Workflow based approach to Template Design & Selection

Workflow based approach to Template Design & Selection Susan Pierce-Richards, MSN, ARNP Nurse Practitioner & Clinical Applications Coordinator Yakama Indian Health Clinic Toppenish WA

Introduction Our CACs are: • Susan Pierce-Richards, MSN, ARNP • Nurse Practitioner/CAC • Sarah Michael, PharmD • Pharmacist/CAC Yakama Indian Health Clinic is a large, multi-service ambulatory care clinic. We proactively sought to fulfill the CAC responsibilities with a job share model. Each CAC provides 20 hours of CAC duties and the remainder of our duties are direct patient care. Our CAC team is a collaborative effort between the disciplines of Medical, Pharmacy and Nursing.

Background • Providers are documenting MORE in the EHR than previously and are often overwhelmed initially • In an ideal world, providers would not duplicate their documentation. The TIU template objects would pull into the note necessary. • Often, template design is not well matched with the workflow leading to frustration and duplication of documentation • Medical providers often do not understand the system (EHR) capabilities and limitations. It is important for CACs to actively elicit information about and observe workflow processes to better understand provider needs. REMEMBER: EHR is a documentation tool. To maximize its effectiveness, it must be customized to the users.

OBJECTIVES USING A PROVIDER PATIENT ENCOUNTER AS AN EXAMPLE: • Understand the importance of clinician workflow in the design and selection of TIU templates • Be able to use a stepwise approach to evaluate your clinicians’ workflow and documentation needs • Provide overview of template design options • Understand how to take a basic template design and manipulate it to meet workflow needs

Overall goals of EHR documentation • Appropriate documentation for presenting complaints and problems addressed • Medical/legal necessity • Communicate encounter details to future providers • Appropriate documentation for billing code • Minimize: • Clicks/keystrokes for provider • Duplication of documentation • Maximize: • Standardization of mandatory items and location of basic documentation (i.e. Basic layout similar so everyone knows where to find plan, follow up, etc when reviewing other providers documentation) • Flexibility • Expedient capture of needed data • Customizability

Overview of template needs assessment • DOCUMENTATION NEEDS • Use accepted standards of medical documentation • Determine what is MANDATORY and what is OPTIONAL in an encounter note • Determine what can be pulled in with OBJECTS from RPMS • WORKFLOW • The order in which data is collected • The order in which data is recorded • The order in which clinical decisions/plans are made • What is the SAME for all providers • What is VARIABLE for providers

Overview of assessment of workflow • Provider skill level/preference • Excellent keyboarding skills • Poor keyboarding skills • Mouse vs keyboard • CTS • Voice recognition • Review documentation needs/desires, how work done to determine: • Entry and exit points within templates • Styles of templates (free text, editable word processing fields, templated sentences with optional word changes)

DOCUMENTATION NEEDS • Determine what is MANDATORY and what is OPTIONAL for encounters • May be different for different types of visits (ie sick visit vs yearly preventive visit) • Consider using objects to bring in MANDATORY (ie. Allergies, Chief Complaint, Vital Measurements) • Consider using Mandatory Template fields sparingly (ie. Check box that allergies were reviewed)

HISTORICAL DATA***objects that may be used to pull in some info in RED*** • Historical lab, vitals, exam data • Lab objects • Measurements • Flowsheet objects • Labs • Exams • Measurements

OBJECTIVE***objects that may be used to pull in some info in RED******template fields options or free text*** Vital signs |V MEASUREMENT| • Physical Exam (text, template) • Lab results from TODAY |TODAY'S LABS| • Interpretations of x-ray, ekg, pft, etc (text)

PROCEDURES • Wound repair • I&D • Joint injection/aspiration • Biopsy Use template guided documentation based on accepted standards

Sample PROVIDER workflow (where work done)History and Physical Exam • Nurse enters VS, CC, LMP, Tobacco and ETOH screen • Provider enters room • Reviews Allergies/Alerts, CC, problem list(postings, cover sheet, POV tab, orders tab for allergy entry) • Takes History Adds/changes CC if needed • HPI(notes) • +/- PMH, FMH, Social hx(POV, notes) • +/- historical lab, procedure, chart review(lab, notes, chart) • ROS (notes) • Examines patient(notes)

Sample PROVIDER workflow Diagnostic work up/Assessment/Plan • Orders labs, xrays, ekg, repeat vitals, etc (orders) • Reviews labs, xrays, repeat VS, etc (orders, notes) • Assessment/Plan (POV, Wellness, notes) • Makes diagnoses or impression • Discusses with patient, Discusses with patient. Orders meds, +/- further work up. Discusses with patient • Determines/discusses follow up • Assigns level of visit (now knows 99213, 99214, etc) (Services) • THE ORDER IN WHICH YOUR PROVIDER WORKS DETERMINES: • THE ORDER IN WHICH YOU SET UP YOUR TABS • ENTRY/EXIT OPTIONS FOR TEMPLATES

TEMPLATE EXAMPLES

Basic “Start To Finish”TRAINING DATABASE, NOT A REAL PATIENT!

Basic “Start To Finish” • GOOD FOR: • Simple straight forward visits (ie. Scabies, Pediculosis) • Providers who have good keyboarding skills • Benefits • Simple • Easy to navigate either with mouse or keyboard (tab key) • Drawbacks • Have to complete all tabs in EHR prior to writing note • Cannot exit and reenter without losing data OR needing to edit completed note • Need to go back into text to add data

Split template (S&O, A&P) TRAINING DATABASE, NOT A REAL PATIENT!

Split template (S&O, A&P) • GOOD FOR: • Providers who document H&P initially, then document on the other tabs • More extended visits • New EHR users • BENEFITS: • Easy to get in and out of for providers who document H&P prior to completing other tabs • Can be “unbundled” by the CACs very easily to give additional entry/exit points for users • DRAWBACKS: • Not as readily navigated by keyboard • “Hiding” the sections of the templates add clicks • Cannot imbed reminder dialogues • Our providers used this initially but then wanted them “unbundled” once they became more proficient in EHR to decrease the “clicks”

“Build a note” folderTRAINING DATABASE, NOT A REAL PATIENT!

“Build a note” folder • GOOD FOR: • Any type of visit • Can create other folders for documentation of phone calls, letters, etc • Best for more experienced EHR users • BENEFITS: • Quick • Highly customizable • Provider can decide what to put in note • Extremely easy to navigate other tabs during note writing, so can be readily matched to different documentation styles • Can include reminder diaolgues in the folder that can be place in the appropriate part of note (ie. Pt ed in Plan, Tobacco use in Social History) • DRAWBACKS • Must be “cursor aware” during note writing • Not as readily navigated by keyboard alone • Not as much guidance for new providers/students

Template styles • Provider skills vary dramatically • Need to match layout to skills of provider • Provide a variety and let providers choose • Be aware of what type of template fields suit keyboard only navigation (ie. Combo boxes do not work well for this type navigation)

Free Text – for the keyboard adept

Editable word processing – for the more keyboard challenged, can be easily altered

Pre-templated sentences with word change options – for the keyboard challenged

Combined styles

YAKAMA – our approach Ambulatory encounters • ALL TEMPATES – imbedded • Allergies ADR (object) • Mandatory check box for review of allergies • LMP (object) • Chief Complaint (object) • Vital signs (object) • POV (object) • ORDERS (object) • ALL but very brief template include • Pt education • Meds • Future appts/follow up

YAKAMA – our approach • SPECIALIZED TEMPLATES • We have some specialized templates to assist providers in creating complete documentation for specific types of visits: • Preventive visits • WCC – we used the WA DSHS approved forms as a guide and templated these • Adult Yearly Preventive exam is a larger, more inclusive template • Diabetic follow ups • Imbed standards of care review

YAKAMA – our approach • Basic templates for routine follow up and sick visits include options to include: • Med list • Active problems • Habits (smoking, alcohol HF objects) • Additional ROS • Medication reconciliation

YAKAMA – our approach • Template “Build a note” folders include ALL OPTIONS • Provider move this into their Personal Templates and remove/add to their liking • “Build a note Add Ons” provides additional options providers may add to their folders • Allows the most flexibility and user customization

YAKAMA – our approach • Most templates allow provider to chose from a few documentation styles. For instance, a provider choose a SOAP free text note but at the PE, has the option to use the PE template. • This allows flexibility within the template. • Must be careful not to make the template too cumbersome or too “clicky”

YAKAMA – our approach • We have 13 medical providers (including our 2 PHN/NP’s) with a WIDE variation in computer skills • We have a several styles of templates • Each provider has a small number of templates they like to use that they have in their MY TEMPLATES • No 2 providers have the identical group! • Only AFTER our providers were exposed to different styles and types of templates were they really able to articulate their needs and desires for template changes! • Most of our providers are quite satisfied with the templates and feel they have choices

Putting it all together • Demonstration of some basic template options • Demonstration of customization of templates

Template development • Make “template parts” that you can use in numerous templates for common uses • Note start with Allergies, CC, HPI • Review of systems • Physical exams (you may want a few types) • Plan (Orders, Pt ed, Follow up) • You can also “steal” templates parts from other templates This will help you create templates faster, and have the appearance more consistent for users. Remember if you change these templates, you may be changing all of them!

2 entry point template

Multiple entry point template

Folders

“Deconstructing” a 2 entry point template

When bundled and hidden, templates are layered one inside of another inside of another, etc. When you want to create additional entry points, you need for the templates to be independent, yet bundled in the parent in such a way that you do not have to “open” the parent to get to the “children”

To “un-bundle”, move the templates out from underneath the PARENTS and list them in the order in which they will be utilized. You then set the “GRAND-PARENT” to display only, then when the template opens, the access points are visible on the left had of the template window

Constructing a 2 entry point template • More complicated than “deconstructing” • Generally, you want a parent dialogue that displays 2 separate dialogues whose children are hidden

Create a PARENT that is a DIALOGUE and check DISPLAY ONLY on the dialogue properties.Put 2 CHILDREN in the PARENT dialogue. Make them CHILDREN DIALOGUES. You MUST have something in the boilerplate before you can manipulate the dialogue properties BUT you don’t want it to display SO insert a TEXT TEMPLATE FIELD that is EXCLUDED FROM THE NOTE to serve as the title of the CHILDREN on the PARENT.

Now you have your shell.

The next step is to put the appropriate templates in the appropriate dialogue.

The last step will be setting the dialogue parameters so it displays you way you want it. The PARENT is set to DISPLAY ONLY and the 2 CHILD DIALOGUES are set to INDENT DIALOGUE ITEMS and HIDE DIALOGUE ITEMS. You are hiding the GRAND-CHILDREN. You may choose to “HIDE ITEMS IN TEMPLATE DRAWERS” to simplify display for the user.

Workflow based approach to Template Design & Selection