Using an EMR to Manage Using an EMR to Manage Patients with Chronic Patients with Chronic DiseaseDiseaseDoctoring 3 Longitudinal, 2009-2010

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Goals of Morning ActivitiesGoals of Morning ActivitiesUse technology with patients

effectivelyUse 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 decisions2

Using Technology with Using Technology with PatientsPatientsWhat is wrong with this encounter?

Click on image to bring up video from YouTube3

CLC Checklist for Good Patient CLC Checklist for Good Patient CommunicationCommunication

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?4

Possible Adverse EffectsPossible Adverse Effects Computer creates barrier between doctor or

student and patientPoor eye contactClosed ended questions driven by templatesMissing teaching momentsPauses while typing/looking for patient

education not engaged with patient

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What specific actions can we take to avoid these situations?

Arranging the Exam RoomArranging the Exam RoomWhich of these is best? Why?

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5 Tips for Using EMR5 Tips for Using EMR

1. Construct a triad with doctor (student), patient and computer

2. Introduce the computer into the encounter

3. Adjust screen so patient can see it4. Share EMR information on screen

with patient5. Alert patient verbally “sign

posting” when turning to EMR

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Using Tablet ModeUsing Tablet ModeAdvantages? Disadvantages?

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Ideas for Sharing EMR with Ideas for Sharing EMR with PatientPatient

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 Major Points for EMR CommunicationCommunication1. Introduced self BEFORE turning to

computer2. Introduced the computer into the

doctor/patient/computer triad3. 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 D3 Longitudinal OrientationOrientation

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Objectives for Remainder of Objectives for Remainder of SessionSessionUnderstand student expectationsProvide mechanism to achieve

expectationsUse 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 ActivityResources for ActivityIntranetSOAPware icon on rightAll training materials including

◦Basic Instructions◦Data Collection forms◦Instructions for uploading patients

SOAPware on student laptops

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Article reviewing EMRshttp://www.medscape.com/viewarticle/570380

Why are we using Why are we using SOAPware?SOAPware?Runs on your laptop disconnected

(the only EMR with remote access)Easy to learnAllows you to export patient recordsAllows for review your charts and give

feedback, monitor progress over yearCustomizable so we can add

templates, flow sheets, etc. for curricular purposes

Donated to FSU CoM

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SOAPware Modules SOAPware Modules NotNot Included/UsedIncluded/Used

3rd party software NOT free includes◦ 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 dataTemplates for Diagnosis visits

◦ Reduce typing, speed productivity16

Select Patients to Select Patients to DocumentDocumentWith your preceptor6 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 SOAPwareCreate Chart in SOAPwareHIPAA 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 PanelStrategy for Building PanelWork with preceptor and staff to

identify likely patients1st 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 Year’s ChartsUsing Last Year’s ChartsOkay to build on existing chart

from last year if your longitudinal preceptor had student last year

Talk to 4th year studentFigure out if same patientTell IT name on chart and get

chart imported

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Build Chart on Panel over Build Chart on Panel over YearYearUse during visitEncounter notes for each visitSummary Complete

◦Problems List with ICD-9 code ◦Medications list (justification)◦Family history, social history, allergies,

etc.Reminder system with pertinent itemsFlow Sheet for at least one chronic

diagnosis

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TimelineTimelineUpload 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 Upload Patients to IntranetIntranet

Student Laptop

Zip File

Zip File

Export Patient ChartsTo 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 SuccessSuggestions for SuccessNegotiate 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 InstructionsSOAPware InstructionsRunning SOAPwareCreating a ChartEntering Vital SignsWriting an Encounter NoteCompleting Summary Page

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Items in Reminder SystemItems in Reminder SystemHealth 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 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 PerformHow Often to PerformSample: 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 GuidelinesSources for Guidelines Health Maintenance

ePSS (USPSTF) on PDA or online Disease Specific

ACP PIER online only – see Follow-UpEssential Evidence+ Guidelines, which

are linked to… National Guidelines Clearinghouse

guidelines.gov Links on Library Website under

Clinical ResourcesInformatics Web Site, Clinical Information

Management, Clinical Resources

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Practice ExercisePractice ExerciseUsing Reminder System Form decide what items need to be done on the case provided

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Flow SheetsFlow SheetsPurpose 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 InstructionsSOAPware Instructions

Setting up RemindersUsing a Flow Sheet

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GradingGradingQuality and timeliness of patient

documentation will be considered in recommendation for Honors in D3

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For Help with SOAPwareFor 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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