Using an EMR to Manage Patients with Chronic Disease

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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
• 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

• Introduce self
• Establish rapport
• Open ended questions at beginning
• Maintain good eye contact
• Be supportive and concerned
• Used transitional statements

• 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

• 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

• Which of these is best? Why?

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5 Tips for Using EMR

• 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

• Advantages? Disadvantages?

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Ideas for Sharing EMR with Patient

• Verify Medication List and Problem List with
  patient
• Show patient his/her vital signs, including
  weight (gain or loss)
• Graph patients 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
• Introduced the computer into the
  doctor/patient/computer triad
• If sitting, adjust the chair to be at eye level
  with patient and so the patient can see screen
• 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

• Understand student expectations
• Provide mechanism to achieve expectations
• Use SOAPware to
• 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
• Basic Instructions
• Data Collection forms
• Instructions for uploading patients
• SOAPware on student laptops

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Article reviewing EMRs http//www.medscape.com/vie
warticle/570380
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Why are we using SOAPware?

• 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

• 3rd party software NOT free includes
• Prescription writer (Epocrates database)
• Medication Interaction checker
• Evaluation and Management (EM) Coding Tools
• Billing
• Instant Medical History integration
• Device Integration EKG, Holter, Spirometry
• Electronic transfer of lab data
• Templates for Diagnosis visits
• 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

• HIPAA requirements
• 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.
• Complete summary page, start a flow sheet and set
  up reminders for future visits

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Using Last Years 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

• 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

• 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
SOAPware Intranet Site
Export Patient Charts To Desktop
Upload Zip file to SOAPware Intranet Site
Student Laptop

• IT personnel will upload to SOAPware Server
  Installation
• Informatics Curriculum Director will monitor and
  give you feedback

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Suggestions for Success

• 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

• Health Maintenance items
• age and gender appropriate general (USPSTF)
• Considerations like past medical history (PMH),
  family history (FH), social history (SH)
• Disease specific items
• based on that patients 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

• Health Maintenance
• ePSS (USPSTF) on PDA or online
• Disease Specific
• ACP PIER online only see Follow-Up
• Essential Evidence Guidelines, which are linked
  to
• National Guidelines Clearinghouse guidelines.gov
• 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
• 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

• 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