Advanced Template Design By Donald T. Stewart, MD July 2006

Me and You Me: Family Practice, sole proprietor x 20 years, now employee –Paper “templates” for visit notes since 1983 –Disease Management templates since 1993 –EMR templates since 1997 –Practice Partner templates since 2001 You: –Physicians? –Nurse Practitioners? –PAs? –MAs or Nurses? –Practice “Tech” people?

Resources for this Talk This Power Point presentation: –Advanced Template Design.ppt Second Power Point presentation: –Designing a Chronic Disease Template.ppt PDF Handout (a “how to” with lots of extra stuff): –Advanced Template Programming.pdf Due to a Kinko’s issue and unexpected demand for this presentation, we are short today. –Check PP web site soon, or – me for copies of all of the above

Overview Why use templates? –Speed of data entry –Structured data entry You know where to find things You don’t forget to document things You can save things for later use –The ability to “pull” data into your note

What is wrong with Templates? One size does not fit all Needs for chronic disease management quite different from needs for urgent care Easy to be fraudulent Excessive length of notes “Cook-Book Medicine” The patient’s story is the most important diagnostic tool, and templates tend to depersonalize it.

Urgent Care Templates Goal is to get paid and document what you did. Speed of entry a priority Chronic disease management NOT an issue.

Chronic Care Templates: Subjective These templates should provide a summary of the chronic issues you are addressing, including –Past history of the problem –Current status of symptoms, disease activity markers, quality of care markers –Past and current lab values that matter –Patient Self-Management Goals –Other related and important issues

Chronic Care Templates: Objective Past pertinent physical findings should be visible when the patient is being examined Vital signs that are not to goal should be flagged The template should remind the provider to do and document the necessary elements of the exam

Chronic Care Templates: Assessment The template should prompt the provider to consider all appropriate parameters It should show the important data so the provider does not have to scroll back through the note. It should be easy to understand

Chronic Care Templates: Plan Should document treatment changes Follow-up plans Counseling activities –What was said –How much time was spent Labs, consultations, and procedures ordered

Acute Care Templates in the Primary Care Setting Should be –Quick to fill out –Uncomplicated Should document the visit adequately for reimbursement Should remind the provider of other chronic conditions or health maintenance issues that might need to be addressed

Primary Care Templates Both Acute or Urgent Care and Chronic Care have to be served by the same template You have to be able to address multiple issues in a given visit, both acute and chronic. Essentially, you need a Super Template, as developed by Greg Omura, MD, or you need a flexible templating system as developed by Rita Hanson, MD. Both of these systems are available for sale by their authors.

History Section Templates Past Medical History Family History Social History How you set these up takes special consideration, since this is a place where you can store important data to be imported into your notes

Past Medical History Surgeries: Approximate Date, perhaps the location, perhaps who the surgeon was, complications Medical Hospitalizations: Date, location, outcome, who the physicians were, significant procedures or tests done Psychiatric or Substance-related treatment Transfusions Significant past medical illnesses or conditions Significant environmental exposures

Past Medical History Uses This is a great place to enter, for example, the details of a cardiac cath or bypass surgery that will be important in the patient’s future management. It might be a great place to put a paragraph that updates the status of a patient with Crohn’s disease or RA.

Past Medical History Uses The point is that this section can be pulled into your notes any time you want, can be as large as you want, and can be formatted however you like. You should update it regularly and be sure to include the date of last update

Family History This can be a tremendous practice-builder and patient relationship builder for anyone in primary care. Lots of important social history included here. Important to include: –Date updated –Approximate ages of family members or age at death –Significant medical problems and health status –Names of children (tremendously helpful in primary care), where they live, and what they do

Family History Additional Information Status of parents, if elderly, quite important – where they live, who checks on them, what responsibilities the patient has for their care. Number of grandchildren Which siblings live close, and which ones are far away.

Social History: What makes the patient unique as a person Where were they born? Where did they grow up? Where do they live, and for how long? Who do they live with? How far did they go in school? What is their family and marital status? What is their occupation? What do they do for fun? What are their goals? (retire, move, etc?) What unusual stresses are they experiencing?

Let’s create a Primary Care Template We will start by modifying the SOAP: Single or Multi-Problem Template that ships with Please refer to the Handout for details on this.

Project 1—Improving the Drop- Down Subjective Menu— What to do when the patient has another problem?

The Solution Recursive Quick Text – expands to include itself, so it can be clicked again

Recursive Subjective List

What it Looks Like

If you click “ *S Chronic ” you get this menu

If you click “ *Subjectives “ you get this menu

“ S- “ expands to:

The other choice expands to Cascading Quick Text ordered by Organ System

The Canned “Abdominal Pain” choice under the “S-” menu:

Project 2 – Cleaning up Patient Data The patient histories (PMH, SH, FH) and Medications and Allergies quick texts make the template seem cluttered We will create a drop-down menu for these, and add some functionality

This is what you get if you chose “BMP” off the Lab Results Menu

Conditional Logic for the Exam

The Handout for this Talk We are now up to page 3 of the 12 page Power Point handout for this talk. The rest of the handout discusses such issues as –Making quick text “Subjective Templates” for chronic disease management –Making your templates “Disease Aware” –Saving physical findings as lab values In the interest of saving time for questions, I will now present some additional concepts

Messaging Templates Messaging templates are a new feature in Practice Partner 8.x which offer the opportunity to greatly improve workflow By pulling patient information into the message itself, you are spared the time wasted by opening the chart and looking for things like the patient’s Date of Birth, Phone Number, Recent Lab Values, Medication List, Allergies, etc

Messaging Templates (2) In a given messaging document, you and your co-workers may need to use several different templates. This is because unexpanded Quick Text in the template will disappear each time the message is sent to someone.

Messaging Templates (3) For example, the receptionist or medical assistant may start with a template that pulls in the basic information and request The provider might bring in a template with responses, questions, and orders The MA or Nurse might bring in another template to document how the orders were accomplished

Rx Refill Template For Rx refills, a typical workflow would have the receptionist taking the call and starting a template, which is sent to the MA. The MA would check the request against protocol, and either handle it, or forward it to the Provider. The Provider would review the request, and either ask for more information or make a decision, forwarding it back to the MA

Rx Refill Template (2) The MA would then either get the additional information requested, or would call or fax in the provider’s response to the pharmacy and to the patient The MA would then save the message as documentation of the transaction

You get to the Template Menu from “Template” in Message Editor

The person who starts the note sees this

When this goes to the Provider, a new template is added

After the Provider has given orders, the MA adds a new template

Thank You for Coming Questions, Demonstrations, Examples? For early copies of this presentation, request to