Using an EMR to Manage Patients with Chronic Disease Doctoring 3 Longitudinal, 2009-2010

Goals of Morning Activities Use technology with patients effectively Use an EMR to help manage chronic conditions Problem List Medications List Vital signs flow sheet Chronic Disease flow sheets Reminder System Incorporate evidence based guidelines in management decisions

Using Technology with Patients What is wrong with this encounter? All current medical students will use an EMR in their future practice. Assuming that your goal for using an EMR in practice will be to improve safety while having all patient charts in a form that will make them more transportable, reportable, accurate and legible. Also, the EMR should eventually improve your productivity, so that you can complete all your documentation while seeing the patient instead of having to do it after you see the patient. There are a number of impacts that use of technology in the patient encounter can have on communication. What is wrong with this encounter. Click on image to bring up video from YouTube

CLC Checklist for Good Patient Communication Introduce self Establish rapport Open ended questions at beginning Maintain good eye contact Be supportive and concerned Used transitional statements Avoid using medical jargon Allow patient to speak without interruption Summarize history Gave patient a chance to ask questions Appear poised, professional, confident How can an Electronic Medical Record (EMR) adversely effect patient communication?

Possible Adverse Effects Computer creates barrier between doctor or student and patient Poor eye contact Closed ended questions driven by templates Missing teaching moments Pauses while typing/looking for patient education not engaged with patient All of these adverse effects have been identified in the literature. Lets look at one thing– the room arrangement… What specific actions can we take to avoid these situations?

Arranging the Exam Room Which of these is best? Why? We don’t expect that you will be able to do anything about the room arrangement of your clinical faculty’s clinic. However, in case you do have a say in your own clinic set up, or are using a portable computer,…

5 Tips for Using EMR Construct a triad with doctor (student), patient and computer Introduce the computer into the encounter Adjust screen so patient can see it Share EMR information on screen with patient Alert patient verbally “sign posting” when turning to EMR Sign Posting refers to the yellow signs that used to be on the highways that warned the driver of upcoming curves or stop signs. Just as you would alert the patient that you were going to do a certain exam, you should tell the patient that you are going to enter some data or look up the patient’s information in the computer.

Using Tablet Mode Advantages? Disadvantages? Have a discussion of what you can do with a tablet.

Ideas for Sharing EMR with Patient Verify Medication List and Problem List with patient Show patient his/her vital signs, including weight (gain or loss) Graph patient’s weight or show flow sheets or show trends about chronic diagnosis If printer available, ask if patient would like a copy of his/her data If time allows, access other online patient education materials for patient Summary of ideas,

Major Points for EMR Communication Introduced self BEFORE turning to computer Introduced the computer into the doctor/patient/computer triad If sitting, adjust the chair to be at eye level with patient and so the patient can see screen Patient should be alerted verbally when turning attention from patient to the computer for longer periods of typing Wrap up

D3 Longitudinal Orientation

Objectives for Remainder of Session Understand student expectations Provide mechanism to achieve expectations Use SOAPware to Create a patient using HIPAA rules Populate the Summary page Use codes to speed up data entry Add vital signs Create a basic progress note Set up reminder system and start using flow sheets

Resources for Activity Intranet SOAPware icon on right All training materials including Basic Instructions Data Collection forms Instructions for uploading patients SOAPware on student laptops

Article reviewing EMRs This article clearly ranks SOAPware among the most popular EMRs in use today in private practice, especially in small (1 or 2 physician) clinics. Article reviewing EMRs http://www.medscape.com/viewarticle/570380

Why are we using SOAPware? Runs on your laptop disconnected (the only EMR with remote access) Easy to learn Allows you to export patient records Allows for review your charts and give feedback, monitor progress over year Customizable so we can add templates, flow sheets, etc. for curricular purposes Donated to FSU CoM

SOAPware Modules Not Included/Used 3rd party software NOT free includes Prescription writer (Epocrates’ database) Medication Interaction checker Evaluation and Management (E&M) Coding Tools Billing Instant Medical History integration Device Integration: EKG, Holter, Spirometry Electronic transfer of lab data Templates for Diagnosis visits Reduce typing, speed productivity SOAPware appears stripped down because for our purposes it is. We did not purchase all these components because they were not critical to meet the objectives of the activity. We still want you to use Epocrates or PEPID to do drug interactions on patients.

Select Patients to Document With your preceptor 6 patients from panel (not all) Patients with common chronic diagnosis, examples include: diabetes, asthma, hypertension, hyperlipidemia, congestive heart failure, osteoarthritis, depression, obesity, attention deficit disorder well child (development) and obstetrics visits (following for entire pregnancy) Mine their charts for pertinent historical data Can use Chart Data Collection forms – child, adult, or geriatric

Create Chart in SOAPware HIPAA requirements No patient identifiable information Last name: your last name First name: A, B, C… Keep list of real name and chart name on paper in clinic in safe place as a separate document Birth date: January 1 of year born Gender OK, marital status OK No SSN, address, phone

Strategy for Building Panel Work with preceptor and staff to identify likely patients 1st visit, create charts for patients who seem likely to be on panel and do encounter note (Do Not Sign Notes) Once 2nd visit, confirm as on panel. Complete summary page, start a flow sheet and set up reminders for future visits

Using Last Year’s Charts Okay to build on existing chart from last year if your longitudinal preceptor had student last year Talk to 4th year student Figure out if same patient Tell IT name on chart and get chart imported We will allow you to use a chart created last year on a patient or patients created by a student last year. This will require that you find out if your preceptor had a student last year, then contacting and talking to that 4th year student to see if any of their patients were good ones to select for your panel, (they were reliable about coming in to see the student during their half day in clinic). Try to do this in July, because we need to archive the old patients from last year. You will need to find out what the patient name was, like B. Smith, and let us know so we can import that chart into your laptop SOAPware installation. Then you can change the name to fit our scheme, with your last name, etc. [ICDs: The list of longitudinal faculty and students by campus from last year and this year is posted under the SOAPware intranet site in the Support Staff Documents folder. It is called 2007-2008_2008-2009_longitudinal.xls]

Build Chart on Panel over Year Use during visit Encounter notes for each visit Summary Complete Problems List with ICD-9 code Medications list (justification) Family history, social history, allergies, etc. Reminder system with pertinent items Flow Sheet for at least one chronic diagnosis

Timeline Upload monthly, by the 1stday of each month starting in September patients definitely in Panel of 6 (2nd visit) In future months, email Informatics Curriculum Director (ICD) with what has changed since last month, and any situations with which you might need advice provided monthly Feedback to you on your documentation will be provided monthly A report is generated of all student entries and provided to your ICD and Dr. Harrison each month Uploading is mandatory. Failure to upload monthly will require a meeting with your ICD. Any computer problems or other extenuating circumstances need to be reported to your ICD promptly. Repeated failure to upload is a professionalism issue.

Upload Patients to Intranet Zip File SOAPware Intranet Site Export Patient Charts To Desktop Student Laptop Upload Zip file to SOAPware Intranet Site IT personnel will upload to SOAPware Server Installation Informatics Curriculum Director will monitor and give you feedback

Suggestions for Success Negotiate with longitudinal faculty which patients would be most appropriate for you to follow over the year Get to clinic early, then spend time reviewing charts prior to seeing patients Walk patients to appointment desk to help make another appointment to see you If you get to see one of your 6 patients, try to take part of morning to finish documenting in SOAPware Not responsible for documenting in faculty EMR on panel patients (try not to duplicate work)

SOAPware Instructions Running SOAPware Creating a Chart Entering Vital Signs Writing an Encounter Note Completing Summary Page At this point, switch to SOAPware and go thru instruction for each of these using the sample patient data in the training materials.

Items in Reminder System Health Maintenance items age and gender appropriate general (USPSTF) Considerations like past medical history (PMH), family history (FH), social history (SH) Disease specific items based on that patient’s chronic condition general stage of progression of disease medications the patient is taking co-morbid conditions  

How Often to Perform Sample: How often should a patient with hypertension have their BP checked? Combination of clinical judgment and guidelines and recommendations

Sources for Guidelines Health Maintenance ePSS (USPSTF) on PDA or online Disease Specific ACP PIER online only – see Follow-Up Essential Evidence+ Guidelines, which are linked to… National Guidelines Clearinghouse guidelines.gov Links on Library Website under Clinical Resources Informatics Web Site, Clinical Information Management, Clinical Resources

Practice Exercise Using Reminder System Form decide what items need to be done on the case provided We will use the page at the end of the Chart Transition Form to determine what items need to be included in our test patient’s reminder system, the frequency these should be performed.

Flow Sheets Purpose is to view in visual format to discern tendencies over time Items to be included vital signs lab values Medications with current doses clinical observations

SOAPware Instructions Setting up Reminders Using a Flow Sheet

Grading Quality and timeliness of patient documentation will be considered in recommendation for Honors in D3

For Help with SOAPware Instructions on SOAPware Intranet site, link on main Intranet Page Questions or problems with SOAPware, contact me via email Technical problems, your IT person