VeHU

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VeHU 164Using CPRS Tools to Manage Chronic
Diseases
Charles S. Demosthenes, MD Atlanta VAMC, Smyrna
CBOC Jessica Murphy, MD South Texas VHCS
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• Please write down questions on 3x5 cards, and
  hand them to assistants in the room.
• Questions will be answered at the end of the
  presentation.

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Objectives

• Identify tools available in CPRS to aid in the
  management of chronic diseases
• Discuss how they can be applied to managing
  diseases
• Demonstrate practical examples
• Discuss implementation methods

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Practice Characteristics

• Primary Care in CBOC setting (no residents)
• Team Leader
• Panel has been 1175-1305 over past yr
• 195 patients over 80
• 293 patients age 70-80 (488 over 70)
• 140 patients under age 50
• Approximately 1/3 are diabetic
• Approximately 1/3 have elevated creatinine
• Approximately 1/3 are anemic
• 96 have had an appointment w/in past 12 mo
• 88 have had an appointment within past 7 mo

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CPRS Tools

• Problem List
• Traditional method of managing problems.
• High level view of the patient
• Variable use dependent on clinician comments can
  add rich detailed information about a problem
• Progress Notes
• Detailed view of patient status at a specific
  point in time
• Record of current status, meds, orders
• Discharge Instructions
• Medication reconciliation
• Upcoming appointments
• Referrals and other instruction

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CPRS Tools (continued)

• Patient Letters
• Informs patients of results of tests
• Closes the loop on care
• Menus can make orders easier
• Can be built to encompass common tasks
• Order sets can order multiple tests with single
  click
• Common medicines can be included.
• Clinical Reminders
• Highly specific to patient/diagnosis, assures
  certain things get done.
• Performs documentation in patients record
• Initiates orders and/or consults
• Graphs
• Excellent for seeing trends and educating patients

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Using Advanced Template Techniques to Create
Better Notes

• Follow a predefined structure/outline
• Does not need to duplicate reminders
• More complete and easy to decipher notes
• Record important information without much typing
• Avoid Charting Errors (templates containing
  things not actually done)
• Somewhat complicated to create, easy to use

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Using templates for history

• Make several disease specific templates
• Cover key elements of the history
• Allow flexibility
• Comply with documentation guidelines.
• Most of our patients are fairly complicated,
  probably require time appropriate for a 99214
  visit
• Make sure documentation matches level of care
• Let patients help you, filling out forms while
  waiting can save a great deal of time.

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Bad Example 1
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Progress note outline Chronic Dz(expanded SOAP
format)

• Chief Complaint
• Paragraph form history notes
• Outline of active chronic diseases
• PMH
• Social Hx and Family Hx
• Review of Systems
• Active meds
• Exam
• Assessment/Plan (combined)
• Orders
• Clinical reminders
• D/C instructions and medication reconciliation.
• Lab report letter is added subsequently as an
  addendum

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Diabetes is one of four templates under a chronic
disease template

• Hypertension
• Diabetes
• Coronary artery disease
• Hyperlipidemia
• This technique can be used for anything seen
  frequently, using dialog templates to allow
  inclusion and exclusion of history items as
  appropriate to the patient.

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Use Paper Forms to Collect Pertinent Information

• We use a 3 page medical history for new enrollees
  with no prior records.
• We use a one page medical history update in our
  office, that saves some significant time in the
  exam room.
• Has matching templates for charting.
• Doesnt work for all patients.

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Progress note outline (expanded SOAP format)

• Chief Complaint
• Paragraph form history notes
• Outline of active chronic diseases
• PMH
• Social History and Family History
• Review of Systems
• Active meds
• Exam
• Assessment/Plan (combined)
• Orders
• Clinical reminders
• D/C instructions and medication reconciliation.
• Lab report letter is added subsequently as an
  addendum

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New Patient History
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Progress note outline (expanded SOAP format)

• Chief Complaint
• Paragraph form history notes
• Outline of active chronic diseases
• PMH
• Social History and Family History
• Review of Systems
• Active meds
• Exam
• Assessment/Plan (combined)
• Orders
• Clinical reminders
• D/C instructions and medication reconciliation.
• Lab report letter is added subsequently as an
  addendum

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Returning Visits Update Form
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Progress note outline (expanded SOAP format)

• Chief Complaint
• Paragraph form history notes
• Outline of active chronic diseases
• PMH
• Social History and Family History
• Review of Systems
• Active meds
• Exam
• Assessment/Plan (combined)
• Orders
• Clinical reminders
• D/C instructions and medication reconciliation.
• Lab report letter is added subsequently as an
  addendum

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Simple Templates
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Progress note outline (expanded SOAP format)

• Chief Complaint
• Paragraph form history notes
• Outline of active chronic diseases
• PMH
• Social History and Family History
• Review of Systems
• Active meds
• Exam
• Assessment/Plan (combined)
• Orders
• Clinical reminders
• D/C instructions and medication reconciliation.
• Lab report letter is added subsequently as an
  addendum

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Progress note outline (expanded SOAP format)

• Chief Complaint
• Paragraph form history notes
• Outline of active chronic diseases
• PMH
• Social History and Family History
• Review of Systems
• Active meds
• Exam
• Assessment/Plan (combined)
• Orders
• Clinical reminders
• D/C instructions and medication reconciliation.
• Lab report letter is added subsequently as an
  addendum

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Simple Templates
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Progress note outline (expanded SOAP format)

• Chief Complaint
• Paragraph form history notes
• Outline of active chronic diseases
• PMH
• Social History and Family History
• Review of Systems
• Active meds
• Exam
• Assessment/Plan (combined)
• Orders
• Clinical reminders
• D/C instructions and medication reconciliation.
• Lab report letter is added subsequently as an
  addendum

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Patient Instructions

• Provide the patient a concise set of instructions
  when they leave the clinic
• Medication reconciliation with a new medication
  list.
• Other orders/expectations

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Using Template Fields
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Template Field Choices
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Complicated Templates

• Interactive
• Requires specific action to include a historical,
  exam or data element
• Avoids using a boilerplate of a standard normal
  history or exam with the intent to (hopefully)
  edit.
• Once created, easy to use, easy to add additional
  elements.

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Use Templates to

• Follow an outline specific to the disease you are
  managing
• Record a concise, readable note useful to
  yourself and others
• Improve accuracy
• Eliminate irrelevant information
• By following an outline, it is easy to review
  prior notes
• Provide good patient instructions

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Suggestions for clinicians

• Have multiple small templates to build notes and
  manage patients.
• Use dialog templates
• Use template fields to avoid typing
• Rummage around in the template editor to see what
  is available
• Work with CACs to find or create what you need.
  Be clear about what you want and how youll use
  it with attention to spacing and default
  selections.
• Use patient data objects
• If requesting one to be created, be clear about
  what you need and dont need to be included in
  the data object.

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Suggestions for Clinical Application Coordinators

• Understand what the clinician wants to
  accomplish.
• Pay attention to spacing, will template object be
  in a tabular or free text format.
• Patient data objects should include minimal
  information. Minimize unrelated dataallow the
  clinician to combine objects as appropriate to
  their need.

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Data Object Example
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Example Problem List Data Object
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A bit cleaner
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Using Menus to Aid Orders

• Try to be inclusive
• In primary care, we have a high percentage of
  visits involving DM, Htn and Hyperlipidemia, CAD,
  arthritis back pain,
• Use as much screen real estate as possible.
• Set up a table showing the menu selections
• Describe each selection for the menu builder to
  work from.

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Use a table to specify menu items
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Describe Menu Section items
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Include Medicines in Quick Orders
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Imaging and Consults
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Dr. Jessica Murphy

• Clinical Informatacist
• South Texas VHCA

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Session Overview

• Using CPRS tools within Clinical Reminders
• Customizing Consults
• Other Exciting CPRS tools
• Tools menu
• Web links
• Graphing

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Using CPRS Tools within Clinical Reminders

• Orders
• Allergies
• Meds
• Consults
• Documenting Co-Managed Care
• Use of Health Factors

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Reminder Dialog Options
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Entering Allergies from Reminder Dialog
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Documenting the allergy
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Generating a Medication Order from Reminder Dialog
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Order Generated by Reminder
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Completed Progress Note
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Using Health Factors to Document Co-Managed Care
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Using Health Factors to Document Co-Managed Care
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Getting More Information
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Getting More Information
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Clinical Maintenance
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Ordering Multiple Items From a Clinical Reminder
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Ordering Multiple Items from a Clinical Reminder
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Customizing Consults
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Customizing Consults
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Non Formulary Quick Order
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CPRS Tools

• Tools Menu
• Lab Lists
• Graphing

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Tools Menu
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Tools Menu Hyperlinks
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Pharmacy Web Page
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Link to Drug Photograph
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Customized Worksheets
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Customized Worksheets
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Customized Worksheets
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Customized Worksheets
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Graphing
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Graphing
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Conclusion

• Progress Note Templates
• Menus
• Clinical Reminders
• Tools Menu
• Graphing

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• Questions?