Templates for Chronic Disease Management

Donald T. Stewart, MD

Evergreen Medical Group

September 1, 2006

Agenda

• 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?”

• 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:– 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

• 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?

• Type II Diabetes• ASCVD• Breast CA• Colon CA• Melanoma• Osteoporosis• Ovarian CA• Prostate CA

• 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

• Cardiologist• Coronary Calcium• StressTestDate• AngiogramDate• EchodardiogramDate• SPECT Scan• EjectionFraction• Has CHF?

• Carotid US Date• AAA Screen Type• AAA Screen Date• Abdominal US Date• Has ASCVD?

– PH MI?– PH Stent?– PH CABG?

Diabetes Dataset

• DiabetesDxDate• DiabetesEduDate• Endocrinologist• Does Glucose Test?• Last FBS• Checks BP?• HomeBPReadings• DiabetesConcerns

• LastEyeExam• Ophthalmologist• Optometrist• LastFootExam• Takes Aspirin?• SelfManagementGoal• SelfManageSpecific• SelfManageTime

Diabetes ROS

• HypoglycemicEpisod

• LowerExtrPains

• LowerExtrNumbness

• Polyuria

• Polydipsia

• Blurred Vision

• Erectile Dysfunction

Diabetes Exam

• Carotid Bruits

• Carotid Scars

• CABAG Scars

• Pacemaker Scars

• Foot Pulses

• Monofilament Exam / Vibration Sense

AF Dataset

• Cardiovascular Dataset

• AF Dx Date

• Last AF Date

• TypeAnticoagulation

• Rate Control Meds– Digoxin– Beta blockers– CCBs

CHF Dataset

• Cardiovascular Dataset• CHF Dx Date• CHF Cause• CHF Episode Date• CHF Episode Weight• Last Visit Weight• Meds:

– ACEI / ARB– Beta Blockers– Spironolactone

Asthma Dataset

• 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