Transcript Using an EMR to Manage Patients with Chronic Disease

Using an EMR to Manage
Patients with Chronic Disease
Doctoring 3 Longitudinal, 2009-2010
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Goals of Morning Activities
Use technology with patients effectively
 Use an EMR to help manage chronic
conditions
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Problem List
Medications List
Vital signs flow sheet
Chronic Disease flow sheets
Reminder System
Incorporate evidence based guidelines in management
decisions
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Using Technology with Patients
What is wrong with this encounter?
Click on image to bring up video from YouTube
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CLC Checklist for Good Patient Communication
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Introduce self
Establish rapport
Open ended questions at
beginning
Maintain good eye contact
Be supportive and
concerned
Used transitional
statements
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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?
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Possible Adverse Effects
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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
What specific actions can we take
to avoid these situations?
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Arranging the Exam Room
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Which of these is best? Why?
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5 Tips for Using EMR
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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
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Using Tablet Mode
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Advantages? Disadvantages?
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Ideas for Sharing EMR with Patient
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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
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Major Points for EMR Communication
Introduced self BEFORE turning to computer
2. Introduced the computer into the
doctor/patient/computer triad
3. If sitting, adjust the chair to be at eye level with
patient and so the patient can see screen
4. Patient should be alerted verbally when turning
attention from patient to the computer for
longer periods of typing
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D3 Longitudinal Orientation
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Objectives for Remainder of Session
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Understand student expectations
Provide mechanism to achieve expectations
Use SOAPware to
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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
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Resources for Activity
Intranet
 SOAPware icon on right
 All training materials including
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◦ Basic Instructions
◦ Data Collection forms
◦ Instructions for uploading patients
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SOAPware on student laptops
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Article reviewing EMRs
http://www.medscape.com/viewarticle/570380
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Why are we using SOAPware?
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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
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SOAPware Modules Not Included/Used
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3rd party software NOT free includes
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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
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◦ Reduce typing, speed productivity
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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
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Create Chart in SOAPware
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HIPAA requirements
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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
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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.
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◦ Complete summary page, start a flow sheet
and set up reminders for future visits
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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
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Build Chart on Panel over Year
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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
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Timeline
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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
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Upload Patients to Intranet
Zip File
Student Laptop
Export
Patient Charts
To Desktop
SOAPware
Intranet Site
Upload Zip
file to
SOAPware
Intranet Site
• IT personnel will upload to SOAPware
Server Installation
• Informatics Curriculum Director will
monitor and give you feedback
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Suggestions for Success
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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)
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SOAPware Instructions
Running SOAPware
Creating a Chart
Entering Vital Signs
Writing an Encounter Note
Completing Summary Page
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Items in Reminder System
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Health Maintenance items
◦ age and gender appropriate general (USPSTF)
◦ Considerations like past medical history
(PMH), family history (FH), social history (SH)
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Disease specific items
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based on that patient’s chronic condition
general stage of progression of disease
medications the patient is taking
co-morbid conditions
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How Often to Perform
Sample: How often should a patient with
hypertension have their BP checked?
 Combination of clinical judgment and
guidelines and recommendations
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Sources for Guidelines
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Health Maintenance
 ePSS (USPSTF) on PDA or online
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Disease Specific
 ACP PIER online only – see Follow-Up
 Essential Evidence+ Guidelines, which are linked
to…
 National Guidelines Clearinghouse guidelines.gov
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Links on Library Website under Clinical
Resources
 Informatics Web Site, Clinical Information
Management, Clinical Resources
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Practice Exercise
Using Reminder System Form
decide what items need to be done on
the case provided
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Flow Sheets
Purpose is to view in visual format to
discern tendencies over time
 Items to be included
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vital signs
lab values
Medications with current doses
clinical observations
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SOAPware Instructions
Setting up Reminders
Using a Flow Sheet
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Grading
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Quality and timeliness of patient
documentation will be considered in
recommendation for Honors in D3
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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
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