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These changes significantly improve Epic EMRs outpatient user experience and puts it nearly on par with some of the better outpatient systems, and possibly my favorite, Allscripts Professional. Just because something is popular however, doesnt meant that its good. Epic EHR covers most of the functions provided by electronic health record systems. Pre-visit lab testing saves time, improves patient engagement in health management, and reduces the amount of work needed to report and respond to results. 1. The patient is then given the option at check-out of receiving an automated reminder phone call, text message, or letter closer to the time of the appointment. I copy and pasted the entire article below if you don't want to click through as well. Medical charts build a complete record of patient information and medical history, 45050, Zapopan, Jalisco, Mexico, 2 105 CONSUMERS DRWHITBY ON L1N 1C4 Canada, Dubai Internet City, 1st Floor, Building Number 12, Premises ED 29, Dubai, UAE, 163 Bangalore Town, Main Shahrah-e-Faisal, Karachi 75350, Pakistan705, Business Center, PECHS Block-6, Shahrah-e-Faisal, Karachi 75350, PakistanFirst Floor, Blue Mall 8-R, MM Alam Road Gulberg III, Lahore. Pre-visit labs can also aid safety. Electronic charting in Epic also increases the availability of information throughout the entire organization, including doctors, nurses, specialists, and members of different departments. Well, it is one that follows the privacy rules dictated by HIPAA. NTBkYTVhMjM1NmY4ODU4ZDg0Nzg3ZDJmYWJhMmJjNzYxZjBkYjMxZDcyYTU1 All Epic modules are built on the same platform with the same data structure, making information sharing and system integration simpler and more effective. Please be wary of how you use macros and make sure your charts are accurate. On the edit note tab that shows up, youll see a tiny downward pointing arrow, click this and youll see the option for move to floating window. Typing also paced me to where I knew what I wanted to say as I wrote it. MjIxYmZkYTRlMzljN2FhNzQwY2U0ZDIwODJiN2EzYTgyZDg2ODI5MjEyMmVm (The "Post-appointment order sheet" is available in the FPM Toolbox). WebWe are builders and inventors who develop our software as a single comprehensive It consists of several modules relating to eligibility, member enrolment, plan benefits, authorization and referrals, CRM, member premium billing, accounts payable, claims and contracting, utilization management, and plan benefits. Viewing Patient Banner in SnapShot from the Schedule . 6. In particular, I focus on knowledge gaps Ive seen in senior residents when learning how to chart. 1301 Shoreway Road, Suite 160, Belmont, CA 94002, 6701Koll Center Parkway, #250 Pleasanton, CA 94566Tel: +1 408 365 4638, Export House, Cawsey Way, Woking, Surrey, GU21 6QXTel: +44 (0) 14 8339 7625, 49 Bacho Kiro Street, Sofia 1000, Bulgaria, Amado Nervo #2200, Edificio Esfera 1 piso 4, Col. Jardines del Sol, CP. In my own outpatient practice, most of my patients have already had pretty extensive evaluations and in about half of the new patients, I spend > 30 minutes sifting through office notes, lab tests, cardiovascular tests, chest CT images, pulmonary function tests, etc. Chronicles allow data to be stored in a non-tabular form and then sends it to Clarity, a relational data. What is Health Information Exchange, and its importance with HL7, Hospital Patient Flow Best Practices | Patient Flow Optimization, At this point, its needless to say that there are multiple powerful features available with the Epic system. American Medical Association's practice transformation website. Ok, so maybe that was a bit harsh. One thing I've noticed about dragon is that my notes with it are way longer which I'm not sure is a good thing. NDUwMGU1MWZkYTQ5MjcwOTJiZjI2YTZiNzdmYjUxOWM5NWY4MzM0NmE0Yzk1 overpriced, sub-standard, half-baked systems designed by polytech school dropouts. WebCarelign. Calling the patient ahead of his or her visit can help the clinical team prepare more thoroughly by clarifying the patient's agenda, anticipating any special needs, and completing many of the tasks usually performed during rooming, such as reviewing medications or screening for depression or falling. It was tailored to be integrated with Epics software so that it could be used by them. Web2. As a consequence, I find that. 3. Epic Systems were made to support functions and processes relevant to patient care, such as scheduling and registration. 2. I found myself being able to save about an hour per shift of charting, and real time dictation has saved me hundreds of hours of my life that I would have otherwise spent typing. The physician is already familiar with the patient's conditions and medications, so it should take very little time to identify the appropriate tests for the next visit. Each component adds efficiency and supports a rapid understanding of why the patient is visiting and what his or her comprehensive needs are. Because pre-charting is often relegated to the last thing that I do each day (since it is usually the least urgent), pre-charting becomes the task that keeps me at work an hour longer each day and so I now negatively associate it with being the thing that steals my time away from my family in the evening. Transcription is not ideal. Maybe you can attend training again. This content is owned by the AAFP. Organize your medical decision making(MDM) with a general dot phrase. Folio3 is a California based software solutions partner for entrepreneurs and Fortune 500 companies that specializes in digital healthcare software solutions. how does this work? SmartPhrasesare similar to SmartTexts, but can be personalized. Intuitive user interface. This dramatically increases performance and scalability, which enhances business agility. This is a question our experts keep getting from time to time. $1200 is the starting cost for self-hosted systems. Also, information shared by patients is not sent to Epic directly. Epic now (finally!) Several roles have Learning Home dashboards that contain specific training materials and links within Epic. In addition, it will ensure that doctors are able to gain the best outcome from Epic systems. I put the HPI smartblock in a note, but I couldn't find an "illness" complaint. Others arrange for patients to have their blood drawn 15 minutes to an hour before their scheduled appointment and then use point-of-care testing or rapid turnaround of standard lab testing. Masks are required inside all of our care facilities, COVID-19 testing locations on Maryland.gov, Using Epic for Research at Johns Hopkins: Tips and Resources, Johns Hopkins Launches New Precision Medicine Tools, Dragon Medical One Brings Voice Recognition to Epic, Epic Promotes Evidence-Based Blood Use, Saving $1.8 Million, News about current Epic features coming to productionare posted in. Gather subjective evidence. Learn more:Using Epic for Research at Johns Hopkins: Tips and Resources. Because Epic does not currently have the functionality to auto route notes to other providers besides the author and primary care provider. There are several types of crimes for which nurses may be charged as a result of a nursing error. MTM0NmVkN2Y2YzgxMjdiZDRmYTFiZjJmOGEzZGM3OGFlMTlkYTQ2NWJiZTMw I have found that using Epics custom HPI forms actually take much longer. Our consultants have you covered. M2Q1ZmFlN2NlZGI5ZTg3NTRlNTdlYTE1ZTY2ZWUwY2FmNmQ5OGRmNTZlMWM2 Assume Android for the voice to dictation? NTYyNTliMzliZGUwOTliY2Y1MmRkNmIzMTU2OTM3MTE2MDJjNzdkNzMzNzYx Findresources and reportson the Epic toolbar by going to theMy Dashboardsworkspace and selecting the template specific to your role and entity, then linking to resources or running reports. In an effort to be more patient-centered, we've also found that asking the patient when he or she would like to return is an effective way to share decision-making and give patients an active role in their own care. Unparalleled Security features that are Common Criteria EAL 3 certified. Create an account to follow your favorite communities and start taking part in conversations. Standardized questions applicable to the particular practice, such as screening questions for falls, depression, or domestic abuse, can also be asked. Learn more: Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor Guidelines | Coronavirus. 5 tips to chart faster in Epic. Illness HPI form. Dictate, dictate, dictate (real time) Minimize your dot phrases. Use floating windows. Make sure all of your wrenches are optimized! -----BEGIN REPORT----- Epic Caboodle, previously known as Epic Cogito, is designed to cover the whole "kit and caboodle" when it comes to streamlining organizational operations and maximizing Epic Healthy Planet was initially created as an accountable care and population management system module in response to the Affordable Care Act (ACA). ZGEwMmRmNmJlMTQ4YmVjOWVmODRkMzFlY2ViY2IzYjNlM2ZkZWFlYTYyMzNk Sounds too good to be true, right? Our experts have done a research to get accurate and detailed answers for you. 1. Way too many clicks and variations. Look before clickingto make sure that the correct patient is being documented and that accurate information has been added to the record. By pre-charting, I have been able to identify where those radiographs were done so that my office staff can contact that hospitals radiology department and have the images sent over the internet. -----END REPORT-----. Here are links to Quick Start Guides and Power Point tutorials to review Some practices reserve pre-visit phone calls for complex patients. Also, Epic EHR has telehealth options, ranging from video call support, patient monitoring, and follow-ups after a surgical procedure. Thus we have proof that EMR designers can evolve and transform their systems over time, albeit very slowly. Need help navigating through the core EHR features of your new Epic system? Did we get them? But for them to stay constantly busy, I have to be constantly busy. Some features of this powerful software include: Due to these robust tools, Epic partnered with and has been using InterSystems Cache databases for several decades. Im unclear how that helps with efficiency. Thus, patients can access their information privately and securely using the Epic mobile application anytime. If youre one of those that hasnt switched over to real time dictation, please do. Request free assistance: With new tools and resources, Johns Hopkins Medicine is making it easier for clinicians to conduct precision medicine research and use the results to improve patient care. You can implement Tapestry depending on your needs. The Epic Software system is used within the healthcare sector for the purposes of electronic medical record keeping. It also contains every kind of module. Epic has created its own Cache Database is essentially a more specialty-based version of the Cache database owned by InterSystems. You will have to open these notes in the chart to complete them. Epic provides both EHR and EMR services, which come under the same umbrella. Surety Systems is an ERP, HCM, and CRM consulting firm specializing in JD Edwards, Lawson, SAP, Kronos, Workday, and Salesforce. Post switching over to real time dictation, I was able to finish charts much more easily on shift and have almost every chart done prior to the end of a shift. You can then type as fast (and sometimes faster) as people speak. MGIyYzZiNWRkMDMxZDEyNTFkNjBiMmFmODNmZjhiMmFhNTRjYzFkZjFhNmFk Its a constant reminder to finish your note or update it. If the patient no-shows, the system will cause the pre-note to self destruct and then cause an angry looking troll to display on the patients phone until they reschedule (though that last part may still be in beta). I dont think that pre-charting save me any of the total time I spend on any given week but I dont think it requires any more of my time either it just shifts some of the documentation time around from after the clinic hours to before the clinic hours. NDBjZDJlMDY1ZTU1NTc3MTBlMzJlNDRiMWJmZTc5OTdmOTc4ODAwZGI5MDJj For nurses, doctors, paramedics, and others relevant to healthcare, there are elaborate clinical systems available. I mean, am I right? When you create an epic, you'll need to enter the following details: Epic name - A short identifier for your epic. Not only do they take longer to create, update, and access, but they also put important information at greater risk of being misplaced or tampered with. Over 250 organizations within healthcare use Epic, and over 45 percent of the population have their records stored on the Epic system. Investigations are not duplicated; communication is enhanced among not just providers but also between patients and providers. 4 yr. ago ED Attending. Select the In Basket message for the affected person's event and click Select Patient to open the patient's chart. There are serious penalties if the rules are not followed. Dragon voice recognition software is now available in Epic for all Johns Hopkins providers. WebSelect the Home tab and hover over each type of event in the Event Monitor section to review recent events for your patients. In my opinion, having to wait for a transcription service and then review it for accuracy hours later is not efficient. But with outpatient practice, you can work leisurely at your own pace before office hours and after office hours but during office hours, you are in a constant state of demand for time efficiency. I have more time to spend just talking with my patients since I am not trying to furiously type into the EMR as much when I am in the exam room with the patient. Furthermore, you may be able to head home an hour earlier, feeling satisfied with the day and a job well-done, knowing that your patients and staff feel the same. This trick is a particular time-saver for nurses, respiratory therapists and others who document frequently in flowsheets. Pre-visit planning takes place in several steps: 1. Distributed systems are supported by Epic Cache across several networked servers. before they will appear elsewhere in the chart, including in the History activity. Because of this, I assumed that I could always keep typing faster than I could dictate. WebEpic record, select the Chart Review activity tab > Media tab> Patient Scans button On the day of or the day before a visit, the medical assistant or nurse can do a quick review of the patient's record to see what needs the patient may have during the appointment. To create a new SmartList record, use the Create tab and enter in a new name. Epic CRM enables healthcare organizations to keep a record of all relationships with suppliers, customers, and other clients. Epic is widely known in the healthcare IT industry. And this adds up I estimate that my clinical receipts will increase about $13,000 per year from this CPT, alone. Personally, I believe that the trainees learn a lot about how to comb through old records for diagnostic clues efficiently by actually doing it themselves and when I pre-chart, I am depriving them of this opportunity. See permissionsforcopyrightquestions and/or permission requests. more than 60 days overdue, they will not appear in this widget and you will have to look in the chart. Daily traffic can be increased without compromising on patient treatment quality. Devastation in Puerto Rico leads to hospital shortages in U.S. A felony is a serious crime (contrasted with misdemeanors and infractions, less serious crimes), usually punishable by a prison term of more than 1 year or, in some cases, by death. On the bottom menu, click on Care Plan c. At the top right click on Action and Import PennChart Problem List d. Now go through and enter information about each problem and plan e. But after getting through 1.5 years, I really could think and speak on the fly, but only recently got into dragon, and I wish I used it earlier. NTljY2NkNTQwMjhmMjIyMWJhM2U2OTQzYmNjODQ4M2Q4MTc1MDcyZjcyZWNj WebView in English Eng. You can read more about pre-visit planning, pre-visit labs, huddles, pre-appointment questionnaires, and building a culture of team-work at the American Medical Association's practice transformation website. For ROS, you can use a macro, but obviously need to make sure you're being accurate. With a system that allows you to track and update a patients records in real time, you can reduce the risk for error when completing charts and increase the accuracy of diagnoses and treatment recommendations. For a full year that our hospital turned on dictation I refused to switch over, feeling that I could type faster. By default, all patients have a Vitals flowsheet. If you have the ability to dictate, dictate. You receive a record of all interactions. Continue through the sign-on screen, and you find that fonts and colors are slightly different, but overall the change is similar to the effect of changing the theme on your computer or smartphone. Junior doctors in the UK are voting on a 72-hour Whats a term used in medicine that really annoys you Press J to jump to the feed. However, the doctors can get overwhelmed since the systems are still new. MjI4YmU1YjU1ZjFjNzhlN2IyYmZiOTA4ODViM2FlMzc0ZmY0YzdkMzA2YjZi Type your message to the patient and click Accept and Send. Do you have any more tips youd like me to add to this? Failing to document prior treatment events. ZWVhNTRiMTI0YTcwZWFmYWY2MGQwMTkwNmIyZGU4ZDg0ZjgxMWRlZDkwNDEz ODI1MjIwNWEzYjVhOWFkZjdiNmNlM2Y0MDVlMzY4N2E3ZWY2Mzc1ODE4NWRm Medical charts contain comprehensive patient information that gives physicians a clearer patient picture and helps them make better, more-informed decisions when it comes to patient care and treatment. Information is stored temporarily while you are using the application. WebSend a message, get online diagnosis and treatment, talk face-to-face over video, or All upgrade materials are posted on thisupgrade pageand may include quick start guides, PowerPoint slides, recordings and tip sheets. Dragon real time dictation has been a life changer. I'm with you on Dragon. YTkyZDVjYTBhNTlhMjVkYjI2OWJjOWZlZTI4YWIxZDg0YzZmOTFiNTY2Njhh My favorite efficiency feature from this is that once its enabled, every time you open the patients chart, your note pops up if you have not pended it or completed it. Luckily for you, there is. That way when you type en the word endorses shows up. Here are a few of the main features of the system, as well as how using the Epic medical charting system can transform your organization: Epic MyChart and MyChart Bedside both offer various patient monitoring features, improved ability to manage and exchange data, and increased visibility for patients and physicians. The more customization youre doing with your chart, the more time and complexity youre adding. If you log in to the wrong department, use the Epic button and then clickChange Contextto quickly log in to another department without logging out of Epic. The most widely used and popular software that most hospitals in the US use are called Epic Systems. ZmJiYzU5ZTQ1MTJhMGI3NzQ3OTM2MGFlNTA1ZTUzMTJmZjcyZTk3ZWQwMTIz Here are a few of the main advantages of the Epic Charting system for nurses, doctors, and patients: Electronic charting systems (like Epic) make the process of completing medical records with proper documentation more efficient, not only giving physicians more time to spend with their patients, but also reducing the amount of manual work required to fill out and submit patient charts. Now, we have got the complete detailed explanation and answer for everyone, who is interested! An ID doc we rotate with is pissing me TF off. I thought I could type better. Lets dive in. Quick start guides (QSGs), which provide overviews of Epic use by role, can be found under Additional Resources within the role-specific pages. 2020, Folio3 Software Inc., All rights reserved. Its a small thing, but makes your HPI so much faster over time. Epic systems provide their client the tools to maintain the database, run reports, and run queries. Although we have not found many studies measuring the overall financial savings of pre-visit planning, our personal experience is that pre-visit planning definitely reduces the time spent on a patient's care during or after the visit. If your hospital doesn't have dragon, you can do something else: Open Google keep or Google docs, use your phones voice to text to talk, and then copy and paste to epic from computer Google keep/docs as it will update in real time. No one has ever heard from that physician again. Web1. YTEyZTJiZTM4OTkxNmRmMzYyNDkxNGI2MzQ2MGJmMDdjNjk2YTA1MmY0M2Mw I'd love to hear any more suggestions or optimization techniques that residents use that I can add to my lectures and add to the original article. Epic, is not one of those early systems. In this article, you will find everything you need to know about Epic Systems Corporation, all their offerings, and why they are the number one choice of all healthcare consulting firms in California. Chronicles is the primary database running the Epic software. What Is The Ideal Hospital Occupancy Rate? You just studied 12 terms! And that was a problem, because that interface was excessively busy for the inpatient environment, offering too many tabs, menus, doohickeys and thingies, and submenus of those thingies. General "illness" tab has key ROS things. Clearly, the intent is not to commit fraud when nurses pre-chart routine and reasonably anticipated events such as discharging or transferring patients; giving report; passing, counting or wasting medications; and performing other routine tasks. ZTBiN2Q0Nzk5NzEzMDFhOGUxNjBiNyJ9 Tips and Tricks for Getting the Most out of Epic - Hopkins Medicine You will get support from your administration simply by saying it will help get charts done faster so that insurance can billed sooner. You can also highlight a word with your mouse, right-click and select Search for Selected Word.. ZWQ5OTkyNDk1ZTY0NzFmZjE2NDRhNTE2NjBmOTc1NDgxMGIzOGEwMGI2OGNh This is your one-stop encyclopedia that has numerous frequently asked questions answered. Accurate medical records and up-to-date medical history are necessary in any healthcare organization. Epic offers two programs One on One and Epic Learning Centers One on One (PK 12th) Choice of curriculum. There is also a MyChart Bedside feature for patients who are admitted to the hospital. Epic EHR software mainly focuses on how to facilitate remote care and on patient engagement. WebMost appropriate activity for you to start in each day Epic button Find activities that area not on the tool bae Story board Contain details about the chart you are currently in Task highlight in yellow is overdue task True: completed, discontinued, and future meds appear on MAR with different color background compared to current medication With inpatient practice, you see patients at your own pace during rounds and if you want to stop for a moment to have a cup of coffee or speak with a colleague, it doesnt disrupt your workday. Thought this might be helpful in this thread. A newPersonalizebutton on the Epic toolbar helps tailor SmartPhrases, order sets and preference lists. The short answer is, yes. Epic on the other hand, has been rocking the same look and functionality since about 3 or 4 iphone generations ago. Generated by Wordfence at Wed, 18 Jan 2023 15:43:14 GMT.Your computer's time: document.write(new Date().toUTCString());. Folio3 EHR/EMR integration services allow a fully integrated system to be installed in a healthcare facility so that not only will it process clinical information but also billing, patient scheduling, and registration. Real time dictation is the best. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. In our practice, we use a checklist to help us plan for the next visit. Not only is it far better than those early systems, it is now the Jupiter of the EMR universe, far outpacing rivals in terms of adoption. Copyright 2023 American Academy of Family Physicians. The List tab presents many options for defining and configuring the behavior of your SmartList. Epic MyChart Bedside operates similarly to MyChart, but instead of focusing on outpatient care, the solution offers greater engagement for patients while theyre admitted to the hospital or clinical practice. Dive deeper, though, and there are some real changes, but only in one crucial aspect. With electronic charting systems, patient information is stored in one place, making it easy for doctors and nurses to instantly view comprehensive data whenever they need it. Pre-visit planning is a team-based approach to planning for patient The Epic Cache Database was developed to enable quick KB-SQL access to their database and to make the DBA process more simple. You dont want to end your clinical day or night with an inbox of charts that are blank! Some EHRs are designed so that the patients' answers to the pre-visit questionnaire can be imported into the visit note, reducing the amount of data entry required of physicians and clinical staff. Epic has the most complete, easy to- use functionality, not just for individual physician practices, but for implementing an EHR that can be effectively shared by an entire health care community. Conducting visit prep can be an effective tool in panel management and can positively affect the health of the entire patient population. The result was that I didnt have as much dictation and chart work after office hours but the EMR documentation encroached on the time that I was with the patients. 2. Patients were happy with the care that they got but they were not happy about the time they spent in the waiting room when I ran behind and they often commented that they didnt get enough time to spend with the doctor once they were in the exam room. Consider that the average family medicine patient age 65 or older presents with four problems per visit and, in our experience, one or more care gaps needing to be addressed.4 This is more work than a physician can typically handle alone yet is too important to leave to chance. Cue the Epic Charting System. ROS & Physical Exam macros or smart phrases. This way, all patient data is kept safely in one place and can be accessed or edited by physicians at any time. WebCopy Chart (in follow up section) Attending to co-sign. A pre-visit questionnaire is a list of questions the patient completes either on paper in the waiting room or through an online patient portal from home. a) A MyChart encounter opens b) Open the MyChart Message section of the Visit Navigator and click Reply. How do I create a new note in epic? Wait more details on this? Here are the names of some of them: EpicCare by Epic Systems Corporation is a solution for out-patient departments that allows physicians to monitor their patients healthcare from start to finish. Reviewing the patient's record outside of the office visit requires more time than planning forward, but it is still more efficient than not doing any pre-visit planning. Epic uses HIPAA- compliant software development techniques because it takes the protection of patient privacy very seriously. ZDM3M2U1Y2VhNDU0MjBmMjVkYWE3NDY5OWVhMmFlOTJjOWU4MWE5MzY5ODAw A rough estimate is that pre-visit planning takes about an hour of nursing time per day and saves about an hour of physician time and up to two hours of nursing time. Epic EHR is a cloud-based system that caters to most specialties. I am an Emeritus Professor of Internal Medicine at the Ohio State University and former Medical Director, OSU East Hospital, The other obvious change is the reduction of menus on the left, to about 10, whereas the inpatient screen has 15, as well as numerous submenus. I often have residents and fellows in the office with me. This will allow you to access historical test results better, allow you to see vital signs better, and much more. They can use this to get in touch with the medical team caring for them. Because patients are able to review their test results together with their physician at the appointment, it is less likely that an important result will be overlooked or lost in the system. Assessment/Plan smart phrases when possible. The database, which works using a hierarchy system, was specially designed for business agility, reliability, and maximum speed. Any big healthcare mobile app development company, the USA would agree that this is the best ambulatory solution. We have received mostly supportive feedback from our patients regarding pre-visit planning. For my setup, real time dragon dictation is built right into epic, and we have power mics that allow us to dictate at the press of a button right into the chart. Plan forward, or The next appointment starts today. 5 The most efficient form of pre They don't have to wait after the appointment for lab results or instructions based on those results, and they can speak with their physician about those management decisions. With over a decade of experience and expertise in the healthcare space, we have built groundbreaking digital transformation healthcare solutions for some of the worlds leading healthcare companies. Home > Insights > Epic Charting System: Your Key to Improving Patient Records. MGQ5Y2QzNmU1ZGJlMDQ5MDg2YTE4NDI3MjQ0NjgxNDViYjE3NGE2MmNhODZl Did you know Epic is a resource for all kinds of clinical research? See the questionnaire our practice uses. Johns Hopkins' medical concierge services offer complimentary assistance with appointments and travel planning. Pitbull is popular, but all he does is sing words is Spanish and repeat them in English. The software is primarily based on Epics own database management system known as Chronicles. Press question mark to learn the rest of the keyboard shortcuts. I am only frustrated that I didnt use it sooner when it was available. EMR and EHR software, like Epic Systems, replaces paper records with electronic charts and eliminates the risk for legibility or translation issues that could pose a threat on the accuracy of a physicians diagnosis or treatment. I am less likely to get behind on my schedule and so my patients are spending less time in the waiting room. 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