HandOUTforSEPTEMBER2019 HIGH PERFORMANCE TEAM DOCUMENTATION FOR OUTPATIENT CLINICAL SETTING September 2019 Handout to compliment lecture for Iowa Physician Assistant annual medical conference held in Coralville, Iowa October, 2019 Author: Gina M. Perri MD Goal: Introduce model of care that is highly functional using electronic medical record in outpatient clinical setting. Highly functional implies highly efficient team that delivers evidence based, quality, standard of care medicine in a timely manner. Emergence of Model circa 2009 How can I restructure the delivery of healthcare to make more sense in today’s world with adoption of evolving technology? 5% of clinicians across country have simultaneously developed similar model out of shear necessity Highlights of Team Based Documentation Model: 1. Improves Patient Access to Care – Benefit to patient 2. Reduces Burn Out phenomenon (Avg clinician spends 5 hrs per day typing and clicking)- benefit to Clinician 3. Increases Clinician Productivity- benefit to financial health satisfying administration Patients can get in to see their personal clinician in a timely manner “DONE BY 5” Reduces or eradicates physician burn out Clinician gets to spend the evenings doing hobbies, exercise, personal growth, professional growth, Clinician’s family gets their loved one back. 6 month Honeymoon phase after transition, then something special happens, once balance resored in life of clinician- “what more could I be doing?” Blueprint: Electronic Medical Record Outpatient Clinical Setting
Transcript
HandOUTforSEPTEMBER2019
HIGH PERFORMANCE TEAM DOCUMENTATION FOR OUTPATIENT CLINICAL SETTING September 2019
Handout to compliment lecture for Iowa Physician Assistant annual medical conference held in Coralville, Iowa October, 2019
Author: Gina M. Perri MD
Goal: Introduce model of care that is highly functional using electronic medical record in outpatient clinical setting. Highly functional implies highly efficient team that delivers evidence based, quality, standard of care medicine in a timely manner.
Emergence of Model circa 2009 How can I restructure the delivery of healthcare to make more sense in today’s world with adoption of evolving technology? 5% of clinicians across country have simultaneously developed similar model out of shear necessity
Highlights of Team Based Documentation Model: 1. Improves Patient Access to Care – Benefit to patient 2. Reduces Burn Out phenomenon (Avg clinician spends 5 hrs per day typing and clicking)- benefit to Clinician
3. Increases Clinician Productivity- benefit to financial health satisfying administration Patients can get in to see their personal clinician in a timely manner
“DONE BY 5”
Reduces or eradicates physician burn out Clinician gets to spend the evenings doing hobbies, exercise, personal growth, professional growth, Clinician’s family gets their loved one back.
6 month Honeymoon phase after transition, then something special happens, once balance resored in life of clinician- “what more could I be doing?”
Blueprint: Electronic Medical Record Outpatient Clinical Setting
Healthcare Delivery Team
Proper Attitude
Healthcare Delivery Team Clinician (Physician Assistant, MD,DO,ARNP)
Clinical Support Staff Clerical staff
Clinical Support Staff: 1. Clinical Scribe emr Navigator (CSeN): licensed or certified (RN LPN MA) 2. optional RN phone triage nurse but runs smoother
Clerical Staff
1. Receptionist/appointment scheduling/ 2. Scheduler/coordinator for diagnostic tests/referrals
Each Clinician needs their own team of Clinical Scribe emr Nagivators, but the other positions can be shared amongst multiple Clinicians
Time frame to implement Team Based Documentation: Preimplementation: decision to move towards Team Based to G0 Live : 2 months to 6 months Implementaion: 2 weeks with 8-12 week ramp up
Clinician Role: Leads Team Develops content of tolls for documentation
Works with administration to get approval
Overseas training, implementation, execution “I want to do this…..Here’s why…..and Here’s how”
Getting Administrative Buy-In: Speak the language: $$$$$$$$ Increased production
Increased patient access to care with Tsunami Affect: the more patients Clinician sees, the more utilization of the entire health care system. Not intended for unnecessary over-use of resources, but will naturally result in proper expansion.
Better patient experience as Clinician can focus on patient and not all of the usual navigation duties in emr.
Realistic Production Volumes- dependent on staffing and exam room availability:
Formula: Volume of patients per day Number of CSeN Number of Exam Rooms
20 2 2
30 3 3 40 4 4
50 5 5
Financial Pro Forma: run various Pro Forma’s
Avg: PA can do 20 patients per day Avg: MD/DO can do 20-30
More motivated can do 30-40
Extremely motivated 40+
How Do I get More Clinical Staff in era of shortages? Answer to this start by asking what is the root cause of this phenom?
Everything boils down to effort exerted per time unit and compensation. Who wants to work in an environment of continuous burn-out with no end in site?
Do you want to work with a clinician and organization that is recognizing the problem and actively making changes? Look at Pro Forma speculations and decide how much more your can pay the MA,LPN, RN per hour when having them go in to the role. $1 -$2 or more per hour motivates people.
High Burn Out leads to high turn over.
Creating a culture of reasonable work day and workload along with adoption of fresh exciting innovative processes, fosters loyalty. Consider use of CNA’s who are more plentiful- identify roles they can do and use them in that capacity to offset workload of MA/RN/LPN to maximize their efficiency. They can do data entry, and with training diagnostic orders.
Role of Clinician in Team Documentation Model: Review your daily appointment schedule
Point of Care live patients: 1. Listen to CSeN briefly highlight patient to you: why they are here and any issues or med refills or
needing diagnostic results reviewed, new problems, status of chronic problems. 2. Enter exam room with CSeN 3. Ask directed questions to patient to elicit any other info not obtained by CSeN
4. Examine patient 5. Convey exam findings to CSeN to document positive exam findings in real time (“lung exam:
rales heard right Lower Lobe” “neck exam: limited ROM flexion”
6. Discuss diagnostic tests 7. State assessment(s) and plans (medications, labs, imaging, referrals, lifestyle recommendations,
other advice) 8. Counsel patient of various issues 9. Perform any procedures and CSeN uses templates to document
10. Supplemental dictation for matters deem appropriate (e.g. the CSeN should be able to capture in the Assessment and Plan “Abdominal Pain new and requires further evaluation” and then have all the diagnostics and follow ups and treatments in the note, but you may wish to dictate a discussion such as what you are considering like most likely gastritis but considering pancreatitis , biliary tract dis etc
Tip: most EMRs have apps for mobile devices like iPAD . If so use these devices in exam rooms instead of bulky laptops. They are often easier to navigate and can view vitals, problem lists, medications, vaccinations, diagnostic tests, consults etc. Clinician does not need to do any data entry in exam room.
Work outside of point of care = Indirect work = administrative work
During time you are not in exam room: tend to lab results, phone questions, review correspondence.
This could be an entire lecture in itself. Basically, any work you do should be associated with an office visit. Make the work or your day have economic value. Examples, all medications refills should be done at office visit and give enough until you want to see patient again to minimize incoming requests for refills. Do not refill controlled substances over the phone. Do not fill out patient or employer requested forms, jury duty excuses, disability, FMLA etc without an associated office visit. Do not do engage in free telephone medicine. If a patient has a need or a symptom, they should be seen in the office- this is good medical practice in general as everything has to be documented. (Hospice care would be the exception).
Time commitment for Clinician, once team is trained
30 pts or less per day: 8-5 pm
40 pts per day: 8-6 pm (pts done by 5 pm) 50 pts per day: 8-7:30 pm (pts done by 5 pm)
Role of support staff: RN phone triage nurse: self explanatory
Clinical Scribe emr Navigators: Gets patient from exam room
Gets or verifies/documents the following (order should be constant but can vary depending on clinic flow and emr) Vitals
Chief Complaint
Allergies Medications
Quality Measures Vaccinations
Templated HPI
Templated Past Medical/Surgical/Social/Family history Templated ROS
Anticipates Templated Exam appropriate for visit Gets Clinician and highlights visit to Clinician
Goes back in exam room with Clinician and navigates visit
Adds any additional info in HPI or medical history gleaned while clinician in exam room Adjusts physical exam template as directed by Clinician for positive findings
Builds Assessment and Plan- uses macros, Smart Phases, Autotexts etc to assist documentation Lists Clinician directed diagnoses/condition(s) and associates therapeutic plan or diagnostics work up with appropriate diagnosis or condition.
Orders Clinician directed medications.
Follow up Navigates wrapping up visit /follow up/ reviews plans of care/ explains where to go for tests or who will be contacting them with regard to additional diagnostic tests or referrals.
In between patients, this person tends to indirect work such as call backs, in basket
Development/ Teaching and Implementation of Clinical Scribe emr Navigators Clinician makes all documentation tools Content for HPI templates (comprehensive set) Content for Past Medical History/Surgical History
Content for Social History – does not need to be comprehensive- focus on actionable or quality measure items Content for other Quality Measures or Screenings mandated by Medicare or Individual Healthcare system such as Falling Risk, PQ9, PQ2, etc…. Content for Exam templates Content for macros for assessment and plans
Other helpful reference items to create for staff: Medication lists List of diagnostics tests List of conditions you see and diagnostics tests or referrals that correspond to them Preventive measures Vaccinations List of community resources
Lists: Medications Diagnostic tests Templates for History of Present Illness, ROS, Physical Exam Assessment and Plan documentation tools: Smart Pharses, Autotexts , Macros etc
Length of time to build tools in EMR: Length of time to get admin approval : 2 weeks-6 months Length of time to identify or hire staff: 2 weeks -6 months Length of time to develop documentation tools for emr : 2 weeks to 2 months Length of time to create reference manual for scribe:2 weeks to 2 months Length of time to teach scribes: 2 days of didactics Length of time to implement: 2 weeks- slow pace one per hour suggested Length of tiem for ramp up to speed in 8-12 weeks.
Strategy: Make decision to move toward team documentation Visit or talk with Clinicians who have transitioned
Get administrative approval Create documentation tools and training materials Set GO LIVE date and reduction of schedule for two weeks and then gradually ramp up Make adjustments/tweak processes
Enjoy! Tips: Do not rush Scribes!!!!! Use iPad or other mobile device for viewing data in exam room. Use voice recognition for any supplemental dictation Create or “borrow” documentation tools that fit your practice. Define your practice as a Product so you know what contents to create for HPI, EXAMS, Assessement/Plans TRAP: Impatient Clinician Rushes Scribe and decides to do it for themselves- will lead to failure and underdevelopment of team. It is critical that the CSeN is given opportunity to develop into the role.
Future developments: Artificial Intelligence Using artificial Intelligence for augmenting burden of documentation E.G. Current developers are using AI to create History of Present Illness Templates available and pushed out to patient on their
smart phones: this way the patient can start populating the questions prior to the office visit. The Scribe would still have to verify/edit the HPI. AI intelligence to help with logistics of patients scheduling based on their needs. AI to assist in recommended work up based on HPI gathered information. AI to coordinate the appropriate tests for appropriate conditions, and assist in decision making. AI will never replace a clinician’s judgment: for example, a patient could input AI extracted symptom complex but would then only be able to give a list of numerous possibilities of diagnoses, which would likely be extensive. A clinician would still be needed to guide what is a reasonable course of action.
Examples of Scribe Teaching Tools: Scribe Comprehensive Medication List: (Customize to your practice)
Antihypertensives and Cardiac Meds: Diuretics:
e.g. Hydrochlorothiazide “HCTZ” or in combo as “HCT”
Most common sig: 1 po qday
12.5 mg capsule (Microzide) 12.5 mg tab
25 mg
Potassium
ACEi Combo ACEi/HCT
ARB
ComboARB/HCT Beta Blockers
Calcium Channel Blockers Alpha Blockers
Anticoagulants
Statins
Antimicrobials: Penicillins
Lincosamides Macrolides
Cephalosporins Fluorquinolones
Sulfa
Tetracyclines Aminoglycosides
Misc: Metranidazole
Ripampin
Mupirocin
Antifungals (oral and topical)
Antivirals
Pulmonary Various inhalers
Prednisone
Controlled Substances Narcotic/Opiates Stimulants
Benzodiazepines
Non-opiate analgesics: Topical NSAIDS
Oral NSAIDS Topical lidocaine
COX-2 inhibitors
Muscle relaxers Antidepressants used for chronic pain
HTN: yearly CBC CMP TSH LIPIDS Baseline EKG at time of diagnosis
(optional Urine dip or Urine for Protein/Cr, or microalbumin)
Low Back Pain LS spine Xray
CBC
CMP or BMP
UA dip and micro ( Cult and Sens) MRI LS spine ( generally without contrast)
JOINT/Muscle pain
CBC CMP TSH
ANA RF ESR CRP CK – MM
SPEP UPEP Nuclear Bone Scan (not DEXA Bone Density)
25 Hydroxy Vit D Lyme Titer
Various Plain Xrays
Chest Pain CBC CMP TSH LIPIDS Troponin
BNP (Brain Natriuretic Peptide)
D Dimer H.Pylori Stool Ag
CXR PA and Lat Chest CT P.E. Protocol
ECG
Echocardiogram (TTE transthoracic echo- most common) vs TEE (Transesophageal echo for stroke work –up) Cardiac Stress Stress 9Cardiolyte, Dobutamine, Treadmill)
Cardiology Referral
GI referral RUQ US
HIDA
Palpitations:
CBC CMP TSH ECG
Echo (TTE transthoracic)
Holter Monitor 24 Hr Holter King of Hearts Monitor- patient activated one month
Women: HCG, GC and Chlamydia, Wet Prep ESR, CRP-sensitive, Transvaginal Pelvic US
Flank Pain CBC with diff, CMP TSH
UA dip and micro, C and S
Abd CT renal protocol without contrast; without contrast rule out stone
Fever UA dip and micro, C and S
CBC with Diff, CMP , TSH
Rapid Strep Test Influenza
Lyme Titer
TB skin test MONO
HIV1/HIV2- 4th gen Respiratory Panel
CXR pa and lat
Chest CT Abd CT
Abdominal pelvic CT ANA RF ESR CRP Uric Acid
Echocardiogram rule out vegetations
Infectious disease consult
Fatigue
CBC with diff CMP TSH ANA ESR CRP RF
UA dip Micro C and S MONO
CMV panel
EBV panel Hep C Ab
Hep B Surface Ag HIV1/2
ECG
Echo Polysomnogram
PHQ 9 (Depression screen questionnaire)
Others: Anemia
CKD STI –asymptomatic
STI- symptomatic female STI- symptomatic male
Osteoporosis
Chronic diarrhea Dysphagia
Hot Flushes Hyponatremia
Stroke
Tingling/paresthesia LE edema
Unexplained weight loss
Scribe Documentation Tools Templates macros smart phrases autotexts etc… Should follow standards for documentation and billing requirements and standards of care History of Present Illness Templates:
Develop a comprehensive set to handle acute problems, chronic problems, wellness visits, preop visit.
Versatile enough to handle any new problem; Any new pain, multiple chronic illnesses
Try to build templates in systematic fashion:
List issue Onset: abrupt/gradual
Problem is old/new
Problem began x days /weeks/months/years ago Severity: mild moderate severe
Problem is constant/intermittent
Course over time is improving/worsening/same
Problem interferes/does not interfere with activities Alleviating factors
Aggravating factors Associated symptoms
Example: Any New Pain:
Pain began: x hours /days/ weeks/ months/ years ago Location: ____________
Onset: abrupt / gradual Severity: mild moderate severe
Occurred in context of _________/injury /randomly/work related
Radiates to ______/does not radiate Course over time is improving, worsening, same
GI: Nausea vomiting diarrhea blood in stool constipation Skin: no clubbing cyanosis or rash
Neuro: change in speech vision
Documentation Tools for Physical Exam: I use a Bare Bones hands off exam when just counseling patients
Bare Bones Template :
Gen: Pleasant Cooperative, No Acute Distress, Well Developed, Well nourished HEENT: PER Conjunctiva non-injected,
Pulm: normal respiratory effort
CV: no edema Neuro: alert, speech clear, gait normal
Then I use site specific if exam added on to Bare Bones if I examine other body parts: For example:
Bare Bones + Shoulder
Bare Bones + Low Back Bare Bones + Cardiopulm
Bare Bones + Neuro
Or We have a URI EXAM that is useful for multiple different visit types and includes:
General: Pleasant Cooperative, No Acute Distress Well Developed, Well Nourished HEENT: Perrl EOMI Fundi benign TMs normal OP without lesions, neck supple without adenopathy, no thyromegaly
Pulm: CTA symmetrical expansion Cardiac: RRR without murmur
Abdomen: BS present soft nondistended nontender , no hepatomegaly, no splenomegaly, no masses
Neuro: speech clear, alert
MS: No acute gross deformities
Skin: warm dry without clubbing cyanosis or rash
Comprehensive Exams for various ages male and female infant , children, teens, adults
Develop exams you use and perform them consistently so less editing- in other words do not do a partial shoulder exam
Our Exam Template Library has the following templates: Bare Bones
Cardiopulmonary (Pulm: CTA, CV:RRR without murmurs gallops) Diabetic foot
GU Female
GU Male Hip
Knee
Low Back Neck
Neuro Psych
Rectal
Shoulder URI (General/Head /Chest/Abd/with brief neuro, musc, skin)
Breast Preop
Comprehensive adult female
Comprehensive adult male Wellness exams for both males and females:
0-3mo
4-9 mo 12-15 mo
18 mo – 3 yo 4-7 yo
8-21 yo (specify tanner stage live)
Documentation Tools for Assessment and Plan
We developed for about 80 conditions/wellness advice e.g. Tobacco dependence:
1. Cessation recommended 2. Pharmacotherapy offered 3. Behavioral Intervention ( Unity Point 319-366-xxxx) for tobacco cessation specialist 4. Quit Line 1-800-Quit NOW (1-800-784-8669) 5. Meds offered unless contraindicated:
Chantix Starter Pack then 1 mg BID, RF one yr, begine one week before quit date Bupropion XR 150 mg qd for 3 d and then 2 tabs (300 mg) qd. RF one yr. Begin 1 week prior to quit date. Not appropriate if seizure history. Nicotine replacement: 21 mg daily up to 2 mo, then 14 mg up to 2 mo then 7 mg up to 2 mo; Alternate: gum , lozenges, inhaler. Cannot smoke on nicotine products. Side effects and treatment expectations discussed
Hypertension Controlled: Labs reviewed/ordered yearly labs : cbc cmp tsh lipids. Continue same meds ***. Refills for one year/Refills not needed/medication is not needed as condition is lifestyle controlled. Follow up in office in 3 , 6 months or sooner if problems. Baseline EKG reviewed or on file/ ordered. Continue healthy lifestyle: keep sodium less than 2000 mg per day. Plant based diet or Mediterranean diet. Allow adequate sleep 7-9 hrs (consider Sleep study if concerns of Sleep Apnea and not treated or tested previously), avoid tobacco, limit alcohol to not more than one standard drink per day ( none if problem drinker. Liver disease or advised by a healthcare provider to do so), practice daily stress management technique such as Yoga, Tai Chi, Paced Breathing, Meditation, Guided Imagery. Avoid products known to elevate blood pressure such as decongestants, caffeine, NSAIDS (ibuprofen, naproxen, meloxicam, etc). Manage your weight and strive to keep at ideal body weight, waist measurement for women under 35 inches and men under 40 inches. Formal weight loss program (such as Weight Watchers, Jenny Craig, Nutrisystem etc) is recommened for those whose BMI is over 25 and unable to loose weight on their own.
Hypertension controlled (short): Continue current medications. Follow up in 6 months or sooner if problems.
Hypertension: uncontrolled: Discussed making further efforts at lifestyle. Medication adjustment is/ is not needed> Continue same medications: ***/ increase medication *** / add new medication *** and reassess in *** weeks/months. Labs ordered BMP in 2-4 weeks to monitor lytes/kidney function. Labs are reviewed and up to date. Lifestyle efforts recommended : ( same as mentioned above)
Hypertension: Blood Pressure low Medication management: continue same medications and drink 64 ounces per day/medication *** reduced to *** mg daily / Medication *** discontinued. Reassess in doctor’s office in ***days/weeks/months.
Elevation of Blood Pressure (Pts without formal dx of HTN) CBC CMP TSH LIPIDS
Follow up for Blood Pressure in 1 weeks, 2 weeks, 4 weeks.
Pillars of health Plant Based or Mediterranean Diet
Limit sodium to less than 2000 mg per day
Practice daily stress management technique Regular physical activity
Consider Polysomnogram if loud snoring, excessive daytime sleepiness, witnessed apnea
Hypercholesterolemia Pooled Cohort 10 yr CV risk calculation is ___ %. Statin is/is not recommended. Repeat lipids/ast alt in 4-6 weeks, 2 months, 3 months, 6 months, yearly
Hypercholesterolemia: uncontrolled but intolerant of statins
GOUT NEW Counseled on disease and treatment management for acute gout. Counseled on chronic daily medications used to lower uric acid and prvent gout attacks and reduce potential for joint destruction in patients with recurrent episodes. Uric acid lowering medications require periodic monitoring, yearly minimum, once the uric acid is controlled. Labs: Uric Acid and BMP or CMP. Medications used to lower uric acid and prevent attacks of gout, such as Allopurinol, are not started until the acute attack settles down after a few weeks. Once Allopurinol is begun, it is taken lifelong on a daily basis.
For acute gout attack, in no contraindications to use of NSAIDS, use NSAID type drug to control pain and inflammation (NSAID choices: indomethacin, ibuprofen, meloxicam, naproxen etc)
Avoid NSAIDS due to contraindication: on anticoagulants (Warfarin, Pradaxa, Xarelto,Eliquis), allergic to aspirin, hx of GI Bleed or Peptic Ulcer, significant Chronic Kidney disease, other ****.
Other options for acute gout attack: prednisone, colchicine discussed and prescribed.
Recommend the following measures for acute gout attack: soak body part in warm water or apply heat, elevate, rest until attack resolves.
Gout controlled/uncontrolled Uric acid level reviewed and : at goal / not at goal/ unknown and ordered new level to be drawn
Continue / increase allopurinol 100 / 200 / 300 / 400 mg total daily dose. Check uric acid level and BMP ( or CMP) yearly
Call doctor’s office if problems.
Follow up in doctor’s office yearly to reassess. For acute attacks, use NSAID (such as indomethacin, Ibuprofen, meloxicam, naproxen), or predinisone, or colchicine
NSAIDS not recommended if on anticoagulant (Warfarin, Pradaxa, Xarelto, ELiquis), Allergy to NSAIDS, History of GI bleed or Peptic Ulcer Disease, or significant Chronic Kidney Disease. Here, use prednisone, colchicine as prescribed for acute attack.
Recommended measures for acute attacks: soak body part in warm water or apply heat, elevate, rest until resolved.
