having physicians doing eight.
to 25 hours of training to figure out how to run this thing. So that's problematic.
Jordan (29:44.558)
That sounds like a lot. I mean in terms of any other tool that we as physicians use, you know the suturing Equipment, you know if you're Literally anything right? So why not spend some time learning how to use your charting tool Maybe 24 hours is excessive
Sarah Smith I Charting Coach (29:51.469)
Mm-hmm.
Sarah Smith I Charting Coach (30:01.45)
Yeah, that's true. So I agree, doing some EMR optimization, having your EMR super user help you kind of design your templates or your lab requisitions or kind of make your use of the EMR easier is obviously important because it's part of the time saving. I think the problem with Connect Care is one siloed from your work if you're in family doctor world. So you've now got to log into this completely different portal to make sure you haven't missed any information about your patients.
So that's a bit problematic about it. And it's now duplicating a lot of the work. So you've got the stuff, you can find it in Netcare or you can find it in Connectcare or you can find it in your EMR. So there's just that little bit of busyness about it. In terms of actual flow of work, you are now doing a lot more administrative work as a physician in Connectcare because you're putting in all your own orders. So it's about a three month slowdown.
before you feel like you're back out to productivity.
Jordan (31:03.93)
And then at that point, is it a net positive? Like, is this a step in the right direction and growing pains? Yeah.
Sarah Smith I Charting Coach (31:07.402)
I think at that point it's a net positive. Yeah. A net positive when you're actually within the hospital system, looking after the hospital based patients. But when you're in community, in your own EMR with Connect Care existing outside of it, it's still big, still that problematic problem. Yeah.
Jordan (31:25.726)
Do you think they'll be able to get it to the point where it works well in the community in an outpatient setting and also ties in with the inpatient system?
Sarah Smith I Charting Coach (31:34.414)
They're not going to let community family doctors use it as their EMR. This is the hospital EMR. So it's not available for family doctors unless they're in our Alberta health care clinic. So it's not intended to replace the EMRs that exist right now. Yeah.
Jordan (31:51.882)
Okay, so just hospital only. Now, have you been on the SCM system that Calgary had up until recently?
Sarah Smith I Charting Coach (31:59.606)
Hmm, no.
Jordan (32:02.27)
It was cool. It was like a digital charting system in the hospital. Like when I did my training in Edmonton up until 2013, uh, or sorry, 2013 to 2017, all the hospitals were paper record based and then coming to Calgary where they had this digital SCM system, I was like, Oh wow, this is fantastic. And so I'm just picturing like that next leap in evolution of that actual electronic health record being that much better. But
Sarah Smith I Charting Coach (32:10.231)
Mm-hmm.
Sarah Smith I Charting Coach (32:15.785)
Oh yeah.
Sarah Smith I Charting Coach (32:26.54)
Mm-hmm.
Jordan (32:30.49)
The only things I see on social media are people not super happy with.
Sarah Smith I Charting Coach (32:35.37)
Yeah, yeah. I think the good thing about us all on the same Connect Care system is I can now, that I have access to it, see my patients who are in the hospital in Edmonton and what's happening for them in real time. So it is that ability to, no matter where your patient is located in Alberta in a hospital, you can kind of see what's happening for them and how the maybe referrals are progressing in the lineup and that sort of thing. So it's got some advantages, even though we all.
you know, like to whine and complain about new things.
Jordan (33:07.418)
It's therapeutic.
Sarah Smith I Charting Coach (33:08.886)
Yeah, exactly.
Jordan (33:11.55)
Get it out of there. Backing up then to, sorry, just in terms of backing up to like the workflow, what does your team look like? Do you have an MOA? Do you have an LPN? Do you have an RN? What does the clinic staff, the org structure look like where you're working?
Sarah Smith I Charting Coach (33:13.119)
validation of it.
Sarah Smith I Charting Coach (33:28.746)
Yeah, so in our particular environment, we have 15 physicians, family physicians in our small rural town. We're all in the one medical center in our small rural town. So we have a couple of people each day on the phone lines to take phone messages and book people in. We have somebody doing the MRI and ultrasound.
booking and following up to make sure that those are being booked and happening. We have somebody scanning in the E-faxes as they come in need to be assigned to different charts so that's somebody's role each day. We have LPN nurse or two depending one is paid for by the primary care network, 50% the other one's paid by us.
And they do things like high weight, blood pressure, baby checks, urine dips, and sending off cultures for us, ordering supplies for the clinic. We have a referrals dedicated person. So all I have to do is write cardiologists and do the letter. And somebody else knows better than me, which I think is important for your team. Who's accepting new patients? Who's the fastest one to get into? How do I, what do they need to have put in place before they will accept this referral?
So we have that person, we have a third party person who negotiates with all the insurance companies and WCB and all of that for us. Clinic manager. And then we have the ushers who will put patients in rooms, make sure the drawers are stocked according to the photograph of how we like the drawers stocked or the list of what should be in each drawer, clean the rooms and put the next patient in. So that's excellent. So we have each.
We'll have two working consultation rooms for the day and our office where we do phone calls and messages. If I'm emptying my inbox, I will ask the reception to let them know the results or I'll email through the portal or I'll just simply tick it off. And then if I'm setting up a, like if I read an MRI report that says, repeat me in 12 months, I will write that referral right now and put it into our referral portal where it will be done.
Sarah Smith I Charting Coach (35:46.43)
and sent in about nine months later, ready for the next MRI. So the next time I know that referral's ready is when I'm seeing the report.
Jordan (35:50.439)
That's smart.
Jordan (35:56.27)
And so it sounds like a big team. Did you say there was 15 physicians working there?
Sarah Smith I Charting Coach (36:00.79)
Yeah, and about 15 to 18 staff, because not all the staff are full time. So about 15 equivalent staff and 15 physicians. So it's about one staff member for each physician.
Jordan (36:10.018)
How much of that economies of scale model do you think plays into having that efficiency, you know, to the point where you have enough doctors that you can have a single person doing each one of those tasks?
Sarah Smith I Charting Coach (36:23.15)
Great question. So we know that physicians in primary family physicians, you're about 40-ish percent of your salary will go towards clinic costs, whether that be buying supplies, paying for the lights to be on, paying the rent, paying the stuff. So we know about 40% of your wage is gone. That's if you're managing it well as a business. And so we're looking at
How do you manage your business so that your team is optimized so that we're getting the best value out of them and we're not wasting dollars because it's coming out of your pocket? If you've got a really slick clinic, you might get down to 25% of your wage. That would be a very unusual situation. 30% probably, 30 to 40% is about normal.
Jordan (37:19.391)
Yeah, yeah, no, I'd say, yeah, 30 is probably most of what I've seen and worked at. Um, and then that gets you a pretty good amount of, you know, back end support, but it definitely doesn't sound like as, as thorough and comprehensive as the team you've assembled.
Sarah Smith I Charting Coach (37:32.654)
Mm-hmm. Yeah, we have a good team.
Jordan (37:34.822)
Now, you make a good point there. It's not just about optimizing your own time and your charting and all these things, but then there's the half of your costs, almost 40% are going towards paying other people and enabling them. How do you structure that leadership and within a medical clinic? Who is actually in charge of making decisions or what seems to work best? Is there a clear single leader? Is there more of a like...
Sarah Smith I Charting Coach (37:47.763)
Mm-hmm.
Jordan (38:03.634)
democracy going on and then how does that flow down to all the other staff?
Sarah Smith I Charting Coach (38:08.578)
Great question. So I've worked in multiple different types of clinics. And so depending on the clinic style that you're working in or depend how you've set up your structure. So where I've worked previously, the owners have been the decision-maker. We are owner organizations. So we have, I think 12 of us are owners and the rest are contracted physicians to the ownership. So for us, we put together a five-person board which will make most of the...
We need decisions and we meet about once a month for that. I recently stopped being a board member, but we have a five member team and they each have a different role. So one is HR. So when you've got, you know, Sally's late for the third time this month, should we start sending letters? That goes to just one of the physicians, not to like random physicians. So that question will go from the manager to the...
physician who's in charge of HR, we've got one in charge of finance, one in charge of the team building, so that access improvement team. And then we've got policy procedure person and then recruitment, like bringing in new doctors if we need to fill spots is important part of that kind of ongoing sustainability. So the team, how do we empower the team? So we have a physician lead who meets with the
heads of the team. So the nursing head, the reception head, the practice manager and a physician meet together about again, once every month to three months, talking about flow through the clinic, roles and responsibilities. What are we working on to improve efficiency? What are we bottlenecking? And how do we start to move that into different roles? What is being dropped in terms of recall systems? And we just keep our hand on the ball that way.
Jordan (40:04.106)
I guess I'm just making it a regular practice to actually have these discussions is probably where it all starts off, right? Because if there's no problem recognition, there's not going to be any solutioning or improvement.
Sarah Smith I Charting Coach (40:14.346)
Yeah, yeah, and it's not perfect, of course, but it's part of checking if your staff is allocated right. We did a number of years ago, give everybody a clipboard and say, okay, every 10 minutes the buzzer goes off and you write down, what did you do in the last 10 minutes? And what that did was identify for us, oh, our nurse is doing MRIs and ultrasound bookings. That's not nurse work. And it's bottlenecking her from getting to the...
the physical exam pieces we need to be able to get the patients in the rooms for the physicals. Let's take that off her plate and that'll give her all this extra time to do the other pieces that are in her wheelhouse. And that was important.
Jordan (40:53.894)
Yeah, just like the physicians don't want to be spending time doing things that, you know, is sort of within somebody else's scope. The same thing applies for the entire rest of your staff and how you delegate that whole chain of commands. Well, and then in terms of just like having discussions and bringing these things up and like problem identification, you know, that obviously necessitates having an open line of communication and an environment where people feel comfortable.
Sarah Smith I Charting Coach (41:00.594)
Mm-hmm. Yeah.
Sarah Smith I Charting Coach (41:05.27)
Yes.
Jordan (41:18.25)
bringing up these topics or airing their grievances, obviously in a respectable way. How do you go about fostering that type of environment in a clinical setting?
Sarah Smith I Charting Coach (41:20.993)
Mm-hmm.
Sarah Smith I Charting Coach (41:26.526)
Yeah, so typically staff know who their go-to person is. So it could be their direct person that they supervisor or it could be the practice manager. We try and discourage a lot of staff going directly to physicians because that's more of that interruption of the day that we're trying to avoid. But if that is happening, sometimes it is to us identifying, oh, maybe there's an issue with going to.
that person or that person about the problems. And then that requires a conversation. So that's where that board member team could be helpful to say, okay, why are we getting these sorts of comments and how do we manage that? And when do we need to bring staff together to have meetings and up-skilling events as well?
Jordan (42:17.734)
the time and the place for these different things. Cause like you mentioned, you know, that switching cost if you're trying to do something and then something else pings you even digitally, right? Now that the EMRs are getting more connected with the direct messaging systems in there, yeah, it's very distracted. It's an easy way to lose that efficiency in your train of thought.
Sarah Smith I Charting Coach (42:20.043)
Mm-hmm.
Sarah Smith I Charting Coach (42:26.19)
Mm-hmm.
Sarah Smith I Charting Coach (42:30.914)
Yes.
Sarah Smith I Charting Coach (42:35.446)
Absolutely. So you're just looking at a computer screen, but you're doing high level work when you're looking at that inbox, you're taking that patient data and you're trying to remember their clinical presentation, you're trying to make ideas now on your working diagnosis and plan and then how to communicate that to your patient. So you're looking at a computer screen, but you're doing high level work. No one else realizes that, right? So as your staff member comes up to you, well, you're looking at a computer just like they do.
So they have no idea the level of concentration that you're trying to coordinate in your head. So letting that be understood, hey, I'll come find you or please come find me at and giving them some guidelines is really helpful for batching those interruptions.
Jordan (43:19.518)
Are there any other like leadership faux pas that you've seen in the clinical environments? What are those some commonly stepped on landmines that we should be looking out for in terms of how we manage staff, how we lead the team, how we structure the organization?
Sarah Smith I Charting Coach (43:25.614)
I'm going to go to bed.
Sarah Smith I Charting Coach (43:37.75)
I think the rules from above doesn't go very well in any situation. So team leadership is something that is worth learning. So being the physician as a team leader, there are a lot of skills to learn here and there's ways you can learn those skills. But having a commonality of problem that you're trying to solve together as a team, knowing that your team all brings something unique to the equation.
and they know why something is or isn't working or could have ideas on what isn't, isn't working. So encouraging your team to say, hey, the printer isn't working again for the third time this week, but rather than just whining about it. And what I did was I called so and so and they said this, this and this would help in solving this problem is much better than whine, whine. Or now you're gonna be calling all these patients
And I want them done before tomorrow. And they're like, but, you know, so that head, that from the top down kind of leadership does not allow your staff to have that level of responsibility, the job satisfaction. We need to help them understand how they can be successful, what does success look like, so that they can win too in their day and be part of a functioning team and important for our patients and doing important work, not just grunt work. Yeah.
Jordan (45:05.758)
Exactly. And really making it, you know, like, collegial. Us versus the problem as opposed to me versus you or him versus her. Yeah, exactly.
Sarah Smith I Charting Coach (45:12.618)
Yeah, me giving you jobs. You'll hear a lot of, but I'm so busy, complaints. They'll come in and say, I asked my MA to do this and she said she couldn't. She was too busy. I'm like, mm, yeah, probably the way we asked. We told rather than asked.
Jordan (45:28.41)
I have one thing I've... Oh, sorry, go ahead.
Sarah Smith I Charting Coach (45:31.966)
No, it's all right. If you just tell them they're doing it, then you're going to get resistance versus a conversation. Yeah. No. Yes, correct.
Jordan (45:38.574)
Nobody likes that, yeah, the art of leading people.
Jordan (45:44.446)
One of the things I've noticed is the clinics that seem to have the staff retention thing figured out seem to be the most effective. You get there and there's an MOA who's been there for 10 years, there's a nurse who's been there for a long time. What leads into that? Or what causes the opposite? You know, rapid turnover.
Sarah Smith I Charting Coach (46:05.45)
Yeah, so staff turnover can be related to satisfaction and that can be related to leadership and your sense of responsibility and the way you can be successful in your role. So nobody likes an environment where you don't feel like you're successful or that you're constantly being micromanaged and you have very little responsibility or autonomy. So that's certainly for both the physician, clinician and the staff is important.
So that's one of the factors. The amount you can pay someone as a family physician in a family physician office, we've lost people to our better health services simply because the wage and conditions is better. Like the wage and the benefits and the pension plans are just simply something we cannot afford to provide. We take that into account and know that
income is important for people to retain their position. So we really worked hard to say, how can we, well, can we kind of do our best to make sure wages are at the best we can offer them, but we still can't compete with organizations. So that makes it tricky. If you've got a good person, they'll be headhunted by other bigger organizations.
Jordan (47:24.034)
So multifactorial, obviously, like the pay and the environment, you know, just the relationship dynamics, the respect, all goes into it. Yeah.
Sarah Smith I Charting Coach (47:31.768)
Yes, respect autonomy, having that level of responsibility and being valued for the job you do and for what you do, bring to the organization.
Jordan (47:44.51)
Now you mentioned we're losing physicians to working elsewhere, including within the hospitals. What is the problem with the primary care model as it exists right now? Is it a billing code issue? Is it the structure of the system in general? There's probably no easy answer for this, but what kind of changes would you like to see worked on to make that more of a equitable decision for physicians where they're not like it's an obvious yes one way or the other?
Sarah Smith I Charting Coach (48:14.074)
Um, that is a great question. I think I was more meaning like our staff want to move to the hospital because they get better paying conditions for the work they're doing. Um, don't tell them, no, not really. Um, they know that. Um, so why are physicians moving into the hospital space? Well, it is similar to that. So when, when you're working within the hospital environment, um, you're not paying overhead, so you're not having to do, um, the wage, the rent, the lights on.
Jordan (48:20.066)
Oh, gotcha.
Jordan (48:28.32)
Yeah.
Sarah Smith I Charting Coach (48:41.998)
the hire and fire staff, the paying the staff wages, that's all taken care of by the big organization. So of course, if you're in family practice, you have to see a certain number of people in order to like patients coming through the doors in order to pay for the rent, then the lights on, then the staff being here, all your insurance and other professional expenses for the year. And that is
Um, yeah. So the first, so many patients for the day or the week are paying that. And then you're paying taxes and then you get to keep the rest. I think that's one of the hard bits. And then the second part of family medicine is if you get into that mental mindset that you're not being valued or that you are being dumped on, um, by specialties or that you're not important, why would you stay?
Right? If you're feeling like that within your day, you're not having that joy of medicine. And so certainly, I absolutely understand the whole dreading work, feeling like you're, you know, stop asking me to do things. I don't have room for anything more. Don't you understand what I'm already doing already? Like that was the first 15 years of my family physician career.
was that overwhelm, but that clinical experience, your experience of medicine can be very different when you learn some of that mindset tools of, hey, I want to be here, I choose to be here, I'm enjoying this part of my day, not just focusing on the things that aren't going well about my day, which was very much my experience before.
Jordan (50:31.078)
Yeah, when you're already feeling underwater and then that sense of under-appreciation is just pushing your head down further, that really weighs on a person.
Sarah Smith I Charting Coach (50:37.239)
Mm-hmm.
Sarah Smith I Charting Coach (50:41.91)
Yeah, that's right. So we love family medicine because of the variety. It's amazingly fun. We love the continuity. We know we do amazing care when we're doing like as a family physician. We have highly evidence-based in regards to reducing morbidity and mortality for patients. We get to do a wide range of medicine for our patients. And just like...
specialists in their clinical day as well who have their private rooms. We're paying overhead, we're paying staff. That's a whole layer, the whole business layer wasn't necessarily taught as we were doing medicine and something you kind of got to put together at the end. So, Chatting Champions I like because it's kind of like finishing school for doctors. You get all the other little pieces that you may not have picked up along the way in medical school. Yeah.
Jordan (51:35.066)
Absolutely. I mean, we had like a one hour session times two or three on business administration, I think during the entire six years of training in medical school. So it's like vastly undertaught. And I don't know, there's kind of this like, you're here to do the healthcare attitude, but I mean, you're, you need to get your business knowledge under your two, right? You come out, you graduate, you do your training.
Sarah Smith I Charting Coach (51:48.194)
Definitely.
Sarah Smith I Charting Coach (51:55.886)
Mmm!
Jordan (52:03.066)
And you're like, okay, I've spent thousands upon thousands of hours, like learning, you know, diagnosis and the pattern recognition and treatment algorithms. And then it comes to like, and now what? Like I got to actually run a practice and it's just very overwhelming. Well, okay. So I've learned a lot today in terms of how can people get a hold of you? What would that best way to get there be like?
Sarah Smith I Charting Coach (52:18.493)
Yeah.
Sarah Smith I Charting Coach (52:26.166)
Yeah, so it's just chatting. Coach.ca is the website that has all of the different programs attached to it. And then you can find me on my own podcast, Sustainable Clinical Medicine podcast, where we have interviews with physicians and clinicians who have kind of redesigned their day to create sustainable models for themselves. So my hidden agenda is to get your home so you can have a life outside of medicine. So that's what I.
just love about what I do is I get to help physicians create hours of their life back. So super fun.
Jordan (53:02.466)
What would people expect if they're signing up? You know, what do the programs actually entail in terms of time commitment, in terms of the medium that they would interact with you through?
Sarah Smith I Charting Coach (53:12.466)
Yeah. Um, so it's all very much what you're needing. So we get the, um, as you kind of join the charting champions program, if it sounds like something that you're interested in, you get the foundational modules of how do we do these steps and it takes an hour and a half in total. So we wanted to keep this short, snappy and very, um, easy to start to implement. And then each month we have, um, and there's no obligation to come to any of it life.
We do six coaching calls where you can come on and get that specific one-on-one help because you'll have physicians coming in from the hospital system, urgent care, family medicine, neurologists, oncologists, like all the different types of physicians. So we wanna be able to make it perfect for them with that access to their executive coaching peers who can help them with that specific help. We have that online peer community where they can get.
support, encouragement, have a wine, have a bad day and get the help they need there. And we bring a guest coach in every month for an additional three hours worth of training in a different topic. And then all of the call replays are inside the membership and they get main pro points or college points for each hour they're in the program making claims. So we love it because it's comprehensive and it's lifetime access. So they get to come in, pivot, do different seasons of their clinical day. Yeah.
Jordan (54:32.498)
Awesome.
Sarah Smith I Charting Coach (54:37.742)
So, pretty fun.
Jordan (54:39.038)
No, that's fantastic. I will say I've seen you talk at a conference before and after doing your session, you were taking some Q&A and there was some like fantastic examples of questions coming out of just dysfunction and how you like very quickly were able to like establish that common ground and then solution problems like even right there on the spot in front of a room of people. So I have no doubt that you'll add a ton of value for all the people listening to it. So.
Thank you so much for chatting with me today. I really appreciate it.
Sarah Smith I Charting Coach (55:10.53)
Yeah, I loved being here. Thanks so much, Jordan.
Jordan (55:15.238)
Have a good one. Take care everyone.
About the Author
Cherry Health
Canada's Medical Network
About the Author
Cherry Health
Canada's Medical Network
About the Author
Cherry Health
Canada's Medical Network
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