Transcript Templates for Chronic Disease Management

Templates for Chronic
Disease Management
Donald T. Stewart, MD
Evergreen Medical Group
September 1, 2006
Agenda
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Health Maintenance Items in Templates
HM Pitfalls
The History Sections of the Chart
What about Habits?
Family History Saved as Lab Values
Cardiovascular Dataset
Chronic Disease Datasets
Using the Problem List Effectively
Questions and Examples
Health Maintenance
• You can set up templates based on age/sex,
problems, Rx, or protocol.
• Practice Partner will automatically offer the
templates when you enter a new problem, add a
medication, or choose a protocol template.
• You update Health Maintenance by Dot Codes in
a note, a note title that is a HM Name, or
importing lab data that are HM Names.
Health Maintenance Active
Reminders
How to Remind Providers of HM?
• HM Window when chart opened? (“Active
Reminder”)
– Probably helpful for MAs, Phone Triage or
Schedulers
– Not very helpful and annoying to providers
• Easy to click past
• Easy to forget the details at the time you need to
remember them
How to Remind Providers of HM?
• Put HM needed in the note template.
• Put it under “Plan” which is where the
provider needs to see it when the provider
needs to see it
• Make it easy to disappear with either a
<<DEL>> after the line (automatically
disappears) or a <<*DelLine>> after the
line (click to make it disappear)
Put the Reminder in the “Plan”
Section of the note
*InsertHMDue Quick Text
HM Pitfalls
• Definition of Item:
– It is important to be very specific about the
definition of your HM items. For example,
what is a “Diabetic Foot Exam?”
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DP and PT pulse palpation?
Vibration Sense or Monofilament exam?
Foot inspection?
All of above?
How will you document it?
HM Pitfalls
• Multiple names for lab tests
• LDL CHOLESTEROL and VAP LDL
CHOLESTEROL the same?
• MICROALBUMIN,UR and
MICROALBUMIN/CREATININE, and what about
24-HOUR URINARY PROTEIN?
• These problems can be fixed by entering
synonyms, and updating appropriate
cross-reference files.
HM Pitfalls
• Procedures done elsewhere
• What is a Diabetic Eye Exam?
• Who can do it?
• What kind of documentation is required?
– Patient’s word?
– Note from specialist?
» Do you scan the note in, hand-enter into HM, or use
dot codes in a note? Perhaps dot-codes on a
scanned note?
History Section Templates
• Past Medical History
• Family History
• Social History
• How you set these up takes special
consideration, since this is a place where
you can store important data to be
imported into your notes
Past Medical History
• Surgeries: Approximate Date, perhaps the
location, perhaps who the surgeon was,
complications
• Medical Hospitalizations: Date, location,
outcome, who the physicians were, significant
procedures or tests done
• Psychiatric or Substance-related treatment
• Transfusions
• Significant past medical illnesses or
conditions
• Significant environmental exposures
Past Medical History
Uses
• This is a great place to enter, for example,
the details of a cardiac cath or bypass
surgery that will be important in the
patient’s future management.
• It might be a great place to put a
paragraph that updates the status of a
patient with Crohn’s disease or RA.
Past Medical History
Uses
• The point is that this section can be pulled
into your notes any time you want, can be
as large as you want, and can be
formatted however you like.
• You should update it regularly and be sure
to include the date of last update
Family History
• This can be a tremendous practice-builder and
patient relationship builder for anyone in primary
care. Lots of important social history included
here.
• Important to include:
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Date updated
Approximate ages of family members or age at death
Significant medical problems and health status
Names of children (tremendously helpful in primary
care), where they live, and what they do
Family History
Additional Information
• Status of parents, if elderly, quite important
– where they live, who checks on them,
what responsibilities the patient has for
their care.
• Number of grandchildren
• Which siblings live close, and which ones
are far away.
Social History:
What makes the patient unique as a person
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Where were they born?
Where did they grow up?
Where do they live, and for how long?
Who do they live with?
How far did they go in school?
What is their family and marital status?
What is their occupation?
What do they do for fun?
What are their goals? (retire, move, etc?)
What unusual stresses are they experiencing?
What About Habits?
• Habits (Alcohol, Tobacco, Diet, Exercise)
are often considered part of “Social
History,” but are most easily updated in
templates if saved as lab values.
• It is easy to make a Quick Text that brings
the habits into the note, and allows
updating.
• «*HabitEntr»
Habit Entry: Before Data
Habit Entry: When First Entered
Habit Entry: After Saving
Habit Entry: On the Next Note
Habit Entry: Editing Next Note
Habit Entry: New Note Saved
To View or Enter in Lab Table
Family History as Lab Data
• The Family History section of the chart is a
great place to put narrative data, but it is
not easily searchable, and doesn’t allow
flexibility in template design for specific
conditions.
• Entering specific conditions you care
about as lab data will solve these
problems.
What FH Items to Save as Lab?
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Type II Diabetes
ASCVD
Breast CA
Colon CA
Melanoma
Osteoporosis
Ovarian CA
Prostate CA
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Depression
Substance Abuse
Asthma
Other items
depending on your
interest and what
templates you might
want to design
When to Update FH Lab Values?
• In a CPX Template
– Especially the first time you do the CPX
• In a Lab Table
– Could be done by MA
• In a Problem Template or Quick Text
– When you need it, e.g.: FH ASCVD in a Chest
Pain Template
Updating in a CPX Template
Updating in a Lab Table
Updating in a Problem Template
CV Dataset (Lab Values)
• Very useful since this is what most of us
die of.
• Probably should be pulled into templates
for Chronic Disease Management like:
ASCVD, AODM, Hypertension,
Hyperlipidemia, Metabolic Syndrome
• Also pulled into acute templates like:
Chest Pain, TIA, CVA
Cardiovascular Dataset
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Cardiologist
Coronary Calcium
StressTestDate
AngiogramDate
EchodardiogramDate
SPECT Scan
EjectionFraction
Has CHF?
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Carotid US Date
AAA Screen Type
AAA Screen Date
Abdominal US Date
Has ASCVD?
– PH MI?
– PH Stent?
– PH CABG?
Diabetes Dataset
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DiabetesDxDate
DiabetesEduDate
Endocrinologist
Does Glucose Test?
Last FBS
Checks BP?
HomeBPReadings
DiabetesConcerns
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LastEyeExam
Ophthalmologist
Optometrist
LastFootExam
Takes Aspirin?
SelfManagementGoal
SelfManageSpecific
SelfManageTime
Diabetes ROS
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HypoglycemicEpisod
LowerExtrPains
LowerExtrNumbness
Polyuria
Polydipsia
Blurred Vision
Erectile Dysfunction
Diabetes Exam
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Carotid Bruits
Carotid Scars
CABAG Scars
Pacemaker Scars
Foot Pulses
Monofilament Exam / Vibration Sense
AF Dataset
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Cardiovascular Dataset
AF Dx Date
Last AF Date
TypeAnticoagulation
Rate Control Meds
– Digoxin
– Beta blockers
– CCBs
CHF Dataset
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Cardiovascular Dataset
CHF Dx Date
CHF Cause
CHF Episode Date
CHF Episode Weight
Last Visit Weight
Meds:
– ACEI / ARB
– Beta Blockers
– Spironolactone
Asthma Dataset
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RescueInhalerFrequency
SteroidInhalerFrequency
HasHomeNebulizer?
Last Spirometry Date
Last Spirometry Results
AsthmaSxFrequency
AsthmaSxSeverity
Using the Problem List Effectively
• Keeping the Major Problem List updated:
– Allows for automatic HM protocol updating
– Makes it easier to create a helpful Progress
Note
– Can help you keep track of clinical information
more easily
Problem List in Version 8.2.2
Problem List at Beginning of Note
New Problem List Module in v.9
• Besides Major Problems, Other Problems,
Diagnoses and Procedures, new sections
include: Risks and Hospitalizations
• Problems can be listed in outline form
• Active/Inactive, most recent date, problem
life cycle, related to, larger note section,
• Change order problems are listed
Problem List in Version 9.x