“Team Documentation”
Ambulatory Value Stream Update, RPIW #6
March 2, 2017
Doug Swanson, MD
Infectious Diseases
Lauren Varel
Endocrinology
©2015 Joan Wellman & Associates, Inc.
Team
Team (left to right front row): Mamta Reddy; Kari Shenkner; Kate Vanlandingham; Joan Benson; Britney Snodgrass;
Lauren Plemons; Lauren Varel;
Team (left to right back row): Kelly Miller; Ellen Meier; Doug Wendt; Shari Cooley; Del Cofield; Doug Swanson; Kristin Allender;
Rocky Kuhlman; Chris Miller; Baha Al-Shawwa
Team (Not pictured): Sarah Edwards; Roha Khalid; Naim Mitre; Chris Kelly
©2015 Joan Wellman & Associates, Inc.
What problems are we trying to solve?
 Four different documentation methods across clinics
•
•
•
•
Phone transcription
Clin Doc (free text/templates)
Power Note
DynDoc
 Significant variation in lead times to complete a clinic document
 Confusion regarding consultation vs new patient
 Difficulty in receiving outside records from referring providers
 Frustration with viewing scanned documents
©2015 Joan Wellman & Associates, Inc.
Process Map – Current State
We used our Ambulatory clinic value stream map to identify the individual pieces of patient information
collected at each step of the patient encounter. We then reviewed each step and identified the wastes
and barriers that are experienced at each step
©2015 Joan Wellman & Associates, Inc.
Vision
• All clinic notes are completed by the end of the appointment
• All relevant clinical information is readily available at the time of the
appointment
• A clearly defined reason for visit and patient type (consult vs new)
• Well-defined roles for every team member (practicing at highest level of
training) to contribute into the final document
• All team members (including trainees and ancillary services) have a clear
understanding of all required elements of the documentation process
• Eliminate redundancy and the need for multiple verification steps
• Minimize the amount of manual data entry
©2015 Joan Wellman & Associates, Inc.
Projects to Achieve “Next Target Condition”
• Update / improve the Consult Form
• Studies completed (Labs, Imaging, etc)
• Clear reason for visit (consult vs new vs follow-up)
• Formulate a communication to referring providers regarding the form and
process changes and why
• Make referral information easily available to providers as it comes in from
referring provider
• Clearly define the roles and responsibilities for team documentation across
the value stream
• Clarify required components of documentation for each visit type
• Create job aids for required components of documentation for each visit type
• Create a standard review of systems and a standard social history
• Identify desired systems per sub-specialty for family history
• Understand what tools are available and create a job aid to reference the
tools to enhance efficiency
• Develop multidisciplinary clinics documentation workflow
©2015 Joan Wellman & Associates, Inc.
1. Before—After (New Consults Forms/Process)
Issue Description:
Post Improvement Benefits:
All outside documents are scanned into Cerner and
have to be opened in “Image Now” for viewing. This
causes delays and frustration for users
Workflow changed to allow consult forms, and their
supporting documents, to be found in a clinic specific
consult folder for immediate viewing
Before Improvement Picture
After Improvement Picture:
I wonder what is in
this document…
How much longer?
©2015 Joan Wellman & Associates, Inc.
2. Before—After (Electronic ROS Form)
Post Improvement Benefits:
Issue Description:
Variation in Review of Systems responsibilities and
process across the model line clinics. ROS was
typically collected on paper and documented by the
provider.
Developed single standard ROS form for use by all
clinics that can be completed by the patient family,
which will eliminate the need for the new patient
questionnaire in some clinics
Before Improvement Picture
After Improvement Picture:
Form will be
completed by
the parent at
time of visit
using an iPad.
There has to be a
better way!
Future state
vision will be
completion of
ROS via the
Patient Portal
prior to the
visit.
©2015 Joan Wellman & Associates, Inc.
3. Before—After (Documentation Requirements)
Issue Description:
Post Improvement Benefits:
Variation in understanding among providers regarding
the required elements for a complete clinic note for
each type of visit
Clearly defined requirements for patient visit type
that not only facilitate the documentation of the
visit, but also facilitate the complete and accurate
coding of the encounter
Before Improvement Picture
After Improvement Picture:
How much do I
need to document?
Communication presentation created for
providers along with the below job aid
NEW PATIENT / CONSULTS* (OUTPATIENT)
Chief Complaint: may be documented alone or as a part of HPI
Consults require mention of requesting provider and
reason for consultation in the history.
HPI (history of present illness) elements:
□ Location
□ Severity
□ Timing
□ Modifying factors
□ Quality
□ Duration
□ Context
□ Associated signs and symptoms
* For time-based billing for consults, use time in parentheses
(Use clock time, i.e. 10:20-10:55 with > 50% spent in counseling)
3 out of 3 elements required
Time
(each element must be in same level)
(Min)
Level
1- History
HPI ROS PFSH
Face to
Face
2-Exam
3- Medical
Complexity
1
1-3
N/A
N/A
1 or >
Minimal
10 (15*)
2
1-3
1
N/A
2-7
Minimal
20 (30*)
3
4
2-9
1
2 – 7 **
Low
30 (40*)
4
4
10
3
8 or >
Moderate
45 (60*)
5
4
10
3
8 or >
High
60 (80*)
**with an extended exam of affected area
ESTABLISHED PATIENTS (OUTPATIENT)
2 out of 3 elements required
Level
1- History
HPI ROS PFSH
Time
(Min)
2-Exam
3-Medical
Complexity
Face to
Face
2
1-3
N/A
N/A
1 or >
Minimal
10
3
4
1
N/A
2–7
Low
15
4
4
2-9
1
2 – 7 **
Moderate
25
5
4
10
2
8 or >
High
40
ROS (review of systems):
□ Constitutional □ ENT □ GI □ Integumentary □ Endo
□ GU
□ Hem/lymph
□ Eyes
□ Card/Vasc
□ Musculo
□ Neuro
□ All/imm
□ Resp
□ Psych
□“All others negative”
PFSH (past medical history, family, social, history) areas:
□ Past history (the patient’s past experiences with illnesses, operations, injuries
and treatments)
□ Family history ( a review of medical events in the patient’s family, including
diseases which may be hereditary or place the patient at risk)
□ Social history (an age appropriate review of past and current activities)
Body areas:
□ Head, including face □ Chest including breast and axillae
□ Abdomen
□ Back, including spine □ Neck □ Genitalia, groin, buttocks □ Each extremity
Organ systems:
□ Constitutional (e.g. vitals, gen app)
□ ENT □ Resp □ Musculo
□ Psych □ GI
□ Skin
□Hem/lymph/imm
□ Eyes
□ Cardiovascular □ GU
□ Neuro
□ Endo
Medical Complexity:
□ Number of diagnoses or new illnesses
□ Review of previous records
□ Orders, with more specific risk identified (Ex., MRI with sedation)
□ Prescription drugs
**with an extended exam of affected area
Front
©2015 Joan Wellman & Associates, Inc.
Back
4. Before—After (Histories Tabs)
Post Improvement Benefits:
Issue Description:
Burden of documenting all required components is
generally on the provider. Duplication of gathering of
historical information. Histories tabs are not fully
utilized.
Nursing standard work will ensure information is
gathered only once from families. Histories will
carry across all encounters across all clinics. This
reduces provider workload burden.
Before Improvement Picture
After Improvement Picture:
It would be helpful if
the histories were
already in my note
©2015 Joan Wellman & Associates, Inc.
5. Before—After (Documentation Tools)
Issue Description:
Post Improvement Benefits:
While there are several great tools available to help
with efficiency in documentation, not everyone knows
what tools are available, their benefits and accuracy
Reviewed current job aids for different technologies
and developed a communication presentation and
training plan to increase awareness and to educate
the clinic providers on those tools
Before Improvement Picture
After Improvement Picture:
Only phone
transcription
is going away.
Oh no! Dictation
is going away!?!
Dragon
dictation
Dictation is
still
available
Power chart touch
©2015 Joan Wellman & Associates, Inc.
Multi-Disciplinary Clinic Documentation
©2015 Joan Wellman & Associates, Inc.
Benefits to Providers
• Team-based approach to help providers complete
clinic notes
◦ Assuring availability of outside medical records
◦ Understanding the reason for referral using a new
consult process
• About 30% of the note will be pre-populated
◦ Family completes ROS electronically
◦ Nursing completes the PMH, FH, SH, Procedure History
• Notes automatically populated with OR procedures
• Plans will automatically populate with orders and
new medications
©2015 Joan Wellman & Associates, Inc.
Benefits to Nursing
• Allows more meaningful contribution
• Makes patient face time more valuable
• Will be trusted and not duplicated
• Supports required, billable elements of the final
document
• Will be used across all encounters and all clinics
©2015 Joan Wellman & Associates, Inc.
Timeline
• “Go Live” Pulm Clinic – March 6
• Replication Workshop – March 27-28
• Phased “Go Live” for the other 5 Model Line clinics
throughout April
©2015 Joan Wellman & Associates, Inc.
True North
Patient-Centered:
Every Action, Every Day
Our patients and their families are our
only customer
©2015 Joan Wellman & Associates, Inc.