Transcript Advanced Template Design - Sammamish Diabetes and Lipid

Advanced Template Design
By
Donald T. Stewart, MD
[email protected]
July 2006
Me and You
• Me: Family Practice, sole proprietor x 20 years,
now employee
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Paper “templates” for visit notes since 1983
Disease Management templates since 1993
EMR templates since 1997
Practice Partner templates since 2001
• You:
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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
– Email me ([email protected]) 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:
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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
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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 8.2.1
• Please refer to the Handout for details on
this.
Project 1—Improving the DropDown 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, email
request to [email protected]