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Visit Types: Teaching Effective Organization of Patient Visits in a New EHR environment Albert Visit Types: Teaching Effective Organization of Patient Visits in a New EHR environment Albert Lichtenstein Ph. D, LMFT Donald Phykitt DO

History n Informal needs assessment n n n Lack of coherent approach to various History n Informal needs assessment n n n Lack of coherent approach to various types of visits apparent in precepting and Video Clinic Evidence in Video Clinic of disconnect between the resident and patient about goals for the visit Asking residents about their expectations for how a visit would go

History n Collaboration between behavioral science and physician faculty to map out a taxonomy History n Collaboration between behavioral science and physician faculty to map out a taxonomy

History n Collaboration between behavioral science and physician faculty to map out a taxonomy History n Collaboration between behavioral science and physician faculty to map out a taxonomy n Mapping out the major dimensions New vs Continuity n Acute problems vs no acute problems n Multiproblem vs single problem n Doctor initiated versus patient initiated f/u n

History n Collaboration between behavioral science and physician faculty to map out a taxonomy History n Collaboration between behavioral science and physician faculty to map out a taxonomy n Expectations for the visit Amount of time n Prioritizing establishing versus acute problems n Prioritizing problems n Setting the frame of the visit (physician’s expectations vs patient’s expectations) n

History n Pilot project to add Visit Types to the curriculum n n Didactic History n Pilot project to add Visit Types to the curriculum n n Didactic workshop Integration into Video Clinic

History n Getting faculty buy in n n Presented the taxonomy to faculty for History n Getting faculty buy in n n Presented the taxonomy to faculty for input Faculty agreement to integrate into ongoing curriculum n Efficient approach to a clinic (Yaeger Rules) n n To be integrated in the third quarter of PGY 1 Teaching visit types with integration into precepting n To be integrated first quarter of PGY 2

History n Implementation of Electronic Health Record n More robust living problem and medication History n Implementation of Electronic Health Record n More robust living problem and medication list Obligation to update and buff n Provides more information n n Use of templates in a visit n Knowing the visit type towards the beginning of the visit facilitates structure of the note

Visit Type Curriculum n The Taxonomy Visit Type Curriculum n The Taxonomy

Determine Visit Type New to Practice New to Provider Continuity tt Determine Visit Type New to Practice New to Provider Continuity tt

New to Practice To Establish Prenatal Check Up Acute Straight Forward Acute No Acute New to Practice To Establish Prenatal Check Up Acute Straight Forward Acute No Acute Complex Acute No Acute

New to Provider To Establish Prenatal Straight Forward Acute No Acute Complex Acute No New to Provider To Establish Prenatal Straight Forward Acute No Acute Complex Acute No Acute

Continuity Dr Initiated F/U Pt Initiated F/U Straight Forward Acute + F/U No Acute Continuity Dr Initiated F/U Pt Initiated F/U Straight Forward Acute + F/U No Acute New Problem Complex Acute + F/U No Acute Straight Forward Complex Acute No acute Annual Routine Straight Forward Complex Acute No acute No Acute

How to determine a visit type n Type of information (when appropriate) n n How to determine a visit type n Type of information (when appropriate) n n Age of patient Previous medical history n n n Number of physicians currently or in the past Recent visits Type of complaint Mental health or relationship issues Coping abilities and personality of the patient

How to determine a visit type (Pre EHR) n Sources of information n Early How to determine a visit type (Pre EHR) n Sources of information n Early preview n n Prior to entering room n n n Schedule Previous chart notes Knowledge of health maintenance for age group Nurse’s note Ask nurse who is in the room and other impressions After entering the room n Get patient’s agenda n Initial open ended question n Ask for additional problems or issues

How to determine a visit type (Post EHR) n Pre Clinic Routine (45 – How to determine a visit type (Post EHR) n Pre Clinic Routine (45 – 60 min) n n n 1. Look at schedule in Epic a. Number of patients b. Continuity or not c. Level of complexity d. When was the last visit e. Age

How to determine a visit type (Post EHR) n n Pre Clinic Routine Continued How to determine a visit type (Post EHR) n n Pre Clinic Routine Continued 2. Continuity patients a. Problem list - get rid of past and redundant problems b. Lab results – update most current lab results d. Chart Notes – 1. Look at all meaningful notes a Skip the history and physical b. look at the assessment and plans of my last visit. 1. Is the current visit part of my plan for f/u. (F/u of a breast nodule, Back pain? Depression. I know the visit is likely for that) e. Medical Hx – Get rid of meaningless dx

How to determine a visit type (Post EHR) n Pre Clinic Routine Continued 3. How to determine a visit type (Post EHR) n Pre Clinic Routine Continued 3. Patients one doesn’t know (eg f/u from hospital, f/u ED) a. Snapshot – Look at meds (is dosage info there and correct) b. Problem list - multiple problems, complexity c. Notes 1. Last note 2. Visit with other providers since last visit 3. Particularly visits that impact reason for coming Did the problems have definitive information. EG. IF heart failure, what was the ejection fraction on the last echo. If diabetes, what was the last glyco and microalbumen/cr ratio. IF COPD, when were the last PFT’s ? My agenda is determined before seeing the patient. Then I can listen to the patient’s agenda, since I am not trying to create my own while listening to theirs.

When to determine a visit type n As soon as possible! n This provides When to determine a visit type n As soon as possible! n This provides for Efficient data gathering n More effective and satisfying interaction n More effective use of EHR templates n

Need to reassess visit type as visit progresses Need to be willing to alter Need to reassess visit type as visit progresses Need to be willing to alter course with new information n Limit areas of discussion based on time Dealing with an acute problem rather than continuity issues if necessary n n Negotiate when to return to other issues Determine whethere is a form to fill out and when it’s required

Goals of Visit n Examples of each visit type are presented with the following Goals of Visit n Examples of each visit type are presented with the following information n n Name of visit type Specific patient example Specific goals to be achieved during the session based on visit type Expected length of visit for a PGY 3

Goals of the Visit n New to Clinic- Straightforward Acute Problem n n Patient Goals of the Visit n New to Clinic- Straightforward Acute Problem n n Patient example: 22 yr old female with UTI Goals of visit: 1. Diagnosis and treatment of the presenting problem 2. Gather history and populate EHR database 3. Investigate and promote continuity (15 - 20)

Goals of the Visit New to Clinic – Complex Acute Problem n n n Goals of the Visit New to Clinic – Complex Acute Problem n n n Patient Example: 65 yr old male diabetic with weakness and malaise Goals of the Visit: 1. 2. 3. 4. 5. Prioritize issues Tease out differentials Get necessary tests Gather history and populate EHR database Get back to PCP or decide on follow up as necessary. (20 - 30 min)

Goals of the Visit n n New to Clinic– To Establish – Straightforward Medical Goals of the Visit n n New to Clinic– To Establish – Straightforward Medical History- No Acute Pt example: 38 yr old male with well controlled hypertension who just moved to the area n Goals of the visit: 1. Take history, perform physical as appropriate and allowed by time 2. Establish relationship a) b) Discuss patient and doctor expectations Discuss policy and procedures of the practice 3. Address age appropriate health maintenance issues 4. Gather history and populate EHR database 5. Agree on format and plan for future (20 – 40 min)

Goals of the Visit New to Clinic- To Establish – Complex Medical History. No Goals of the Visit New to Clinic- To Establish – Complex Medical History. No Acute Problem n Pt example: 73 yr old female with CHF, Diabetes, Depression changing physicians: n n Goals of the visit: 1. 2. 3. 4. 5. 6. 7. 8. 9. Establish relationship Take history, perform physical as appropriate and allowed by time Discuss patient and doctor expectations Discuss policy and procedures of the practice Plan for coordination of care with specialist Clarify role, format and plan for future (plan for assessing and addressing multiple problems) Make arrangements to get old records Gather history and populate EHR database Order further testing based on medical status and what had been done by previous provider (may need to defer until old records are obtained) (30 – 45 min)

Goals of the Visit New to Clinic– To Establish –Straightforward Medical History- Acute Problem Goals of the Visit New to Clinic– To Establish –Straightforward Medical History- Acute Problem n n n Patient example: 40 yr old male whose wife is a patient of yours insists he get a doctor. During review of systems patient complains of headaches: Goals of the visit: 1. 2. 3. 4. 5. 6. Agree about urgency of acute problem Treat acute problem if urgent If not urgent work problem into visit to establish if possible or schedule a follow up. If time allows proceed to establish Gather history and populate EHR database Clarify role, format and plan for future (30 -45 min)

Goals of the Visit New to Clinic -to Establish –Complex Medical history -Acute Problem Goals of the Visit New to Clinic -to Establish –Complex Medical history -Acute Problem n n n Patient example: 43 yr old female, fibromyalgia, chronic back pain, new onset of depression Visit goals: 1. 2. 3. Agree about urgency of acute problem Determine urgency of chronic problems Manage acute problem if urgent. a) b) 4. 5. 6. 7. Negotiate decision regarding what will be covered in the visit If not urgent work problem into visit to establish if possible or schedule a follow up. Address those chronic problems which warrant acute attention If time permits proceed to establish. (see slide with complex no acute) Gather history and populate EHR database Realize that it will take more time to establish. May need to schedule a follow up to continue to gather information to establish. (45 -60 min)

Goals of the Visit n New to Clinic - to Establish – Prenatal n Goals of the Visit n New to Clinic - to Establish – Prenatal n n Patient example: 25 yr old, G 2 P 1, married, new to area after job change Goals for visit: 1. Establish rapport 2. Gather information -Gather history and populate EHR database 3. Inform about clinic team structure and your role 4. Establish any risk factors or problems 5. Educate (eg diet, exercise) 6. Agree on overall plan (may chose to take hx in one session and do PE in the next session) (20 – 30 min)

Goals of the Visit Continuity – Dr. initiated f/u – straightforward medical history– no Goals of the Visit Continuity – Dr. initiated f/u – straightforward medical history– no acute problem n n n Patient example: 56 yr old male, one month f/u for weight loss and BP to discuss lab and progress with diet and exercise Goals for the visit: 1. 2. 3. 4. 5. 6. 7. Clarify your reason for the visit and ascertain whether pt has other problems they want addressed If no other problems proceed as below Update medication and problem list in EHR Investigate medication side effects and compliance with Tx Provide results of labs/other studies Discuss diagnosis and treatment. Negotiate future plan. (15 -20 min)

Goals of the Visit Continuity – Dr. initiated f/u – straightforward medical history– new Goals of the Visit Continuity – Dr. initiated f/u – straightforward medical history– new acute problem n n n Patient example: Same as previous but patient complains of cough and congestion for 7 days Goals of visit 1. 2. 3. 4. Clarify your reason for the visit and ascertain whether pt has other problems they want addressed Negotiate issues to be covered in the visit Proceed with either problem as previously described or combine both problems if time allows Add additional sessions if necessary (15 -20 minutes)

Goals of the Visit n Continuity - Dr. initiated f/u – complex medical history Goals of the Visit n Continuity - Dr. initiated f/u – complex medical history – no acute problem n n Patient example: 75 yr old female, 3 month f/u of CHF, Diabetes, renal insufficiency Goals for the visit: 1. Clarify your reason for the visit and ascertain whether pt has other problems they want addressed a) b) Review and update medications and problem list in EHR Update symptoms, medication side effects, and compliance with Tx 2. Provide results of labs/other studies 3. Discuss diagnosis and negotiate treatment. 4. Negotiate follow up plan. (20 - 30 min)

Goals of the Visit Continuity – Dr. initiated f/u – complex medical history – Goals of the Visit Continuity – Dr. initiated f/u – complex medical history – new acute problem n n n Patient example: Same as previous but daughter describes forgetfulness Goals for the visit: 1. Clarify your reason for the visit and ascertain whether pt has other problems they want addressed a) b) Review and update medications and problem list in EHR Update symptoms, medication side effects, and compliance with Tx 2. Negotiate issues to be covered in the visit (pay particular attention to RRFC and relationship issues) a) Addition studies and referrals as indicated b) Address stable chronic problems if time allows 3. Add additional sessions if necessary (30 - 45 minutes)

Goals of the Visit Continuity – Straightforward Medical History – Pt initiated – Acute Goals of the Visit Continuity – Straightforward Medical History – Pt initiated – Acute problem n n n Pt example: 58 yr old male, otherwise healthy who requests a prescription for Viagra Goals of visit: 1. 2. 3. Diagnosis and treatment of the presenting problem. Update problem and medication list in EHR If there is time check on any ongoing problems, gather needed contextual information, attend to health maintenance – if time does not allow schedule follow up as indicated (15 -20 min)

Goals of the Visit Continuity – Complex Medical History/ Pt initiated – new problem Goals of the Visit Continuity – Complex Medical History/ Pt initiated – new problem n n n Pt Example: 54 yr old female with poorly controlled COPD who comes in after missed visits with leg swelling Goals of visit 1. 2. 3. 4. 5. Prioritize issues, address urgent issues, and negotiate with patient what else will be covered that visit Update problem and medication list in EHR Evaluate adherence, look at motivation for change issues, understand contextual issues (pay particular attention to RRFC and relationship issues) Make appropriate referrals or follow up on previous referrals Arrange for appropriate follow up (20 - 40 min)

Goals of the Visit Continuity – Annual – Routine n n n Pt example: Goals of the Visit Continuity – Annual – Routine n n n Pt example: 46 yr male with no past medical hx presents for routine visit Goals of visit: 1. 2. 3. 4. 5. 6. 7. Inquire about any acute problems patient wants addressed Update problem list, medical hx, medications, allergies, psychosocial changes in EHR Check ongoing control of chronic problems, pt concerns, and adherence (and any barriers) Order appropriate studies and referrals Address age appropriate health maintenance issues Refill medications Negotiate follow up (30 -45 min)

Example of an Encounter Example of an Encounter

How to determine a visit type n Sources of information n Early preview n How to determine a visit type n Sources of information n Early preview n n Prior to entering room n n Schedule Previous chart notes – including problem list and medication list Knowledge of health maintenance for age group Nurse’s note After entering the room n Get patient’s agenda n Initial open ended question n Ask for additional problems or issues

n Sources of information n Early preview n Schedule n Sources of information n Early preview n Schedule

Schedule Schedule

n Sources of information n Early preview n n Schedule Previous chart notes n Sources of information n Early preview n n Schedule Previous chart notes

How to determine a visit type Post EHR (Yaeger Rules) n n Pre Clinic How to determine a visit type Post EHR (Yaeger Rules) n n Pre Clinic Routine Continued 2. Continuity patients a. Problem list - get rid of past and redundant problems b. Lab results – update most current lab results d. Chart Notes – 1. Look at all meaningful notes a Skip the history and physical b. look at the assessment and plans of my last visit. 1. Is the current visit part of my plan for f/u. (F/u of a breast nodule, Back pain? Depression. I know the visit is likely for that) e. Medical Hx – Get rid of meaningless dx

Previous Chart Notes Previous Chart Notes

Previous Chart Notes Previous Chart Notes

n Sources of information n Early preview n n n Schedule Previous chart notes n Sources of information n Early preview n n n Schedule Previous chart notes Problem List

Problem List Problem List

n Sources of information n Early preview n n n Schedule Previous chart notes n Sources of information n Early preview n n n Schedule Previous chart notes Medication list

Medication List Medication List

n Sources of information n Early preview n n n Schedule Previous chart notes n Sources of information n Early preview n n n Schedule Previous chart notes Problem list Medication list Knowledge of health maintenance for age group

n Sources of information n Early preview n n n Schedule Previous chart notes n Sources of information n Early preview n n n Schedule Previous chart notes Problem list Medication list Knowledge of health maintenance for age group Prior to entering room n Nurse’s note

Nurses Note Nurses Note

n Sources of information n Early preview n n Prior to entering room n n Sources of information n Early preview n n Prior to entering room n n Schedule Previous chart notes Knowledge of health maintenance for age group Nurse’s note Problem list and medication list Face Sheet After entering the room n Get patient’s agenda n Initial open ended question n Ask for additional problems or issues

Goals of the Visit n Continuity - Dr. initiated f/u – complex medical history Goals of the Visit n Continuity - Dr. initiated f/u – complex medical history – no acute problem n Goals for the visit: 1. Clarify your reason for the visit and ascertain whether pt has other problems they want addressed a) b) Review and update medications and problem list in EHR Update symptoms, medication side effects, and compliance with Tx 2. Provide results of labs/other studies 3. Discuss diagnosis and negotiate treatment. 4. Negotiate follow up plan. (20 - 30 min)

Summary and Conclusions n n n Lack of awareness of visit type often results Summary and Conclusions n n n Lack of awareness of visit type often results in inefficient or ineffective office visit A taxonomy of visit types and goals for each visit type were developed A structured process for determining visit types was developed and presented

Summary and Conclusions n n Preliminary comments from residents indicated that the taxonomy and Summary and Conclusions n n Preliminary comments from residents indicated that the taxonomy and process were useful and needed Constructive feedback mostly involved simplifying and graphically enhancing the taxonomy chart

Residents Comments n n n “A very valuable topic but it needs work to Residents Comments n n n “A very valuable topic but it needs work to make it clear and concise” “Break up the chart flow. Show the chart pieces before the explanation of each visit type. Work the video into the entire presentation instead of the end” “My first experience was great. It dealt with issues which I frequently face. “

Residents Comments n “I am uncomfortable with “boxes” however I appreciate the intent. The Residents Comments n “I am uncomfortable with “boxes” however I appreciate the intent. The slides describing the visit types are dry. Use a different font to describe the visit type on each slide. ”

Summary and Conclusions n Importance of obtaining faculty buy in n n (Is this Summary and Conclusions n Importance of obtaining faculty buy in n n (Is this a method faculty uses) Clearly integrating this framework into the ongoing curriculum Didactics n Precepting n

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