Advanced Template Design

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Advanced Template Design

• By
• Donald T. Stewart, MD
• DonS_at_PineLakeMed.com
• July 2006

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Me and You

• Me Family Practice, sole proprietor x 20 years,
  now employee
• Paper templates for visit notes since 1983
• Disease Management templates since 1993
• EMR templates since 1997
• Practice Partner templates since 2001
• You
• Physicians?
• Nurse Practitioners?
• PAs?
• MAs or Nurses?
• Practice Tech people?

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Resources for this Talk

• This Power Point presentation
• Advanced Template Design.ppt
• Second Power Point presentation
• Designing a Chronic Disease Template.ppt
• PDF Handout (a how to with lots of extra
  stuff)
• Advanced Template Programming.pdf
• Due to a Kinkos issue and unexpected demand for
  this presentation, we are short today.
• Check PP web site soon, or
• Email me (DonS_at_PineLakeMed.com) for copies of all
  of the above

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Overview

• Why use templates?
• Speed of data entry
• Structured data entry
• You know where to find things
• You dont forget to document things
• You can save things for later use
• The ability to pull data into your note

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What is wrong with Templates?

• One size does not fit all
• Needs for chronic disease management quite
  different from needs for urgent care
• Easy to be fraudulent
• Excessive length of notes
• Cook-Book Medicine
• The patients story is the most important
  diagnostic tool, and templates tend to
  depersonalize it.

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Urgent Care Templates

• Goal is to get paid and document what you did.
• Speed of entry a priority
• Chronic disease management NOT an issue.

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Chronic Care Templates Subjective

• These templates should provide a summary of the
  chronic issues you are addressing, including
• Past history of the problem
• Current status of symptoms, disease activity
  markers, quality of care markers
• Past and current lab values that matter
• Patient Self-Management Goals
• Other related and important issues

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Chronic Care TemplatesObjective

• Past pertinent physical findings should be
  visible when the patient is being examined
• Vital signs that are not to goal should be
  flagged
• The template should remind the provider to do and
  document the necessary elements of the exam

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Chronic Care TemplatesAssessment

• The template should prompt the provider to
  consider all appropriate parameters
• It should show the important data so the provider
  does not have to scroll back through the note.
• It should be easy to understand

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Chronic Care TemplatesPlan

• Should document treatment changes
• Follow-up plans
• Counseling activities
• What was said
• How much time was spent
• Labs, consultations, and procedures ordered

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Acute Care Templates in the Primary Care Setting

• Should be
• Quick to fill out
• Uncomplicated
• Should document the visit adequately for
  reimbursement
• Should remind the provider of other chronic
  conditions or health maintenance issues that
  might need to be addressed

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Primary Care Templates

• Both Acute or Urgent Care and Chronic Care have
  to be served by the same template
• You have to be able to address multiple issues in
  a given visit, both acute and chronic.
• Essentially, you need a Super Template, as
  developed by Greg Omura, MD, or you need a
  flexible templating system as developed by Rita
  Hanson, MD. Both of these systems are available
  for sale by their authors.

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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

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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

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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 patients future
  management.
• It might be a great place to put a paragraph
  that updates the status of a patient with Crohns
  disease or RA.

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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

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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
• 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

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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.

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Social HistoryWhat makes the patient unique as
a person

• 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?

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Lets create a Primary Care Template

• We will start by modifying the SOAP Single or
  Multi-Problem Template that ships with 8.2.1
• Please refer to the Handout for details on this.

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Project 1Improving the Drop-Down Subjective
MenuWhat to do when the patient has another
problem?
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The Solution

• Recursive Quick Text expands to include itself,
  so it can be clicked again

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Recursive Subjective List
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What it Looks Like
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If you click S Chronic you get this menu
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If you click Subjectives you get this menu
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S- expands to
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The other choice expands to Cascading Quick Text
ordered by Organ System
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The Canned Abdominal Pain choice under the S-
menu
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Project 2 Cleaning up Patient Data

• The patient histories (PMH, SH, FH) and
  Medications and Allergies quick texts make the
  template seem cluttered
• We will create a drop-down menu for these, and
  add some functionality

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This is what you get if you chose BMP off the
Lab Results Menu
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Conditional Logic for the Exam
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The Handout for this Talk

• We are now up to page 3 of the 12 page Power
  Point handout for this talk.
• The rest of the handout discusses such issues as
• Making quick text Subjective Templates for
  chronic disease management
• Making your templates Disease Aware
• Saving physical findings as lab values
• In the interest of saving time for questions, I
  will now present some additional concepts

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Messaging Templates

• Messaging templates are a new feature in Practice
  Partner 8.x which offer the opportunity to
  greatly improve workflow
• By pulling patient information into the message
  itself, you are spared the time wasted by opening
  the chart and looking for things like the
  patients Date of Birth, Phone Number, Recent Lab
  Values, Medication List, Allergies, etc

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Messaging Templates (2)

• In a given messaging document, you and your
  co-workers may need to use several different
  templates.
• This is because unexpanded Quick Text in the
  template will disappear each time the message is
  sent to someone.

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Messaging Templates (3)

• For example, the receptionist or medical
  assistant may start with a template that pulls in
  the basic information and request
• The provider might bring in a template with
  responses, questions, and orders
• The MA or Nurse might bring in another template
  to document how the orders were accomplished

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Rx Refill Template

• For Rx refills, a typical workflow would have the
  receptionist taking the call and starting a
  template, which is sent to the MA.
• The MA would check the request against protocol,
  and either handle it, or forward it to the
  Provider.
• The Provider would review the request, and either
  ask for more information or make a decision,
  forwarding it back to the MA

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Rx Refill Template (2)

• The MA would then either get the additional
  information requested, or would call or fax in
  the providers response to the pharmacy and to
  the patient
• The MA would then save the message as
  documentation of the transaction

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You get to the Template Menu from Template in
Message Editor
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The person who starts the note sees this
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When this goes to the Provider, a new template is
added
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After the Provider has given orders, the MA adds
a new template
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Thank You for Coming

• Questions, Demonstrations, Examples?
• For early copies of this presentation, email
  request to DonS_at_PineLakeMed.com