AHLTA Lessons Learned: Providing Better Care and Getting Home Earlier USAFP 13 March 2007

1. AHLTA Lessons Learned:Providing Better Care and Getting Home EarlierUSAFP13 March 2007 Ron Moody MD David Freeman Mark Stack MD Jacob Aaronson DO

2. Agenda • Personal Skills to Improve Efficiency • Clinic Workflow Consideration and the Use of Tool Outside AHLTA • Effective Use of Coming AHLTA Improvements

3. Provider Tipsfor AHLTA Efficiency • Decrease desktop clutter • Health History Module use • User settings that help and hurt • Windows XP tricks • Local PC issues impacting speed • Favorites (List Management Module) • 15 Clinic • 15 My (personal)

4. Decrease Desktop Clutter • AHLTA has many ways to do the same thing • Customize your personal view so that you optimize your clinic “speed” • Limit mouse movements • Only place items in Physician Shortcuts you use during appt • Place in order you use them • Don’t include items presented elsewhere (alerts, actions)

5. Place items in Physician Shortcuts in the order you use them

6. Health History Module • Why use it • Loads all patient’s data in background while you are doing something else • Saves you time as later retrieval is faster and you can ask fewer questions (Don’t repeat what is known) • When to use it in clinic • Open appointment and immediately click HHM so that it loads at beginning of appointment (in hallway if wireless) • Do something else while patient data is loading • When you click on Rads and Labs they will appear faster (on that PC) • How to set it up – Requires a one-time set up

7. HHM: Must set user options Default setting under Tools > Properties

8. User-Defined Settings • AUTOCITE • Only set for current meds, allergies, problems (speeds A/P loading) • Adding labs and rads only slows the system and you are legally liable for any autocite results • Close patient record when not using • Autosave - Set at every eight minutes. This will save data if event occurs. More frequent saves slow system. • No printing of charts • LAB and Rad Settings can be ALL if Health History Module is used so that data loads in the background

9. Autocite: Set User Preferences

10. Other User Settings • The filter used for medication and ancillary results display will impact that modules view and autocite along with speed. • Medication options: Outpatient current/Inpatient All/All current • Rad options: Recommend all or 24 months (2 years) • Labs: Recommend all or 24 months (2 years) • If opening Health History Module at beginning of appointment and letting it load while you do something else • Set Labs to all (two locations to set, make them the same) • Set Meds to all (two locations to set, make them the same) • If NOT using HHM approach • Set labs to last 2 years or time frame that is usually reviewed • Set rads to last 2 years or time frame that is usually reviewed • NOTE :Longer = Slower

11. Setting Ancillary Defaults

12. Lab Module Flowsheet View

13. A simple Windows XP tip to Improve AHLTA Performance (Note: Make the change outlines on the following 2 slides when AHLTA is NOT open/running.) • System sluggishness is a common complaint. • User’s see AHLTA as being slow. • Often the entire workstation (PC) is slow, which means, any software running on it is slow… including AHLTA.

14. A simple tweak that all Providers can do! • Click on Start -> Control Panel -> System -> Advanced Tab -> click Adjust for Best Performance -> click OK. • Recommend that this be the default for any computer that’s primary mission is running AHLTA. • Try it. All windows open a little faster. Every few seconds make a big difference over the course of a day.

15. Screenshots 1. Start -> Settings -> Control Panel 2. Double Click ‘System’ 4. Click the radio button ‘Adjust for best performance’, then click ‘OK’ to close. 3. Click on ‘Advanced’ tab -> then Click on ‘Settings’ to adjust Performance.

16. Recommended ProviderEncounter Workflow • Before Clinic (one-time investment) • Set User Preferences/Defaults • Establish clinic favorite DXs and CPTs (only the most common) • Create personal default template (can be clinic- or MTF-specific) • Team Documentation – Same Template or Clinic • Enter room, greet PT, open appointment, read screening entry and click HHM • Take history and do exam (Most people will not write note while taking history) • Complete A/P with PT in room (limit A/P jumps) • Dx, orders, and Instructions reviewed with PT >>>PT leaves • If the clinic staff began the note, use Edit-No-Yes to take over screening note THEN write note with default template • Augment default template with DxPrompt (if needed) to complete note • Remember to put positive ROS into HPI (using flip button) • Disposition and Sign with a cup of coffee

17. Expanded: Top EUD Performance Issues • User settings • Auto-cites (Extensive Auto-cites will slow system) • Appointment Search Criteria - Allows the user to return all un-signed encounters for all Clinics they are mapped to as well as selecting all Providers in that Clinic • User-configurable • Users requiring extensive encounter lists will operate slower • Number of clinics the which the user is mapped • Database call to “get Clinic data” is used throughout AHLTA - The “get Clinic data” call retrieves: • Appointment Data Types for each Clinic • Clinic Information for each Clinic • Amount of and users in each Clinic • Amount of templates assigned to each Clinic (only for the Template Management Module) • RAM – Moving to 2 Gig

18. Expanded: Top EUD Performance Issues • Spyware • What is in your internet files? • Have you deleted your cookies? • Incorrect version of AHLTA • AHLTA Client Software not in sync with CDR (Database) indexes • User perception • Users are not aware of what takes place in the background when they use a function in AHLTA. • For example: Going between the S/O and A/P modules • The system saves the S/O data, updates and saves the Encounter, updates and saves the Appointment, then opens the A/P module, updates the Appointment, updates the Encounter, retrieves A/P data • This item is corrected with the coming performance enhancements.

19. Issues • Getting items into AHLTA • External consults • Machine results (PFT, EKG) • Drawings/Pictures • Signature

20. EUD Performance Issues:Things to Check to Help Yourself • User settings • Number of clinics where the user is mapped • Spyware/other non-work-related software • Incorrect version of AHLTA • Extraneous running software (Music, email, etc) • User perception (workflow) • Network issues

21. Others Tools • TabletPC • Handwriting recognition • Touch screen • Dictation • Dictation Programs • Use with established template/AIM • Use with team process

22. Health Care Team Approach To Documentation • Team needs to be aware of importance of Proper Documentation (appropriate coding will follow) • Improving clinic efficiency and changing Work Processes will improve quality of care provided, and get you home faster. Coding will be a by-product • Use AHLTA as a tool to bring about change: staffing, staffing type, work

23. General Workflow Documenting Note in AHLTA …keeping speed and efficiency in mind… Remember… do not “drill” down the tree Complete A/P First (Add Dx First, then Add Orders) See Your Patient Yes Did Support Staff Complete the Subjective For Me? No Take Over Note ‘Edit -> No -> Yes’ “Plan B” Yes No Do I have A Template/AIM? Default Template (DT) Loads Free text (DT) ‘Visit For:’ (DT) ROS Tab - Flip to HPI Abnormals, Normals not flipped (DT) PMH Tab - Add anything relevant (DT) PE Tab - Click to add Normals and Abnormals DxPrompt (DxP) * - tab back to HPI (DxP) HPI - Add anything relevant (Don’t forget List size) (DxP) PMH - Add anything relevant (DxP) PE - Add anything relevant Free Text all other Physical Findings not found in DT or DxP, and/or add the ‘Oh by the way’ PE items in Free text. Load the Template/AIM * Free text (Template) ‘Visit For:’ ROS Tab - Flip to HPI Abnormals ROS AutoNeg (Deselect what you did not ask) PMH Tab - add anything relevant PE Tab - Click Abnormals PE AutoNeg (Deselect what you did not examine) Free Text all other Physical Findings. * For Multiple Problem Visits (I.e. DM, HTN, Hypothyroid) - If you have a template, choose the 1 Most Comprehensive, then free text t - If you do a DxPrompt, only DxPrompt Once - on the Most Comprehensive dx, I.e. DM gives terms that can be used to document HTN and Hypothyroid, etc. See Next Patient Or Go Home Early Sip some Coffee Disposition & Sign

24. Health Care Team • Utilizing Health Care Team approach will improve other areas as well: • JCAHO Requirements (Medication Reconciliation, Problem List Updates) • Usage of Wellness Reminders to ensure we are maximizing preventive measures with our patients (and by the way generate more RVUs per visit) • Increase ability of provider to focus on producing a readable, clinically useful note

25. Focus on Health Care Team Using entire health care team can drastically improve efficiency 1) Front Desk/Appointment Clerks • Ensure accurate reason for visit (don’t write “follow up” or “refill”) so Health Care Team knows why patient is there • Ensure accurate contact information for patient • Can use Comments section in Demographics Module to write most current phone number • Encourage patient to go to DEERS office to update information if it isn’t correct • When patient arrives, print problem list and medication list for patient to review and write in corrections • Give patient Visit Screening Form to fill out while waiting

26. Patient is Part of the Team 2) Patient • Make written corrections on Medication List and Master Problem List form (DD 2766) • Fill Out Visit Screening Form (which might mirror a Medcin or AIM Form Template for ease of entry for screener) • Incorporates JCAHO required screening questions • Provides initial HPI/PMH/ROS information • This can meet most of History Coding Requirements • Should help cut down on the surprises (“Oh, by the way…”

27. Improved Screening Process 3) Initial Screening (Use of Good Medcin or AIM Form Encounter Template is Critical Here) • Review and update patients Master Problem List and Medication List • Make sure to add outside meds/OTC/Herbals using Medication Module • Complete Vitals Module (Vitals, Pain Scale, etc…) • Document any Procedures done as part of screening (i.e. Peak Flow, Pulse Oximetry) in A/P Module • This can be done easily using well designed template with clinic procedures already available for selection

28. Improved Screening Process 4) Medical Screening (con’t) • Enter Patient Screening Information • Consider use of patient form • Review and update • Allergies, Current Medications, Family, and Surgical History on Problem • Document action taken in chart • Use appropriate Medcin or AIM Form Template (Reason for visit in Free Text, initial HPI/PMH/ROS bullets) • Review and Address any Wellness Reminders • Order any additional labs and x-rays per local Standard Operation Procedures (UA, HCG’s, X-rays) using order sets in A/P module

31. Comprehensive ROS Organized by System Ability to toggle between ROS and HPI. Positive Findings go in HPI and Negative Findings into ROS. (Improves note readability)

32. Ancillary Staff Can Enter Procedures Easily With A Template -Can use Procedure pick list to avoid need to use search function -Just double click to add

33. Focus on Health Care Team Sample Patient Flow • Provider • Review and confirm MPL and Med List updates • Conduct Patient Encounter • Start with A/P (Select Diagnosis, write Free Text thought process, place any orders, initiate any procedures) • Finish documenting HPI/PMH/ROS, document Exam • Important to use enough free text in note to ensure clinical readability and usefulness • Review and Complete Note

34. Problem List Clean-up • Currently From Problems Module • Add • Delete • Make Inactive • From A/P Module • Current – Change from Chronic to Acute • Future – Delete/Make Inactive

35. Summary • Don’t hurt yourself and be prepared for coming improvements • Make Sure the Entire Team Understands Documentation is their responsibility • Use Health Care Team Approach to Patient Care • Wellness reminders (start with a subset) • Improved clinic efficiency • Improved patient care • Provider not solely responsible for documentation • Improved coding • AHLTA is the Tool to integrate all of the above

36. Questions??? AMEDD Guide to AHLTA Training for Providers At www.usafp.org

37. Problem List Clean-up

38. Adding OTC and Network Medications