1. Templates for Chronic Disease Management Donald T. Stewart, MD Evergreen Medical Group September 1, 2006

2. Agenda Health Maintenance Items in Templates HM Pitfalls The History Sections of the Chart What about Habits? Family History Saved as Lab Values Cardiovascular Dataset Chronic Disease Datasets Using the Problem List Effectively Questions and Examples

3. Health Maintenance You can set up templates based on age/sex, problems, Rx, or protocol. Practice Partner will automatically offer the templates when you enter a new problem, add a medication, or choose a protocol template. You update Health Maintenance by Dot Codes in a note, a note title that is a HM Name, or importing lab data that are HM Names.

4. Health Maintenance Active Reminders

5. How to Remind Providers of HM? HM Window when chart opened? (“Active Reminder”) –Probably helpful for MAs, Phone Triage or Schedulers –Not very helpful and annoying to providers Easy to click past Easy to forget the details at the time you need to remember them

6. How to Remind Providers of HM? Put HM needed in the note template. Put it under “Plan” which is where the provider needs to see it when the provider needs to see it Make it easy to disappear with either a > after the line (automatically disappears) or a > after the line (click to make it disappear)

7. Put the Reminder in the “Plan” Section of the note

8. *InsertHMDue Quick Text

9. HM Pitfalls Definition of Item: –It is important to be very specific about the definition of your HM items. For example, what is a “Diabetic Foot Exam?” DP and PT pulse palpation? Vibration Sense or Monofilament exam? Foot inspection? All of above? How will you document it?

10. HM Pitfalls Multiple names for lab tests LDL CHOLESTEROL and VAP LDL CHOLESTEROL the same? MICROALBUMIN,UR and MICROALBUMIN/CREATININE, and what about 24-HOUR URINARY PROTEIN? These problems can be fixed by entering synonyms, and updating appropriate cross-reference files.

11. HM Pitfalls Procedures done elsewhere What is a Diabetic Eye Exam? Who can do it? What kind of documentation is required? –Patient’s word? –Note from specialist? »Do you scan the note in, hand-enter into HM, or use dot codes in a note? Perhaps dot-codes on a scanned note?

12. 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

13. 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

14. 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.

15. 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

18. 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

19. 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.

22. 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?

25. What About Habits? Habits (Alcohol, Tobacco, Diet, Exercise) are often considered part of “Social History,” but are most easily updated in templates if saved as lab values. It is easy to make a Quick Text that brings the habits into the note, and allows updating. «*HabitEntr»

26. Habit Entry: Before Data

27. Habit Entry: When First Entered

28. Habit Entry: After Saving

29. Habit Entry: On the Next Note

30. Habit Entry: Editing Next Note

31. Habit Entry: New Note Saved

32. To View or Enter in Lab Table

33. Family History as Lab Data The Family History section of the chart is a great place to put narrative data, but it is not easily searchable, and doesn’t allow flexibility in template design for specific conditions. Entering specific conditions you care about as lab data will solve these problems.

34. What FH Items to Save as Lab? Type II Diabetes ASCVD Breast CA Colon CA Melanoma Osteoporosis Ovarian CA Prostate CA Depression Substance Abuse Asthma Other items depending on your interest and what templates you might want to design

35. When to Update FH Lab Values? In a CPX Template –Especially the first time you do the CPX In a Lab Table –Could be done by MA In a Problem Template or Quick Text –When you need it, e.g.: FH ASCVD in a Chest Pain Template

36. Updating in a CPX Template

37. Updating in a Lab Table

38. Updating in a Problem Template

39. CV Dataset (Lab Values) Very useful since this is what most of us die of. Probably should be pulled into templates for Chronic Disease Management like: ASCVD, AODM, Hypertension, Hyperlipidemia, Metabolic Syndrome Also pulled into acute templates like: Chest Pain, TIA, CVA

40. Cardiovascular Dataset Cardiologist Coronary Calcium StressTestDate AngiogramDate EchodardiogramDate SPECT Scan EjectionFraction Has CHF? Carotid US Date AAA Screen Type AAA Screen Date Abdominal US Date Has ASCVD? –PH MI? –PH Stent? –PH CABG?

41. Diabetes Dataset DiabetesDxDate DiabetesEduDate Endocrinologist Does Glucose Test? Last FBS Checks BP? HomeBPReadings DiabetesConcerns LastEyeExam Ophthalmologist Optometrist LastFootExam Takes Aspirin? SelfManagementGoal SelfManageSpecific SelfManageTime

42. Diabetes ROS HypoglycemicEpisod LowerExtrPains LowerExtrNumbness Polyuria Polydipsia Blurred Vision Erectile Dysfunction

43. Diabetes Exam Carotid Bruits Carotid Scars CABAG Scars Pacemaker Scars Foot Pulses Monofilament Exam / Vibration Sense

44. AF Dataset Cardiovascular Dataset AF Dx Date Last AF Date TypeAnticoagulation Rate Control Meds –Digoxin –Beta blockers –CCBs

45. CHF Dataset Cardiovascular Dataset CHF Dx Date CHF Cause CHF Episode Date CHF Episode Weight Last Visit Weight Meds: –ACEI / ARB –Beta Blockers –Spironolactone

46. Asthma Dataset RescueInhalerFrequency SteroidInhalerFrequency HasHomeNebulizer? Last Spirometry Date Last Spirometry Results AsthmaSxFrequency AsthmaSxSeverity

47. Using the Problem List Effectively Keeping the Major Problem List updated: –Allows for automatic HM protocol updating –Makes it easier to create a helpful Progress Note –Can help you keep track of clinical information more easily

48. Problem List in Version 8.2.2

49. Problem List at Beginning of Note

50. New Problem List Module in v.9 Besides Major Problems, Other Problems, Diagnoses and Procedures, new sections include: Risks and Hospitalizations Problems can be listed in outline form Active/Inactive, most recent date, problem life cycle, related to, larger note section, Change order problems are listed

51. Problem List in Version 9.x