1. The Best Tool In the Box: Training Residents to Use an EMR Carl G. Morris MD MPH Kate Estlin MD Family Medicine Residency morris.cg@ghc.org April 5, 2013

2. Best Tool in the Box Outline  Introduction  Background  Curriculum  Outcomes  Discussion

3. Best Tool in the Box Introduction

4. 2 nd most powerful tool in the room Most training inadequate to lousy 2010 - Combined EMR training, clinical efficiency, and patient communication training Created longitudinal, competency-based, resident-directed curriculum

5. Best Tool in the Box Background

6. EMRs are new! EMRs are not intuitive History of frustration and unmet expectations Challenge to productivity and patient-doctor communication Limited improvement in quality and negative impact on provider satisfaction. ? Inadequate training?

7. Background GH – EPIC in 2001 2001-2010 = 4-8 hrs during orientation, yearly chairside Training provided by IT Reviewed basic function Learn via trial and error Inadequate training

8. Be Trained to Use It!! Curriculum

9. Curriculum Principles Training in a clinical context Resident focused = competency driven Integrated with clinical efficiency, team-based care, and improved patient communication Longitudinal – throughout residency

10. Curricular Components R1 training during orientation Longitudinal Q4mo training Self-administered skills assessment Integration with monthly chronic disease didactics. Integration with PCMH work

11. R1 Orientation Hypothesis – integrate with clinical skills training, improved patient communication, and clinical efficiency and residents realize the expectations of the EMR. All teaching should be in a clinical context.

12. Intern Orientation Three four hour sessions Break clinic visit into 12 steps Start with one-problem visits and move to more complex by layering skills

13. 9 Steps of the Clinic Visit 1.Log in/greet pt. 2.Turn screen to pt. 3.Set agenda/visit roadmap 4.Subjective 5.Objective

14. 9 Steps of the Clinic Visit 6.Assessment Diagnoses Orders Associate/sign Patient instructions (AVS) Followup Print AVS Secure Station

15. 9 Steps of the Clinic Visit 7. AVS to patient 8.Finish documentation Finish subj/obj Level of service 9.Next patient ….. If you close as you go, you get to eat lunch and see your loved ones………

16. Intern orientation 1.Routine one problem visit 2.Moderately complex visit 3.Telephone encounter 4.Inbox management 5.Preventive visit 6.Epic Megacode

17. Keys to Happiness – yours and the patient’s 1.Emphasize clinical efficiency Touch type Finish subj, orders, and AVS in the room AVS is your assessment/plan – do it once Close as you go Keep Inbasket clean – see it once Huddle (team) and dyad (w/ MA) efficiency

18. Keys to Happiness – yours and the patient’s 2. Emphasize patient-centered care EMR-based agenda setting/roadmap EMR-based motivational interviewing, patient activation.

19. Longitudinal Training Three-hour training sessions every 4 months for three years 18 month rotating curriculum Mixture of basic skills, EPIC updates, and self-assessed areas of deficiency

20. Longitudinal Training 6 core lectures Inbasket management Encounters Chart Review Clinic Efficiency/Quality Other skills Tools

21. Competency Assessment Tool Resident self assessment 5 minute survey Administered via New Innovations 1-2 weeks prior to training Use results to design upcoming training sessions and track progress/competency IT trainer provides feedback in 1:1 chairsides

22. Skill Not ProficientNeeds ReviewProficientMastery InBasket Create Out of Office Attach an Inbox Send Staff Message Respond to Patient Call message Send Patient Call Back Respond to Rx Auth Review CC'd Chart Review and Release Results Result Note and Routing Cosign Orders Cosign Meds Patient Secure Message

23. Skill Not Proficient Needs ReviewProficientMastery Encounters Enter LOS Utilize Progress Notes Complete Meds and Orders Enter Diagnosis Complete Pt. Instructions Create a Follow Up CC the Chart Print the AVS

24. Skill Not ProficientNeeds ReviewProficientMastery Chart Review Use Filters Save Filters Review Encounters Review Labs Create Lab Flow Sheet Review Imaging Review Procedures Review ECG Review Other Orders Review Meds Review Episodes Review Letters

25. Skill Not ProficientNeeds ReviewProficientMastery Other Activities Review and Update Allergies Review and Update History Review and Update Problem List Review and Update Health Maintenance Review and Update Immunizations Review and Update FYI's Review and Update Patient Lists Use Growth Chart Review Snapshot and Add Reports Review Demographics Review and Update Allergies Review and Update History

26. Skill Not Proficient Needs ReviewProficientMastery Tools Use SmartPhrases Create, Edit and Share SmartPhrases Embed SmartLinks Use and Embed SmartLists Use SmartTexts Use References Use SmartSets Set Up Preference Lists on the fly Set Up Preference Lists in the Workbench Edit Preference List Entries Create Letters Review Flow Sheets

27. Chronic Disease Management Integration with monthly Teaching and Interdisciplinary Care (TIC) training 13 block rotating curriculum on chronic diseases Integrate EMR skills and tool development

28. Chronic Disease Management Examples: Dot phrases Care plans Visits templates Teaching tool dot phrases Links to resources Clinic standard processes

29. PCMH Integration 6 principles Patient-centered Team-based Collaborative Accessible Coordinated by primary care/team Population/panel-based

30. PCMH Integration  Patient-centered = motivational interviewing, computer to patient  Team-based = sharing of responsibilities throughout the team, staff messages, care plans, lab results  Collaborative = e-consultation with specialty

31. PCMH Integration  Accessible = telephone visits, secure messages  Coordinated by primary care/team = chronic disease, prevention using EMR and team  Population/panel-based = work with team using EMR-based reports

32. Be Trained to Use It!! Outcomes

33. Residents like it R1s up to speed faster R2s and R3s achieve high percentage of mastery Senior residents outperforming the faculty

34. SkillR1R2R3Faculty Inbasket Create Out of Office 1.831.752.333.00 Attach an Inbox 2.331.752.003.00 Send Staff Message 3.834.00 3.50 Respond to Patient Call Message 3.333.504.003.50 Send Patient Call Back 3.002.503.673.50 Respond to Rx Auth 3.503.004.003.50 Review CC'd Chart 3.674.00 3.50 Review and Release Results 3.174.00 3.50 Result Note and Routing 2.833.754.003.50 Cosign Orders 3.833.754.003.50 Cosign Meds 3.673.754.003.50 Patient Secure Message 4.00 3.50

35. SkillR1R2R3Faculty Encounters Enter LOS 3.173.504.003.50 Utilize Progress Notes 3.50 4.003.50 Complete Meds and Orders 3.503.754.003.50 Enter Diagnosis 3.503.754.003.50 Complete Pt. Instructions 3.674.00 3.50 Create a Follow Up 3.173.504.003.50 CC the Chart 3.504.00 3.00 Print the AVS 4.00 3.50 Enter LOS 3.173.504.003.50 Utilize Progress Notes 3.50 4.003.50 Complete Meds and Orders 3.503.754.003.50 Enter Diagnosis 3.503.754.003.50

36. SkillR1R2R3Faculty Chart Review Use Filters 3.503.004.003.50 Save Filters 3.173.004.003.50 Review Encounters 3.833.504.003.50 Review Labs 3.833.254.003.50 Create Lab Flowsheet 3.332.754.003.50 Review Imaging 3.503.754.003.50 Review Procedures 3.172.753.673.50 Review ECG 3.333.754.003.50 Review Other Orders 3.003.504.003.50 Review Meds 3.173.004.003.50 Reviewed Episodes 3.00 3.50 Review Letters 3.003.253.673.50

37. SkillR1R2R3Faculty Other Activities Review and Update Allergies 2.673.003.333.50 Review and Update History 3.003.504.003.50 Review and Update Problem List 3.673.503.673.50 Review and Update Health Maintenance 2.172.003.003.50 Review and Update Immunizations 2.002.503.003.50 Review and Update FYI's 2.002.252.003.00 Review and Update Patient Lists 1.832.253.333.50 Use Growth Chart 3.003.254.003.50 Review Snapshot and Add Reports 2.832.503.003.50 Review Demographics 3.173.253.673.50 Review and Update Allergies 2.673.003.333.50 Review and Update History 3.003.504.003.50

38. SkillR1R2R3Faculty Tools Use SmartPhrases 3.173.254.003.50 Create, Edit and Share SmartPhrases 3.333.253.673.00 Embed SmartLinks 2.172.253.333.00 Use and Embed SmartLists 2.172.253.333.00 Use SmartTexts 2.332.503.333.50 Use References 3.00 3.333.00 Use SmartSets 2.832.753.333.50 Set Up Preference Lists 'on-the-fly' 2.332.503.00 Set Up Preference Lists in the Workbench 2.672.253.00 Edit Preference List Entries 2.172.253.003.50 Create Letters 3.333.004.003.50 Review Flow Sheets 3.173.003.333.50

39. SkillR1R2R3Faculty Clinical Efficiency Greet and prepare for documentation 3.333.754.003.50 Turn the screen to the patient 3.173.253.673.00 Agenda set/roadmap 2.673.003.332.50 Subj in the room 3.333.503.673.00 Order/associate as go 3.003.503.333.50 Motivational interviewing using the computer screen 1.832.253.002.50 Communicate effectively (Say it, type it, read it, share it) 2.673.003.672.50 Create AVS w/ patient 2.833.503.333.50 AVS is Assess/Plan 2.673.00 3.50 Touch typing skills 3.333.754.003.50 Close as you go 1.671.753.002.00

40. SkillR1R2R3Faculty Clinical Efficiency InBasket clean 2.672.503.002.00 Huddle efficiency 2.832.503.331.50 Dyad efficiency 2.832.503.002.00

41. Discussion

42. Make it applicable and integrated with clinical teaching EMR mastery and clinical efficiency are not natural outcomes of “practice.” Maybe more of the EMR expectations can be realized.

43. Thank you for your time! Carl G. Morris MD MPH Kate Estlin MD morris.cg@ghc.org