The Efficient Clinical Session October 14 th, 2010 Peggy Chou, MD Craig Noronha, MD Section of GIM

Objectives At end of this seminar we hope that providers can 1) Work more effectively during their clinical sessions 2) Manage patient interactions more efficiently 3) Develop advanced logician techniques

What makes you slow down in the clinic?

Current Reality vs Dreamworld  BMC is NOT getting a new electronic medical record system in the near future  Electronic medical records are NOT going to disappear from the United States health system  We are being asked to see more patients with more medical problems in shorter periods of time  Our patients problem and medication lists will get longer as they age and acquire medical morbidities

So what can we do????  Develop Habits that allow us to be more efficient in clinical settings  Use our clinical interactions with patients more effectively  Use the EMR system to our advantage or at least speed up what we are doing

Helpful Habits Make the chart easier to focus: - Reorder/Clean up medication and problem lists - Add comments to medical problems to help you in future visits - Add titles to visits i.e. visit for knee pain

Being Proactive  Look at the patient’s chart BEFORE you sit in front of the patient.  Looks up labs, review ED reports, other provider visits etc  Start placing orders before seeing patients

Show up early  You cannot control if the patient or staff are running late. BUT if you start late you will never finish on time.

Do only clinic work during sessions  Do not check s or web browse  If you have down time- sign notes, sign forms, review patients for tomorrow etc

“Do Today’s work Today”  The longer you leave notes the longer it will take to finish them  If you see labs that are normal– do a quick follow-up letter.  Use a results letter/form in logician

Do Not Leave the Room Unless You Have To  Page the staff or call them if you need to  Minimize interruptions by negotiating with staff up front

In the room…  Computer-patient-MD triad  Setting the agenda…..and setting limits  Letting go…  Refresh

Working with the computer  Most efficient if type while talking with patient  Position computer if possible  Acknowledge the computer, apologize if necessary (especially if positioning is less than ideal)

Setting the agenda…setting limits  Negotiate agenda up front. This allows you to set limits later  Let the patient control as much of the agenda as possible  “In the time that we have….” “We need to stop for today…”  “Do today’s work today” BUT balance with continuity of care

Baker, LH et al “’What Else?’ Setting the Agenda for the Clinical Interview” Annals (10):

Letting go…  Patient in control of the agenda +  Staff in control of the flow = You can focus on the patients

Refresh In the middle of the session, take a 2 minute break: Quick walk SnackEtc

Logician Tips  Quick text- how to make one and use one  Using previous notes to your advantage  Flag management  Result management  Organize medications and problem lists

Quick Text

htnros = Patient denies any headache, blurred vision, chest pains, shortness of breath, orthopnea, or leg swelling. Patient reports that she takes all medications as directed.

How to “future” flag yourself Flag yourself WHEN you need to worry about something Flag yourself WHEN you need to worry about something  Helps prevent “overflagging” so that you loose track of important things  Good way to remind yourself about following up on patient’s studies, outcomes, visits with other providers etc  Good way to remind yourself to ensure that tests got done ie CT scans that need repeating etc

How to manage results???  If you have several results for one patient sign all but one of them- makes your desktop look cleaner  Result letters- use them to your advantage for stable or normal results  Call the patient only if you have to

Organize your Medication and Problem lists  Place the highest priority or cannot miss diagnoses/medications at the TOP  Place less important diagnoses/medications at the bottom and indent them  Add comments to your diagnoses/medications  Remove old resolved diagnoses ie URI in 2004