1. Using an EMR to Manage Patients with Chronic Disease
Doctoring 3 Longitudinal,

2. 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

3. Using Technology with Patients
What is wrong with this encounter?
All current medical students will use an EMR in their future practice. Assuming that your goal for using an EMR in practice will be to improve safety while having all patient charts in a form that will make them more transportable, reportable, accurate and legible. Also, the EMR should eventually improve your productivity, so that you can complete all your documentation while seeing the patient instead of having to do it after you see the patient. There are a number of impacts that use of technology in the patient encounter can have on communication. What is wrong with this encounter.
Click on image to bring up video from YouTube

4. 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?

5. 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
All of these adverse effects have been identified in the literature. Lets look at one thing– the room arrangement…
What specific actions can we take
to avoid these situations?

6. Arranging the Exam Room
Which of these is best? Why?
We don’t expect that you will be able to do anything about the room arrangement of your clinical faculty’s clinic. However, in case you do have a say in your own clinic set up, or are using a portable computer,…

7. 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
Sign Posting refers to the yellow signs that used to be on the highways that warned the driver of upcoming curves or stop signs. Just as you would alert the patient that you were going to do a certain exam, you should tell the patient that you are going to enter some data or look up the patient’s information in the computer.

8. Using Tablet Mode Advantages? Disadvantages?
Have a discussion of what you can do with a tablet.

9. 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 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
Summary of ideas,

10. 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
Wrap up

11. D3 Longitudinal Orientation

12. 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

13. 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

14. Article reviewing EMRs
This article clearly ranks SOAPware among the most popular EMRs in use today in private practice, especially in small (1 or 2 physician) clinics.
Article reviewing EMRs

15. 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

16. SOAPware Modules Not Included/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 data
Templates for Diagnosis visits
Reduce typing, speed productivity
SOAPware appears stripped down because for our purposes it is. We did not purchase all these components because they were not critical to meet the objectives of the activity. We still want you to use Epocrates or PEPID to do drug interactions on patients.

17. 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

18. 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

19. 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

20. Using Last Year’s 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
We will allow you to use a chart created last year on a patient or patients created by a student last year. This will require that you find out if your preceptor had a student last year, then contacting and talking to that 4th year student to see if any of their patients were good ones to select for your panel, (they were reliable about coming in to see the student during their half day in clinic). Try to do this in July, because we need to archive the old patients from last year. You will need to find out what the patient name was, like B. Smith, and let us know so we can import that chart into your laptop SOAPware installation. Then you can change the name to fit our scheme, with your last name, etc.
[ICDs: The list of longitudinal faculty and students by campus from last year and this year is posted under the SOAPware intranet site in the Support Staff Documents folder. It is called _ _longitudinal.xls]

21. 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

22. Timeline
Upload monthly, by the 1stday of each month starting in September
patients definitely in Panel of 6 (2nd visit)
In future months, 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
Uploading is mandatory. Failure to upload monthly will require a meeting with your ICD. Any computer problems or other extenuating circumstances need to be reported to your ICD promptly. Repeated failure to upload is a professionalism issue.

23. Upload Patients to Intranet
Zip File
SOAPware Intranet Site
Export Patient Charts
To Desktop
Student Laptop
Upload Zip file to SOAPware Intranet Site
IT personnel will upload to SOAPware Server Installation
Informatics Curriculum Director will monitor and give you feedback

24. 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)

25. SOAPware Instructions
Running SOAPware
Creating a Chart
Entering Vital Signs
Writing an Encounter Note
Completing Summary Page
At this point, switch to SOAPware and go thru instruction for each of these using the sample patient data in the training materials.

26. 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 patient’s chronic condition
general stage of progression of disease
medications the patient is taking
co-morbid conditions  

27. How Often to Perform
Sample: How often should a patient with hypertension have their BP checked?
Combination of clinical judgment and guidelines and recommendations

28. 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

29. Practice Exercise Using Reminder System Form
decide what items need to be done on the case provided
We will use the page at the end of the Chart Transition Form to determine what items need to be included in our test patient’s reminder system, the frequency these should be performed.

30. 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

31. SOAPware Instructions
Setting up Reminders
Using a Flow Sheet

32. Grading
Quality and timeliness of patient documentation will be considered in recommendation for Honors in D3

33. For Help with SOAPware
Instructions on SOAPware Intranet site, link on main Intranet Page
Questions or problems with SOAPware, contact me via
Technical problems, your IT person