Defense Health Agency Documentation Motivation for Providers Using AHLTA 3.3.8 Defense Health...

Defense Health Agency

Documentation Motivation for Providers Using AHLTA 3.3.8

Defense Health Clinical SystemsElectronic Health Record Core Program Management Office

Agenda

∎ Purpose∎ Understand providers as people∎ Understand goals of patient care documentation

from a provider perspective∎ Patient Medical Summary Documentation∎ Patient Encounter Note Documentation∎ ICD Coding∎ E&M Coding∎ Summary

Defense Health Clinical Systems 2

Purpose

∎ Educate audience on provider priorities and their impact on patient documentation

∎ Educate audience on historical documentation capability and limitations of AHLTA

∎ Educate audience on documentation enhancements in AHLTA 3.3.7 and 3.3.8

∎ Educate audience on capabilities and limitations of AHLTA for automatic billing coding



Providersas

People

Providers as People

∎ Providers… Chose medicine to help people Conditioned to be confident (Stubborn? Arrogant?) Trained to put care above all else Are still human with bias, concerns, and character flaws

∎ Consequences…. May stubbornly and pridefully resist suggestion of any

importance of documentation beyond medical benefit May not respond to billing pressure in socialized system Will respond to consistent military leadership priorities



Goalsof

Patient CareDocumentation

Medical Record Should be…

∎ Efficiently understandable to future caretakers∎ A concise and understandable explanation of how

conclusions and care plan decisions were reached∎ A concise and understandable explanation of future

evaluation/treatment plans∎ A quick source of medical summary data as the

foundation for evaluation and treatment∎ Statistically useful source of data for epidemiology

Low priority compared to the patient in front of you


Provider Non-Medical Goals

∎ Balance thoroughness of documentation against need to finish note quickly (minimum standard)

∎ Defense against lawsuits (All providers)∎ Stay off leadership “Bad Boy List” (All providers)∎ Justify need for adequate staffing (Some providers)∎ Make money for the MHS (Some providers)


NON-Goals of Military Providers

∎ Code for billing to support personal salary (N/A)∎ Code to most specific level of detail possible

Increased detail will be sought IF the leadership has instilled in the provider a priority for billing AND if additional detail will add billing value to the encounter



Patient Summary

Documentation

Patient Summary Documentation

∎ Medication List∎ Medication Allergy List∎ Past Medical History∎ Past Surgical/Procedure History



∎ Brief – for quick review∎ Complete – All data necessary for safe treatment∎ Easily updated – during routine patient care



∎ Autocite Contents Problem List Surgical/Procedure History Family History Social History Medications Medication Allergies



∎ Autocite – historically rejected because… Not brief Overly complete – Details buried in the forest Not easily updated in previous AHLTA versions Not visible while editing note documentation Navigation unacceptably slow for fast paced clinic


AutoCite “In the past”(Imagine long, duplicative lists below)


Patient Summary Work-Around

∎ AIM (Alternate Input Method) form Textboxes Brief Complete Easily updated during encounter

∎ However…. Dependent on manually copying note data forward Data is NOT mineable for use by population health, 2766,

data quality management, etc


Patient Summary Work Around


Autocite “Now” (Medications)

∎ Medication Reconciliation “Meds” module check box for current medications AutoCite only prints current medications “Meds” module print options

All Active Medications (in use and not in use) Only Active Medications which are currently used Admission/TX Medications Discharge Medications All Medications on record

Abbreviations are expanded for all medication lists Ability to add to list, including homeopathic medications


“Meds” Module AHLTA 3.3.7+


Medication Reconciliation Printout


AutoCite Medication List (3.3.7+)


Medical History Summary Lists

∎ Edited within the “Problems” module View ALL, or only ACTIVE entries Autocite ONLY lists ACTIVE entries Entries not repeated for multiple encounters View encounters associated with a single Entries

No current ability to add clarifying comments


Problem List Update in A/P Module


Problem List


Autocite Problem List (3.3.7+)



PatientEncounter

Documentation

Typical AHLTA Note Body Excerpt


Hematologic: A tendency for easy bruisingNeurologic: No lightheadedness. Memory Lapses or loss.Physical findings...Neck: Appearance: Of the neck was normal....Rectal: Rectum: Normal. Had no mass.

AHLTA note “Quality”

∎ NOT efficiently understandable Wording is mechanical and choppy. Doesn’t flow. Bullet order determined by AHLTA hard-wired

organization rather than by usefulness in reasoning

∎ Overly verbose slow reading and comprehension∎ Statistically mineable for epidemiology (low priority)


Desired note format

∎ S.O.A.P. Subjective Objective Assessment Plan

∎ Natural English language Readable as phrases which flow together Logical sequence leading to conclusions Separated into paragraphs of related information,

organized in a logical sequence to support conclusions


Sample “GOOD” Quality Excerpt


HPI: Pt is a 19 y/o female, 1 week into army boot camp, healthy and active withoutmedical complaint as of 3 hours ago. Two hours ago she began to c/o HA and stiffneck. She then developed photophobia, progressing to crying and irritability and a spreading rash, for which her drill sergeant brought her to sick call clinic.

She shares quarters with 38 recruits. Room mates have no HA’s, back or neck pain,photophobia, or rash. Room mates have only minor c/o myalgias attributed to the rigors of basic training. Otherwise no illness in contacts other then URI sx’s.

Pt Arrival time: 1440

IMM: No Meningococcal vaccine per record review. IMM O/W UTD.

PMH: ….

AHLTA Note Documentation Options

∎ “Paste” good quality note into AHLTA encounter∎ “S.O. Tree” bullet note creation∎ “AIM Form” note creation


“Paste” Note into AHLTA

∎ Create “GOOD” note in Word Processor, and paste note into “Add Note”.



∎ PRO’s Note is clear and concise Data flows logically from one data point to another,

ultimately to final conclusion “Templates” for different complaints can be easily

created/stored by any word processor



∎ CON’s “In the past”, notes could only be “Pasted” after the A/P

This changed the S.O.A.P. note flow to A.P.S.O. Now (AHLTA 3.3.7+), notes can also be pasted in SO or AP

Coding cannot be automated through AHLTA Statistical data mining for epidemiology is not possible “Templates” are not centralized: No standardization “Copy Forward” accomplished by “shadow” folders -

HIPAA Security risk


“S.O. Tree” Bullet Note Creation



∎ PRO’s Built in “Copy Forward” facilitates continuity of care Automatic coding by AHLTA (kind of) Statistical mining for epidemiology can be accomplished Personalized templates easily created Centralized templates facilitate standardization of

practice



∎ CON’s Meaning of bullets often not clear and no logical narrative

flow (not clear and easily understandable) Tendency towards over-documentation (not concise) Difficulty locating desired finding in tree with 1000’s of

medical terms Sometimes provider settles for “close enough” meaning Sometime provider gives up and does not document finding


“Aim Form” Note Creation

∎ Form based template

∎ PRO’s Text boxes facilitate “Free Text” for logical flow Related “Bullets” logically grouped together Balance between medically desirable free text format and

data mineable bullet format Centralized form creation facilitates standardization


“Aim Form” Note Creation

∎ CON’s Notes are not customizable Embedded “Summary Data” not available outside of note If desired bullet is not on form…

Spend extra time getting out of form to find bullet Choose “close enough” bullet for time efficiency Decide to not document bullet if not critical to note

Over-Documentation tendency if form is too complete


“AIM Form” note creation


“Expanded” Neck to find Stiff Neck


“Aim Form” note creation

∎ Couldn’t find “cap refill”∎ Switch to Tree view∎ “Find Term” on refill



∎ Select “a capillary refill test was abnormal”∎ Switch Back to AIM form view and continue on



∎ Petechiae and purpura not on form.∎ Less time to add comment to “Macule” than to “Find

Term” on petechiea and purpura



ICDCoding

Assessment and planICD-9 ICD-10

∎ For notes started before 1 Oct 2014, the A/P module will present ICD-9 codes to the user

∎ For notes started on-or-after 1 Oct 2014, the A/P module will present ICD-10 codes to the user

∎ On-or-after 1 Oct 2014, if a user types and ICD-9 code into the Diagnosis search textbox, all ICD-10 potential codes for that ICD-9 code will be listed


Assessment and planICD-9 ICD-10

∎ 465.9 is the ICD-9 code for Upper Respiratory Infection



E&MCoding

Disposition Module

∎ W/O bullets, History lacks location, duration, destination, quality, etc.


Disposition Module

∎ HPI over-ruled to level 2∎ History coding level increased

Exp. Problem Focused (2) Comprehensive (4) Black (computed) Red (over-ridden)


Disposition Module

∎ Note components used for E&M computation can be viewed by clicking on entries beneath History, Exam, and Med Decision Making HPI PFSH ROS Exam Level Risk Dx/Mgt Options Data Complexity


Coding Bullet Tree Listing


Coding Bullet Summary

∎ Bullets Column - Bullets Present:Bullets Required∎ Met Column – Was body system requirement met?


Sample Note Coding


CMS Body System # Bullets Counted Required Met

Systemic 4 2 2

Neck 4 2 2

Eyes 7 3 3

ENT 21 5 6

Lymph 3 1 4

Lungs 6 2 4

CV 7 2 7

ABD 9 3 4

Neuro 9 2 3

Skin 7 2 2

Disposition Module

∎ AHLTA performs Automatic E&M coding∎ Automatic Coding can be over-ridden∎ Coding based on the bullets selected in the note

Not all bullets count toward E&M coding No simple way to know which bullets count toward

coding

∎ Free text notes do not count toward E&M coding


Provider Documentation Summary

∎ Provider motivation based on patient benefit∎ Encounter note competing priorities

Readability Typed entries flow Bulleted entries choppy and difficult to read

Ease of documentation Typing is easy, but automated coding is not possible Bulleted entries

▻ Easy if finding is formatted appropriately into AIM form▻ If not on AIM form, documentation may be incomplete or

mildly inaccurate



∎ Summary data competing priorities AIM form data easily maintained while in note AHLTA functionality outside of note

Historically inconvenient, time consuming, and not useful Improved in AHLTA 3.3.7+

▻ Usefulness for patient care improved dramatically▻ Still documented partially outside of note▻ Interface will HOPEFULLY be adequately responsive

Providers CAN be trained to use AHLTA functionality, but ONLY with continuous, sustained leadership mandate



∎ ICD-9 coding Provider priority is patient care If best dx cannot be quickly found, provider will find

“close fit”, and expound/clarify in the Dx Textbox If more specific ICD coding is desired, you must convince

provider how it helps patient care or improves billing ICD-9 ICD-10 transition 1 Oct 2014 will happen

automatically. ICD-10 codes will be provided when ICD-9 code is given by the documenting provider



∎ E&M coding reality: automatic coding is incomplete HPI components cannot be reliable captured for coding ROS and Exam findings sporadically captured for coding Data complexity cannot be captured for coding


AHLTA Provider Documentation


Questions?

Questions?

Defense Health Agency Documentation Motivation for Providers Using AHLTA 3.3.8 Defense Health...

Documents

Transcript of Defense Health Agency Documentation Motivation for Providers Using AHLTA 3.3.8 Defense Health...